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{{#Wiki_filter:May 10, 2019
{{#Wiki_filter:May 10, 2019  
Mr. Ken Peters, Senior Vice President
   and Chief Nuclear Officer
VISTRA Operations Company, LLC
P.O. Box 1002
Mr. Ken Peters, Senior Vice President
Glen Rose, TX 76043
   and Chief Nuclear Officer  
SUBJECT:       COMANCHE PEAK NUCLEAR POWER PLANT, UNITS 1 AND 2 - NRC
VISTRA Operations Company, LLC  
                INTEGRATED INSPECTION REPORT 05000445/2019001 AND
P.O. Box 1002  
                05000446/2019001
Glen Rose, TX 76043  
Dear Mr. Peters:
On March 31, 2019, the U.S. Nuclear Regulatory Commission (NRC) completed an inspection
SUBJECT:  
at your Comanche Peak Nuclear Power Plant, Units 1 and 2. On April 2, 2019, the NRC
COMANCHE PEAK NUCLEAR POWER PLANT, UNITS 1 AND 2 - NRC  
inspectors discussed the results of this inspection with Mr. Steven Sewell and other members of
INTEGRATED INSPECTION REPORT 05000445/2019001 AND  
your staff. The results of this inspection are documented in the enclosed report.
05000446/2019001  
NRC inspectors documented seven findings of very low safety significance (Green) in this
report. These findings involved violations of NRC requirements. Additionally, NRC inspectors
Dear Mr. Peters:  
documented one Severity Level IV violation with no associated finding. The NRC is treating
these violations as non-cited violations (NCV) consistent with Section 2.3.2.a of the
On March 31, 2019, the U.S. Nuclear Regulatory Commission (NRC) completed an inspection  
Enforcement Policy.
at your Comanche Peak Nuclear Power Plant, Units 1 and 2. On April 2, 2019, the NRC  
The inspectors also documented a licensee-identified violation which was determined to be of
inspectors discussed the results of this inspection with Mr. Steven Sewell and other members of  
very low safety significance in this report. The NRC is treating this violation as a non-cited
your staff. The results of this inspection are documented in the enclosed report.  
violation (NCV) consistent with Section 2.3.2.a of the Enforcement Policy.
If you contest the violations or significance or severity of the violations documented in this
NRC inspectors documented seven findings of very low safety significance (Green) in this  
inspection report, you should provide a response within 30 days of the date of this inspection
report. These findings involved violations of NRC requirements. Additionally, NRC inspectors  
report, with the basis for your denial, to the U.S. Nuclear Regulatory Commission, ATTN:
documented one Severity Level IV violation with no associated finding. The NRC is treating  
Document Control Desk, Washington, DC 20555-0001; with copies to the Regional
these violations as non-cited violations (NCV) consistent with Section 2.3.2.a of the  
Administrator, Region IV; the Director, Office of Enforcement; and the NRC resident inspector at
Enforcement Policy.  
the Comanche Peak Nuclear Power Plant.
If you disagree with a cross-cutting aspect assignment in this report, you should provide a
The inspectors also documented a licensee-identified violation which was determined to be of  
response within 30 days of the date of this inspection report, with the basis for your
very low safety significance in this report. The NRC is treating this violation as a non-cited  
disagreement, to the U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk,
violation (NCV) consistent with Section 2.3.2.a of the Enforcement Policy.  
Washington, DC 20555-0001; with copies to the Regional Administrator, Region IV; and the
NRC resident inspector at the Comanche Peak Nuclear Power Plant.
If you contest the violations or significance or severity of the violations documented in this  
inspection report, 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 Comanche Peak Nuclear Power Plant.  
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 Comanche Peak Nuclear Power Plant.  


K. Peters                                       2
K. Peters  
This letter, its enclosure, and your response (if any) will be made available for public inspection
2
and copying at http://www.nrc.gov/reading-rm/adams.html and at the NRC Public Document
2  
Room in accordance with 10 CFR 2.390, Public Inspections, Exemptions, Requests for
Withholding.
This letter, its enclosure, and your response (if any) will be made available for public inspection  
                                                Sincerely,
and copying at http://www.nrc.gov/reading-rm/adams.html and at the NRC Public Document  
                                                /RA/
Room in accordance with 10 CFR 2.390, Public Inspections, Exemptions, Requests for  
                                                Mark S. Haire, Chief
Withholding.  
                                                Project Branch A
                                                Division of Reactor Projects
Docket Nos. 50-445 and 50-446
Sincerely,  
License Nos. NPF-87 and NPF-89
Enclosure:
/RA/  
Inspection Report 05000445/2019001
and 05000446/2019001
                                                  2
Mark S. Haire, Chief  
Project Branch A  
Division of Reactor Projects  
Docket Nos. 50-445 and 50-446  
License Nos. NPF-87 and NPF-89  
Enclosure:  
Inspection Report 05000445/2019001
and 05000446/2019001


                          U.S. NUCLEAR REGULATORY COMMISSION
                                        Inspection Report
3
Docket Number(s):     05000445 and 05000446
License Number(s):     NPF-87 and NPF-89
U.S. NUCLEAR REGULATORY COMMISSION  
Report Number(s):     05000445/2019001 and 05000446/2019001
Inspection Report  
Enterprise Identifier: I-2019-001-0011
Licensee:             Vistra Operations Company, LLC
Facility:             Comanche Peak Nuclear Power Plant, Units 1 and 2
Docket Number(s):
Location:             Glen Rose, TX 76043
05000445 and 05000446  
Inspection Dates:     January 1, 2019 to March 31, 2019
Inspectors:           W. Cullum, Reactor Inspector
                      R. Deese, Senior Reactor Analyst
License Number(s):  
                      J. Drake, Senior Reactor Inspector
NPF-87 and NPF-89  
                      J. Josey, Senior Resident Inspector
                      R. Kumana, Resident Inspector
                      W. Sifre, Senior Reactor Inspector
Report Number(s):  
Approved By:           Mark S. Haire, Chief
05000445/2019001 and 05000446/2019001  
                      Project Branch A
                      Division of Reactor Projects
                                                3
Enterprise Identifier: I-2019-001-0011  
Licensee:  
Vistra Operations Company, LLC  
Facility:  
Comanche Peak Nuclear Power Plant, Units 1 and 2  
Location:  
Glen Rose, TX 76043  
Inspection Dates:  
January 1, 2019 to March 31, 2019  
Inspectors:  
W. Cullum, Reactor Inspector  
R. Deese, Senior Reactor Analyst  
J. Drake, Senior Reactor Inspector  
J. Josey, Senior Resident Inspector  
R. Kumana, Resident Inspector  
W. Sifre, Senior Reactor Inspector  
Approved By:  
Mark S. Haire, Chief  
Project Branch A  
Division of Reactor Projects  


                                              SUMMARY
The U.S. Nuclear Regulatory Commission (NRC) continued monitoring the licensees
4
performance by conducting a Quarterly inspection at Comanche Peak Nuclear Power Plant,
Units 1 and 2, in accordance with the Reactor Oversight Process. The Reactor Oversight
SUMMARY  
Process is the NRCs program for overseeing the safe operation of commercial nuclear power
reactors. Refer to https://www.nrc.gov/reactors/operating/oversight.html for more information.
The U.S. Nuclear Regulatory Commission (NRC) continued monitoring the licensees  
Findings and violations being considered in the NRCs assessment are summarized in the table
performance by conducting a Quarterly inspection at Comanche Peak Nuclear Power Plant,  
below. A licensee-identified non-cited violation is documented in report section: 71111.18.
Units 1 and 2, in accordance with the Reactor Oversight Process. The Reactor Oversight  
                                  List of Findings and Violations
Process is the NRCs program for overseeing the safe operation of commercial nuclear power  
  Inadequate Corrective Actions for Failure to Ensure Containment Hatch Closure Capability
reactors. Refer to https://www.nrc.gov/reactors/operating/oversight.html for more information.
  Cornerstone           Significance                               Cross-cutting     Report
Findings and violations being considered in the NRCs assessment are summarized in the table  
                                                                    Aspect            Section
below. A licensee-identified non-cited violation is documented in report section: 71111.18.  
  Barrier Integrity     Green                                     [H.6] - Design    71111.04
                        NCV 05000445; 05000446/2019001-01 Margins
List of Findings and Violations  
                        Closed
  The inspectors identified a Green non-cited violation of 10 CFR Part 50, Appendix B,
Inadequate Corrective Actions for Failure to Ensure Containment Hatch Closure Capability  
  Criterion XVI, Corrective Actions, associated with the licensees failure to take adequate
Cornerstone  
  corrective actions for an inadequate containment closure procedure. Specifically, in
Significance  
  December 2017, the NRC identified that the licensee's procedure for emergency closure of
Cross-cutting  
  the Unit 1 and 2 containment equipment hatches was inadequate, and the licensee failed to
Aspect
  take adequate actions to correct the issue prior to the next outage.
Report  
  Failure to Evaluate a Change to the Facility DC Power System
Section  
  Cornerstone           Significance                               Cross-cutting     Report
Barrier Integrity  
                                                                    Aspect            Section
Green  
  Not Applicable         NCV 05000445/2019001-02                   Not Applicable     71111.04
NCV 05000445; 05000446/2019001-01
                        Closed
Closed
  The inspectors identified a Severity Level IV, non-cited violation of 10 CFR 50.59 for the
[H.6] - Design
  licensees failure to obtain a license amendment or perform a written evaluation
Margins  
  demonstrating the basis for not obtaining a license amendment, prior to making a change to
71111.04
  the facility as described in the final safety analysis report.
The inspectors identified a Green non-cited violation of 10 CFR Part 50, Appendix B,  
  Failure to Monitor or Demonstrate Control of Performance Under the Maintenance Rule
Criterion XVI, Corrective Actions, associated with the licensees failure to take adequate  
  Cornerstone           Significance                               Cross-cutting     Report
corrective actions for an inadequate containment closure procedure. Specifically, in  
                                                                    Aspect            Section
December 2017, the NRC identified that the licensee's procedure for emergency closure of  
  Mitigating             Green                                     None              71111.12
the Unit 1 and 2 containment equipment hatches was inadequate, and the licensee failed to  
  Systems                NCV 05000445; 05000446/2019001-03
take adequate actions to correct the issue prior to the next outage.  
                        Closed
  The inspectors identified a Green non-cited violation of 10 CFR 50.65(a)(2), with
Failure to Evaluate a Change to the Facility DC Power System  
  three examples, for failure to demonstrate effective control of performance of a maintenance
Cornerstone  
  rule scoped system through appropriate preventive maintenance.
Significance  
                                                  4
Cross-cutting  
Aspect
Report  
Section  
Not Applicable  
NCV 05000445/2019001-02
Closed
Not Applicable  
71111.04  
The inspectors identified a Severity Level IV, non-cited violation of 10 CFR 50.59 for the  
licensees failure to obtain a license amendment or perform a written evaluation  
demonstrating the basis for not obtaining a license amendment, prior to making a change to  
the facility as described in the final safety analysis report.  
Failure to Monitor or Demonstrate Control of Performance Under the Maintenance Rule  
Cornerstone  
Significance  
Cross-cutting  
Aspect
Report  
Section  
Mitigating  
Systems
Green  
NCV 05000445; 05000446/2019001-03
Closed  
None
71111.12
The inspectors identified a Green non-cited violation of 10 CFR 50.65(a)(2), with  
three examples, for failure to demonstrate effective control of performance of a maintenance  
rule scoped system through appropriate preventive maintenance.  


Failure to Control Hazard Barriers During Maintenance
Cornerstone           Significance                               Cross-cutting     Report
5
                                                                  Aspect            Section
Mitigating             Green                                     [H.14] -           71111.13
Failure to Control Hazard Barriers During Maintenance  
Systems                NCV 05000445/2019001-04                    Conservative
Cornerstone  
                      Closed                                    Bias
Significance  
The inspectors identified a Green non-cited violation of 10 CFR 50.65(a)(4) for failure to
Cross-cutting  
implement risk mitigating actions during diesel generator maintenance.
Aspect
Failure to Follow Procedure When A Degraded Condition Was Identified
Report  
Cornerstone           Significance                               Cross-cutting     Report
Section  
                                                                  Aspect            Section
Mitigating  
Mitigating             Green                                     [H.14] -          71111.15
Systems
Systems                NCV 05000445; 05000446/2019001-05 Conservative
Green  
                      Closed                                    Bias
NCV 05000445/2019001-04 
The inspectors identified a Green non-cited violation of 10 CFR Part 50, Appendix B,
Closed
Criterion V, Instructions, Procedures, and Drawings, associated with the licensees failure to
[H.14] -  
follow the requirements of Station Procedure STI-421.01, Initiation of Issue Reports,
Conservative  
Revision 0. Specifically, station personnel failed to notify the shift manager of an issue with
Bias  
material storage in the protected area. This issue required evaluations and compensatory
71111.13
actions for resolution.
The inspectors identified a Green non-cited violation of 10 CFR 50.65(a)(4) for failure to  
Failure to Perform Safety Evaluations in Accordance with 10 CFR 50.59
implement risk mitigating actions during diesel generator maintenance.  
Cornerstone           Significance                               Cross-cutting     Report
                                                                  Aspect            Section
Failure to Follow Procedure When A Degraded Condition Was Identified  
Mitigating             Green                                     [H.9] - Training  71111.17T
Cornerstone  
Systems                NCV 05000445; 05000446/2019001-06
Significance  
                      Closed
Cross-cutting  
The inspectors identified a Green, non-cited violation of 10 CFR 50, Appendix B, Criterion V,
Aspect
Instructions, Procedures, and Drawings, (with four examples) in which the licensee failed to
Report  
complete 50.59 evaluations as required by station procedures.
Section  
Inadequate Maintenance Instructions Result in Loss of Assessment Capability
Mitigating  
Cornerstone           Significance                               Cross-cutting     Report
Systems
                                                                  Aspect            Section
Green  
Emergency             Green                                     [H.8] -            71152
NCV 05000445; 05000446/2019001-05
Preparedness          NCV 05000445; 05000446/2019001-07 Procedure
Closed
                      Closed                                    Adherence
[H.14] -
The inspectors reviewed a self-revealed Green, non-citied violation of 10 CFR 50,
Conservative  
Appendix B, Criterion V, "Instruction, Procedures, and Drawings," that occurred due to
Bias  
inadequate maintenance instructions for safety-related radiation monitors that resulted in a
71111.15
major loss of assessment capability.
The inspectors identified a Green non-cited violation of 10 CFR Part 50, Appendix B,  
                                              5
Criterion V, Instructions, Procedures, and Drawings, associated with the licensees failure to  
follow the requirements of Station Procedure STI-421.01, Initiation of Issue Reports,  
Revision 0. Specifically, station personnel failed to notify the shift manager of an issue with  
material storage in the protected area. This issue required evaluations and compensatory  
actions for resolution.  
Failure to Perform Safety Evaluations in Accordance with 10 CFR 50.59  
Cornerstone  
Significance  
Cross-cutting  
Aspect
Report  
Section  
Mitigating  
Systems
Green  
NCV 05000445; 05000446/2019001-06
Closed  
[H.9] - Training
71111.17T
The inspectors identified a Green, non-cited violation of 10 CFR 50, Appendix B, Criterion V,  
Instructions, Procedures, and Drawings, (with four examples) in which the licensee failed to  
complete 50.59 evaluations as required by station procedures.  
Inadequate Maintenance Instructions Result in Loss of Assessment Capability  
Cornerstone  
Significance  
Cross-cutting  
Aspect
Report  
Section  
Emergency  
Preparedness
Green  
NCV 05000445; 05000446/2019001-07
Closed
[H.8] -
Procedure  
Adherence  
71152
The inspectors reviewed a self-revealed Green, non-citied violation of 10 CFR 50,  
Appendix B, Criterion V, "Instruction, Procedures, and Drawings," that occurred due to  
inadequate maintenance instructions for safety-related radiation monitors that resulted in a  
major loss of assessment capability.  


Failure to Establish Adequate Procedural Guidance for Flushing Lithium at Power
Cornerstone           Significance                               Cross-cutting     Report
6
                                                                  Aspect            Section
Mitigating             Green                                     [H.11] -         71152
Failure to Establish Adequate Procedural Guidance for Flushing Lithium at Power  
Systems                NCV 05000446/2019001-08                    Challenge the
Cornerstone  
                      Closed                                    Unknown
Significance  
The inspectors reviewed a Green, self-revealed non-cited violation of 10 CFR Part 50,
Cross-cutting  
Appendix B, Criterion V, Instructions, Procedures, and Drawings, associated with the
Aspect
licensees failure to establish an adequate procedure for flushing lithium from the residual
Report  
heat removal system. This resulted in safety injection accumulators 2-01 and 2-02 discharge
Section  
to the safety injection test header causing level drops in both accumulators and
Mitigating  
accumulator 2-01 pressure dropped to below the operability limit resulting in an unplanned
Systems
component inoperability.
Green  
                                  Additional Tracking Items
NCV 05000446/2019001-08 
Type     Issue Number               Title                               Report       Status
Closed
                                                                        Section
[H.11] -  
NOV       05000446/2018011-01       Failure to Maintain a Quality       92702        Closed
Challenge the  
                                    Record Complete and Accurate
Unknown  
                                    in All Material Respects
71152
LER       05000446/2018-001-00       Unit 2 Automatic Reactor Trip       71153        Closed
The inspectors reviewed a Green, self-revealed non-cited violation of 10 CFR Part 50,  
                                    Due to Turbine Trip, on
Appendix B, Criterion V, Instructions, Procedures, and Drawings, associated with the  
                                    March 19, 2019
licensees failure to establish an adequate procedure for flushing lithium from the residual  
                                                6
heat removal system. This resulted in safety injection accumulators 2-01 and 2-02 discharge  
to the safety injection test header causing level drops in both accumulators and  
accumulator 2-01 pressure dropped to below the operability limit resulting in an unplanned  
component inoperability.  
Additional Tracking Items  
Type  
Issue Number  
Title  
Report  
Section  
Status
NOV  
05000446/2018011-01
Failure to Maintain a Quality  
Record Complete and Accurate  
in All Material Respects  
92702
Closed
LER  
05000446/2018-001-00 Unit 2 Automatic Reactor Trip  
Due to Turbine Trip, on  
March 19, 2019  
71153
Closed


PLANT STATUS
Unit 1 began the inspection period at or near rated thermal power. On February 1, 2019, the
7
unit was down powered to 64 percent for turbine testing. The unit was returned to rated thermal
power the same day. On March 22, 2019, the unit began power coast down to a refueling
PLANT STATUS  
outage, ending the inspection period at 92 percent power.
Unit 2 began the inspection period in a refueling outage. On January 14, 2019, the unit began a
Unit 1 began the inspection period at or near rated thermal power. On February 1, 2019, the  
reactor startup. The unit shut down on January 15, 2019, due to a main turbine primary water
unit was down powered to 64 percent for turbine testing. The unit was returned to rated thermal  
leak. On January 18, 2019, the unit began a reactor startup and reached rated thermal power
power the same day. On March 22, 2019, the unit began power coast down to a refueling  
on January 22, 2019. On March 2, 2019, the unit was tripped due to a failure of a main
outage, ending the inspection period at 92 percent power.  
feedwater isolation valve. The unit began a reactor startup the same day and reached rated
thermal power on March 4, 2019. The unit remained at or near rated thermal power for the
Unit 2 began the inspection period in a refueling outage. On January 14, 2019, the unit began a  
remainder of the inspection period.
reactor startup. The unit shut down on January 15, 2019, due to a main turbine primary water  
INSPECTION SCOPES
leak. On January 18, 2019, the unit began a reactor startup and reached rated thermal power  
Inspections were conducted using the appropriate portions of the inspection procedures (IPs) in
on January 22, 2019. On March 2, 2019, the unit was tripped due to a failure of a main  
effect at the beginning of the inspection unless otherwise noted. Currently approved IPs with
feedwater isolation valve. The unit began a reactor startup the same day and reached rated  
thermal power on March 4, 2019. The unit remained at or near rated thermal power for the  
remainder of the inspection period.  
INSPECTION SCOPES  
Inspections were conducted using the appropriate portions of the inspection procedures (IPs) in  
effect at the beginning of the inspection unless otherwise noted. Currently approved IPs with  
their attached revision histories are located on the public website at http://www.nrc.gov/reading-
their attached revision histories are located on the public website at http://www.nrc.gov/reading-
rm/doc-collections/insp-manual/inspection-procedure/index.html. Samples were declared
rm/doc-collections/insp-manual/inspection-procedure/index.html. Samples were declared  
complete when the IP requirements most appropriate to the inspection activity were met
complete when the IP requirements most appropriate to the inspection activity were met  
consistent with Inspection Manual Chapter 2515, Light-Water Reactor Inspection Program -
consistent with Inspection Manual Chapter 2515, Light-Water Reactor Inspection Program -  
Operations Phase. The inspectors performed plant status activities described in Inspection
Operations Phase. The inspectors performed plant status activities described in Inspection  
Manual Chapter 2515 Appendix D, Plant Status and conducted routine reviews using
Manual Chapter 2515 Appendix D, Plant Status and conducted routine reviews using  
IP 71152, Problem Identification and Resolution. The inspectors reviewed selected
IP 71152, Problem Identification and Resolution. The inspectors reviewed selected  
procedures and records, observed activities, and interviewed personnel to assess licensee
procedures and records, observed activities, and interviewed personnel to assess licensee  
performance and compliance with Commission rules and regulations, license conditions, site
performance and compliance with Commission rules and regulations, license conditions, site  
procedures, and standards.
procedures, and standards.  
REACTOR SAFETY
71111.01 - Adverse Weather Protection
REACTOR SAFETY  
    Impending Severe Weather Sample (IP Section 03.03) (1 Sample)
    The inspectors evaluated readiness for impending adverse weather conditions for severe
71111.01 - Adverse Weather Protection  
    thunderstorms on March 13, 2019.
71111.04 - Equipment Alignment
Impending Severe Weather Sample (IP Section 03.03) (1 Sample)  
    Partial Walkdown (IP Section 02.01) (4 Samples)
    The inspectors evaluated system configurations during partial walkdowns of the following
The inspectors evaluated readiness for impending adverse weather conditions for severe  
    systems/trains:
thunderstorms on March 13, 2019.  
    (1)     Unit 1, safety injection pump 1-01 while 1-02 was out of service for maintenance on
            February 5, 2019
71111.04 - Equipment Alignment  
    (2)     Unit 2, containment hatches on February 13, 2019
                                                  7
Partial Walkdown (IP Section 02.01) (4 Samples)  
The inspectors evaluated system configurations during partial walkdowns of the following  
systems/trains:  
(1)  
Unit 1, safety injection pump 1-01 while 1-02 was out of service for maintenance on  
February 5, 2019  
(2)  
Unit 2, containment hatches on February 13, 2019  


  (3)   Units 1 and 2, common class-1E DC power on March 5, 2019
  (4)   Units 1 and 2, seismic monitoring system on March 18, 2019
8
71111.05Q - Fire Protection
  Quarterly Inspection (IP Section 03.01) (5 Samples)
(3)  
  The inspectors evaluated fire protection program implementation in the following selected
Units 1 and 2, common class-1E DC power on March 5, 2019  
  areas:
  (1)   fire area 2CA, Unit 2 reactor building on January 9, 2019
(4)  
  (2)   fire zones TB201 and TB202, control room emergency lighting battery rooms on
Units 1 and 2, seismic monitoring system on March 18, 2019  
          January 14, 2019
  (3)   fire zone 1SB2A, Unit 1 safety injection pump 1-01 on March 11, 2019
71111.05Q - Fire Protection  
  (4)   fire zone 2SB4, Unit 2 containment spray chemical add tank on March 13, 2019
  (5)   fire zone SM157, stairwell in the southeast corner of the safeguards building on
Quarterly Inspection (IP Section 03.01) (5 Samples)  
          March 26, 2019
71111.06 - Flood Protection Measures
The inspectors evaluated fire protection program implementation in the following selected  
  Inspection Activities - Internal Flooding (IP Section 02.02a.) (1 Sample)
areas:  
  The inspectors evaluated internal flooding mitigation protections in the service water intake
  structure on March 12, 2019.
(1)  
71111.11Q - Licensed Operator Requalification Program and Licensed Operator Performance
fire area 2CA, Unit 2 reactor building on January 9, 2019  
  Licensed Operator Performance in the Actual Plant/Main Control Room (IP Section 03.01)
  (2 Samples)
(2)  
  (1)   The inspectors observed and evaluated licensed operator performance in the Control
fire zones TB201 and TB202, control room emergency lighting battery rooms on  
          Room during Unit 2 startup on January 14, 2019.
January 14, 2019  
  (2)   The inspectors observed and evaluated licensed operator performance in the Control
          Room during Unit 2 startup on January 18, 2019.
(3)  
  Licensed Operator Requalification Training/Examinations (IP Section 03.02) (1 Sample)
fire zone 1SB2A, Unit 1 safety injection pump 1-01 on March 11, 2019  
  The inspectors observed and evaluated a simulator-based loss of coolant accident scenario
  on March 27, 2019.
(4)  
                                                  8
fire zone 2SB4, Unit 2 containment spray chemical add tank on March 13, 2019  
(5)  
fire zone SM157, stairwell in the southeast corner of the safeguards building on  
March 26, 2019  
71111.06 - Flood Protection Measures  
Inspection Activities - Internal Flooding (IP Section 02.02a.) (1 Sample)  
The inspectors evaluated internal flooding mitigation protections in the service water intake  
structure on March 12, 2019.  
71111.11Q - Licensed Operator Requalification Program and Licensed Operator Performance  
Licensed Operator Performance in the Actual Plant/Main Control Room (IP Section 03.01)  
(2 Samples)  
(1)  
The inspectors observed and evaluated licensed operator performance in the Control  
Room during Unit 2 startup on January 14, 2019.  
(2)  
The inspectors observed and evaluated licensed operator performance in the Control  
Room during Unit 2 startup on January 18, 2019.  
Licensed Operator Requalification Training/Examinations (IP Section 03.02) (1 Sample)  
The inspectors observed and evaluated a simulator-based loss of coolant accident scenario  
on March 27, 2019.  


71111.12 - Maintenance Effectiveness
  Routine Maintenance Effectiveness Inspection (IP Section 02.01) (3 Samples)
9
  The inspectors evaluated the effectiveness of routine maintenance activities associated with
  the following equipment and/or safety significant functions:
71111.12 - Maintenance Effectiveness  
  (1)     common low voltage power distribution failure to align to normal power supply on
          February 28, 2019
Routine Maintenance Effectiveness Inspection (IP Section 02.01) (3 Samples)  
  (2)     Unit 1, battery charger and inverter failures which occurred in June 2018, on
          February 28, 2019
The inspectors evaluated the effectiveness of routine maintenance activities associated with  
  (3)     service air check valve failure during surveillance testing on March 14, 2019
the following equipment and/or safety significant functions:  
71111.13 - Maintenance Risk Assessments and Emergent Work Control
  Risk Assessment and Management Sample (IP Section 03.01) (5 Samples)
(1)  
  The inspectors evaluated the risk assessments for the following planned and emergent work
common low voltage power distribution failure to align to normal power supply on  
  activities:
February 28, 2019  
  (1)     Unit 1, risk mitigating actions during emergency diesel generator 1-01 lube oil fill on
          January 17, 2019
(2)  
  (2)     Unit 1, risk mitigating actions while safety injection pump 1-02 was out of service on
Unit 1, battery charger and inverter failures which occurred in June 2018, on
          February 5, 2019
February 28, 2019  
  (3)     Unit 1, risk assessment during sequencer undervoltage replacement on
          February 13, 2019
(3)  
  (4)     Units 1 and 2, removal of service water pipe tunnel missile shield CPX-SWMEBB-01
service air check valve failure during surveillance testing on March 14, 2019  
          on February 28, 2019
  (5)     Units 1 and 2, risk mitigating actions with transformer XST2 unavailable on
71111.13 - Maintenance Risk Assessments and Emergent Work Control  
          March 29, 2019
71111.15 - Operability Determinations and Functionality Assessments
Risk Assessment and Management Sample (IP Section 03.01) (5 Samples)  
  Sample Selection (IP Section 02.01) (5 Samples)
  The inspectors evaluated the following operability determinations and functionality
The inspectors evaluated the risk assessments for the following planned and emergent work  
  assessments:
activities:  
  (1)     CR-2019-000324, Units 1 and 2, environmental qualification of steam generator
          atmospheric relief valves on January 10, 2019
(1)  
  (2)     CR-2019-000456, Units 1 and 2, Electroswitch Part 21 relay issue on
Unit 1, risk mitigating actions during emergency diesel generator 1-01 lube oil fill on  
          January 14, 2019
January 17, 2019  
                                                  9
(2)  
Unit 1, risk mitigating actions while safety injection pump 1-02 was out of service on  
February 5, 2019  
(3)  
Unit 1, risk assessment during sequencer undervoltage replacement on  
February 13, 2019  
(4)  
Units 1 and 2, removal of service water pipe tunnel missile shield CPX-SWMEBB-01  
on February 28, 2019  
(5)  
Units 1 and 2, risk mitigating actions with transformer XST2 unavailable on  
March 29, 2019  
71111.15 - Operability Determinations and Functionality Assessments  
Sample Selection (IP Section 02.01) (5 Samples)  
The inspectors evaluated the following operability determinations and functionality  
assessments:  
(1)  
CR-2019-000324, Units 1 and 2, environmental qualification of steam generator  
atmospheric relief valves on January 10, 2019  
(2)  
CR-2019-000456, Units 1 and 2, Electroswitch Part 21 relay issue on  
January 14, 2019  


  (3)   TR-2019-001119, Units 1 and 2, tornado missile evaluation for equipment storage on
        February 13, 2019
10
  (4)   TR-2019-000805, Units 1 and 2, operations support center HVAC sensor failure on
        February 14, 2019
(3)  
  (5)   CR-2019-002132, Unit 1, environmental qualification of service water valves with
TR-2019-001119, Units 1 and 2, tornado missile evaluation for equipment storage on  
        teflon components on March 12, 2019
February 13, 2019  
71111.17T - Evaluations of Changes, Tests, and Experiments
  Sample Selection (IP Section 02.01) (35 Samples)
(4)  
  The inspectors reviewed the following evaluations (items 1 through 8), screenings, and/or
TR-2019-000805, Units 1 and 2, operations support center HVAC sensor failure on  
  applicability determinations for 10 CFR 50.59 from September 30, 2016, to
February 14, 2019  
  January 14, 2019.
  (1)   EV-CR-2016-001706-8, Revision1; FDA-2016-000025-01 temporary modification of
(5)  
        2RC-8054A to repair a leak on pressurizer 01 Pressure Transmitter.
CR-2019-002132, Unit 1, environmental qualification of service water valves with  
  (2)   AEV-CR-2016-005587-9; FDA-2016-000142-01, LDCR SA-2016-013 and
teflon components on March 12, 2019  
        LDC R TR-2016-003, Missile Probability Analysis Revision.
  (3)   EV-TR-2017-003173-5 ABN-104, Revision 9; PCN-9 addition of alternate residual
71111.17T - Evaluations of Changes, Tests, and Experiments  
        heat removal path and use of safety injection pump for core cooling in Mode 6.
  (4)   EV-TR-2017-007959-13; Perform 50.59 Evaluation for FDA-2017-000106-02
Sample Selection (IP Section 02.01) (35 Samples)  
        Generator Repair Plan and 59SC-2017-000106-02.
  (5)   EV-2014-013052-9; Modification to change the isolated phase bus cooling fans start
The inspectors reviewed the following evaluations (items 1 through 8), screenings, and/or  
        logic to provide seven out of eight dampers open requirement using digital
applicability determinations for 10 CFR 50.59 from September 30, 2016, to  
        equipment.
January 14, 2019.  
  (6)   EV-CR-2016-003267-10; FDA-2016-000075-01 Unit 1 pressurizer instrument
        isolation valves class change (LDCR-SA-2016-010).
(1)  
  (7)   EV-TR-2018-004520-14; Evaluate operator action for isolation of faulted battery
EV-CR-2016-001706-8, Revision1; FDA-2016-000025-01 temporary modification of
        charger from its battery per 50.59 screen EV-TR-2018-004520-13.
2RC-8054A to repair a leak on pressurizer 01 Pressure Transmitter.  
  (8)   EV-CR-2017-004574-2; 59SC - STA-707-1 50.59 screen for 2RF16 changes to
        procedures for reactor vessel head and upper internals lifts.
(2)  
  (9)   EV-TR-2015-006849-4; 59SC - Provide 50.59 SC to support DCP-17-000010 to input
AEV-CR-2016-005587-9; FDA-2016-000142-01, LDCR SA-2016-013 and  
        FZ locations of raceways and equipment into GENESIS in support of
LDC R TR-2016-003, Missile Probability Analysis Revision.  
        ME-CA-0000-1086 revision.
  (10) EV-TR-2018-004520-10; 59SC - Perform a 50.59 screen for a compensatory
(3)  
        measure to jumper battery cell.
EV-TR-2017-003173-5 ABN-104, Revision 9; PCN-9 addition of alternate residual  
                                              10
heat removal path and use of safety injection pump for core cooling in Mode 6.  
(4)  
EV-TR-2017-007959-13; Perform 50.59 Evaluation for FDA-2017-000106-02  
Generator Repair Plan and 59SC-2017-000106-02.  
(5)  
EV-2014-013052-9; Modification to change the isolated phase bus cooling fans start  
logic to provide seven out of eight dampers open requirement using digital  
equipment.  
(6)  
EV-CR-2016-003267-10; FDA-2016-000075-01 Unit 1 pressurizer instrument  
isolation valves class change (LDCR-SA-2016-010).  
(7)  
EV-TR-2018-004520-14; Evaluate operator action for isolation of faulted battery  
charger from its battery per 50.59 screen EV-TR-2018-004520-13.  
(8)  
EV-CR-2017-004574-2; 59SC - STA-707-1 50.59 screen for 2RF16 changes to  
procedures for reactor vessel head and upper internals lifts.  
(9)  
EV-TR-2015-006849-4; 59SC - Provide 50.59 SC to support DCP-17-000010 to input  
FZ locations of raceways and equipment into GENESIS in support of
ME-CA-0000-1086 revision.  
(10)  
EV-TR-2018-004520-10; 59SC - Perform a 50.59 screen for a compensatory  
measure to jumper battery cell.  


(11) EV-CR-2014-003412-18; 59SC - Perform 50.59 applicability determination and
    screen for additional plugging for component cooling water heat exchanger 2-01 in
11
    2RF14.
(12) EV-TR-2018-003799-6; Perform 10CFR50.59 review of minor fuel design changes
(11)  
    documented in NF-TB-16-21.
EV-CR-2014-003412-18; 59SC - Perform 50.59 applicability determination and  
(13) EV-TR-2018-003700-2; Refer to the attached VDRT package which contains the
screen for additional plugging for component cooling water heat exchanger 2-01 in  
    requested screen and complete VDRT-5608075 package for valve XWT-0634.
2RF14.  
(14) EV-TR-2018-000169-4; 50.59 screen for backseating of 1MS-0357, SG 1-03
    blowdown downstream isolation valve.
(12)  
(15) EV-TR-2018-000198-1; Maintenance clearance placed for isolation of 1-LG-2706A
EV-TR-2018-003799-6; Perform 10CFR50.59 review of minor fuel design changes  
    may exceed 90 days.
documented in NF-TB-16-21.
(16) EV-TR-2018-000199-1; Maintenance clearance placed for diesel generator starting
    compressor solenoid 1-SV-3422-1F may exceed 90 days.
(13)  
(17) EV-TR-2018-000600-1; Shift manager clearance placed to isolate TBX-CSFLSI-01
EV-TR-2018-003700-2; Refer to the attached VDRT package which contains the  
    seal water injection filter 01.
requested screen and complete VDRT-5608075 package for valve XWT-0634.  
(18) EV-CR-2016-008147-3; Compensatory action of installing scaffolding for medium
    energy line break (MELB) barrier.
(14)  
(19) EV-CR-2017-007829-1; 59SC - Compensatory actions to install temporary equipment
EV-TR-2018-000169-4; 50.59 screen for backseating of 1MS-0357, SG 1-03  
    for flow measurement.
blowdown downstream isolation valve.  
(20) EV-CR-2017-010212-1; 59SC - Shift manager clearance CP17-0913 due to
    feedpump deluge valve not resetting.
(15)  
(21) EV-CR-2017-012952-28; 59SC - Shift manager clearance to remove fuses 2-
EV-TR-2018-000198-1; Maintenance clearance placed for isolation of 1-LG-2706A  
    KXA/0746 and 2-KXB/0746.
may exceed 90 days.  
(22) EV-CR-2018-004743-2; 59SC - Compensatory action to blow down the receiver once
    per shift.
(16)  
(23) EV-TR-2016-005840-10; 59SC - VDRT-5575487 Which includes vendor final
EV-TR-2018-000199-1; Maintenance clearance placed for diesel generator starting  
    acceptance tests for open phase protection equipment for XST1.
compressor solenoid 1-SV-3422-1F may exceed 90 days.  
(24) EV-TR-2017-000041-32; 59SC - VDRT-5397434, Fuel transfer system transfer cart
    weldment.
(17)  
(25) EV-TR-2017-003173-4; 59SC - Review for revision to ABN-104 based on
EV-TR-2018-000600-1; Shift manager clearance placed to isolate TBX-CSFLSI-01  
    EV-TR-2017-003173-3 for loss of residual heat removal events.
seal water injection filter 01.  
(26) EV-CR-2018-002390-5; 59SC - Changes made under EV-CR-2018-002390-4.
(27) EV-CR-2018-006758-1; 59SC - Screen for the compensatory action for average
(18)  
    containment temperature.
EV-CR-2016-008147-3; Compensatory action of installing scaffolding for medium  
                                          11
energy line break (MELB) barrier.  
(19)  
EV-CR-2017-007829-1; 59SC - Compensatory actions to install temporary equipment  
for flow measurement.  
(20)  
EV-CR-2017-010212-1; 59SC - Shift manager clearance CP17-0913 due to  
feedpump deluge valve not resetting.  
(21)  
EV-CR-2017-012952-28; 59SC - Shift manager clearance to remove fuses 2-
KXA/0746 and 2-KXB/0746.  
(22)  
EV-CR-2018-004743-2; 59SC - Compensatory action to blow down the receiver once  
per shift.  
(23)  
EV-TR-2016-005840-10; 59SC - VDRT-5575487 Which includes vendor final  
acceptance tests for open phase protection equipment for XST1.  
(24)  
EV-TR-2017-000041-32; 59SC - VDRT-5397434, Fuel transfer system transfer cart  
weldment.  
(25)  
EV-TR-2017-003173-4; 59SC - Review for revision to ABN-104 based on
EV-TR-2017-003173-3 for loss of residual heat removal events.  
(26)  
EV-CR-2018-002390-5; 59SC - Changes made under EV-CR-2018-002390-4.  
(27)  
EV-CR-2018-006758-1; 59SC - Screen for the compensatory action for average  
containment temperature.  


  (28) EV-CR-2018-007384-1; 59SC - Perform 50.59 screen changes to procedures
        OPT-612B and OPT-613B.
12
  (29) EV-CR-2016-007812-1; 59SC - Perform a 10CFR50.59 Review per STA-707 to
        update UFSAR Table 9.5-18 to specify tube plugging limit for diesel generator jacket
(28)  
        water coolers for Unit 1 and Unit 2.
EV-CR-2018-007384-1; 59SC - Perform 50.59 screen changes to procedures
  (30) EV-TR-2018-008391-16; 59SC - Perform a 10CFR50.59 Review per STA-707 to plug
OPT-612B and OPT-613B.  
        tubes in the component cooling water heat exchangers.
  (31) EV-CR-2018-002189-2; 59SC - 50.59 screen for compensatory action to maintain
(29)  
        2-HV-2334A accumulator pressure above 2100psi.
EV-CR-2016-007812-1; 59SC - Perform a 10CFR50.59 Review per STA-707 to  
  (32) EV-CR-2016-008215-20; 59SC - 50.59 review of compensatory measures to isolate
update UFSAR Table 9.5-18 to specify tube plugging limit for diesel generator jacket  
        suction and discharge pressure indication on CT and SF pumps;
water coolers for Unit 1 and Unit 2.  
        ref: EV-CR-2016-008215-19.
  (33) EV-TR-2016-009344-1; 59SC - Shift Manager Clearance CP16-1381 initiated to
(30)  
        maintain X-PV-3218A isolated following failure of a functional stroke; request a
EV-TR-2018-008391-16; 59SC - Perform a 10CFR50.59 Review per STA-707 to plug  
        50.59SC to determine impact on the plant.
tubes in the component cooling water heat exchangers.  
  (34) EV-CR-2018-005954-3; 59SC - Seal injection filters housing bolts and potential
        excessive torque specification VDRT-5655877.
(31)  
  (35) EV-TR-2016-010572-2; 59SC - 59SC - Perform a 50.59 screen for hanging shift
EV-CR-2018-002189-2; 59SC - 50.59 screen for compensatory action to maintain
        manager clearance CP16-1614 on 2-HS-2802A for damage to upper journal bearings
2-HV-2334A accumulator pressure above 2100psi.  
        on the motor for Circulating Water Pump Motor 2-03.
71111.18 - Plant Modifications
(32)  
  Temporary Modifications and/or Permanent Modifications (IP Section 03.01 and/or 03.02)
EV-CR-2016-008215-20; 59SC - 50.59 review of compensatory measures to isolate  
  (2 Samples)
suction and discharge pressure indication on CT and SF pumps;  
  The inspectors evaluated the following temporary or permanent modifications:
ref: EV-CR-2016-008215-19.  
  (1)   Unit 2, pressurizer power operated relief valve accumulator pressure setpoint
        modification on February 14, 2019
(33)  
  (2)   bladder addition to safety-related tanks on March 11, 2019
EV-TR-2016-009344-1; 59SC - Shift Manager Clearance CP16-1381 initiated to  
71111.19 - Post Maintenance Testing
maintain X-PV-3218A isolated following failure of a functional stroke; request a  
  Post Maintenance Test Sample (IP Section 03.01) (5 Samples)
50.59SC to determine impact on the plant.  
  The inspectors evaluated the following post maintenance tests:
  (1)   Unit 2, diesel generator 2-02 following intercooler crack and jacket water repair on
(34)  
        February 12, 2019
EV-CR-2018-005954-3; 59SC - Seal injection filters housing bolts and potential  
  (2)   Unit 2, pressurizer spray valve following actuator rebuild on February 20, 2019
excessive torque specification VDRT-5655877.  
                                              12
(35)  
EV-TR-2016-010572-2; 59SC - 59SC - Perform a 50.59 screen for hanging shift  
manager clearance CP16-1614 on 2-HS-2802A for damage to upper journal bearings  
on the motor for Circulating Water Pump Motor 2-03.  
71111.18 - Plant Modifications  
Temporary Modifications and/or Permanent Modifications (IP Section 03.01 and/or 03.02)
(2 Samples)  
The inspectors evaluated the following temporary or permanent modifications:  
(1)  
Unit 2, pressurizer power operated relief valve accumulator pressure setpoint  
modification on February 14, 2019  
(2)  
bladder addition to safety-related tanks on March 11, 2019  
71111.19 - Post Maintenance Testing  
Post Maintenance Test Sample (IP Section 03.01) (5 Samples)  
The inspectors evaluated the following post maintenance tests:  
(1)  
Unit 2, diesel generator 2-02 following intercooler crack and jacket water repair on  
February 12, 2019
(2)  
Unit 2, pressurizer spray valve following actuator rebuild on February 20, 2019  


  (3)   Unit 1, diesel generator 1-01 following fuel injector torqueing on March 13, 2019
  (4)   Unit 2, residual heat removal pump 2-02 following pump refurbishment on
13
          March 19, 2019
  (5)   Unit 2, auxiliary feedwater pump 2-01 following maintenance on March 20, 2019
(3)  
71111.20 - Refueling and Other Outage Activities
Unit 1, diesel generator 1-01 following fuel injector torqueing on March 13, 2019  
  Refueling/Other Outage Sample (IP Section 03.01) (1 Sample)
  The inspectors evaluated refueling outage 2RF17 activities from January 1, 2019, to
(4)  
  January 18, 2019, completing the sample for the refueling outage which started on
Unit 2, residual heat removal pump 2-02 following pump refurbishment on  
  December 8, 2018 (see Inspection Report 05000445/2018004; 05000446/2018004 (ADAMS
March 19, 2019  
  Accession No. ML19042A345)). Specifically, the inspectors completed Inspection
  Procedure 71111.20, Sections 03.01.d through e, during this inspection period.
(5)  
71111.22 - Surveillance Testing
Unit 2, auxiliary feedwater pump 2-01 following maintenance on March 20, 2019  
The inspectors evaluated the following surveillance tests:
  Containment Isolation Valve (ISO) (IP Section 03.01) (1 Sample)
71111.20 - Refueling and Other Outage Activities  
  Unit 2, service air containment isolation valve test on March 7, 2019
  Surveillance Testing (IP Section 03.01) (1 Sample)
Refueling/Other Outage Sample (IP Section 03.01) (1 Sample)  
  Unit 2, OPT-601B auxiliary feedwater flow control valve accumulator pressure drop test on
  March 26, 2019
The inspectors evaluated refueling outage 2RF17 activities from January 1, 2019, to  
OTHER ACTIVITIES - BASELINE
January 18, 2019, completing the sample for the refueling outage which started on  
71151 - Performance Indicator Verification
December 8, 2018 (see Inspection Report 05000445/2018004; 05000446/2018004 (ADAMS  
The inspectors verified licensee performance indicators submittals listed below:
Accession No. ML19042A345)). Specifically, the inspectors completed Inspection  
  IE01: Unplanned Scrams per 7000 Critical Hours Sample (IP Section 02.01) (2 Samples)
Procedure 71111.20, Sections 03.01.d through e, during this inspection period.  
  (1)   Unit 1 from January 2018 through December 2018
  (2)   Unit 2 from January 2018 through December 2018
71111.22 - Surveillance Testing  
  IE03: Unplanned Power Changes per 7000 Critical Hours Sample (IP Section 02.02)
  (2 Samples)
The inspectors evaluated the following surveillance tests:  
  (1)   Unit 1 from January 2018 through December 2018
  (2)   Unit 2 from January 2018 through December 2018
Containment Isolation Valve (ISO) (IP Section 03.01) (1 Sample)  
                                                13
Unit 2, service air containment isolation valve test on March 7, 2019  
Surveillance Testing (IP Section 03.01) (1 Sample)  
Unit 2, OPT-601B auxiliary feedwater flow control valve accumulator pressure drop test on  
March 26, 2019  
OTHER ACTIVITIES - BASELINE  
71151 - Performance Indicator Verification  
The inspectors verified licensee performance indicators submittals listed below:  
IE01: Unplanned Scrams per 7000 Critical Hours Sample (IP Section 02.01) (2 Samples)  
(1)  
Unit 1 from January 2018 through December 2018  
(2)  
Unit 2 from January 2018 through December 2018  
IE03: Unplanned Power Changes per 7000 Critical Hours Sample (IP Section 02.02)
(2 Samples)  
(1)  
Unit 1 from January 2018 through December 2018  
(2)  
Unit 2 from January 2018 through December 2018  


  IE04: Unplanned Scrams with Complications (USwC) Sample (IP Section 02.03)
  (2 Samples)
14
  (1)     Unit 1 from January 2018 through December 2018
  (2)     Unit 2 from January 2018 through December 2018
IE04: Unplanned Scrams with Complications (USwC) Sample (IP Section 02.03)
71152 - Problem Identification and Resolution
(2 Samples)  
  Annual Follow-up of Selected Issues (IP Section 02.03) (2 Samples)
  The inspectors reviewed the licensees implementation of its corrective action program
(1)  
  related to the following issues:
Unit 1 from January 2018 through December 2018  
  (1)     radiation monitor failures due to failure to install a jumper during maintenance on
(2)  
          February 28, 2019
Unit 2 from January 2018 through December 2018  
  (2)     safety injection accumulator discharge due to inadequate procedure on
          March 29, 2019
71152 - Problem Identification and Resolution  
71153 - Follow-up of Events and Notices of Enforcement Discretion
  Event Report (IP Section 03.02) (1 Sample)
Annual Follow-up of Selected Issues (IP Section 02.03) (2 Samples)  
  The inspectors evaluated the following licensee event reports which can be accessed at
  https://lersearch.inl.gov/LERSearchCriteria.aspx:
The inspectors reviewed the licensees implementation of its corrective action program  
  (1)     Licensee Event Report 05000446/2018-001-00, "Unit 2 Automatic Reactor Trip Due
related to the following issues:  
          to Turbine Trip," on March 19, 2019
  The inspectors determined that it was not reasonable to foresee or correct the cause
(1)  
  discussed in the LER; therefore, no performance deficiency was identified. The inspectors
radiation monitor failures due to failure to install a jumper during maintenance on  
  also concluded that no violation of NRC requirements occurred.
February 28, 2019  
OTHER ACTIVITIES - TEMPORARY INSTRUCTIONS, INFREQUENT AND ABNORMAL
92702 - Follow-up on Corrective Actions for Violations And Deviations
(2)  
  Follow-up - Corrective Actions - Violations and Deviations (1 Sample)
safety injection accumulator discharge due to inadequate procedure on  
  On March 28, 2019, the inspectors reviewed the licensees response to
March 29, 2019  
  NOV 05000446/2018011-01, "Failure to Maintain a Quality Record Complete and Accurate
  in All Material Respects," and determined that the reason for the violation, corrective actions
71153 - Follow-up of Events and Notices of Enforcement Discretion  
  taken and planned to address recurrence, and the date when full compliance will be
  achieved for this violation is adequately addressed and captured on the docket.
Event Report (IP Section 03.02) (1 Sample)  
                                                  14
The inspectors evaluated the following licensee event reports which can be accessed at  
https://lersearch.inl.gov/LERSearchCriteria.aspx:  
(1)  
Licensee Event Report 05000446/2018-001-00, "Unit 2 Automatic Reactor Trip Due  
to Turbine Trip," on March 19, 2019  
The inspectors determined that it was not reasonable to foresee or correct the cause  
discussed in the LER; therefore, no performance deficiency was identified. The inspectors  
also concluded that no violation of NRC requirements occurred.
OTHER ACTIVITIES - TEMPORARY INSTRUCTIONS, INFREQUENT AND ABNORMAL  
92702 - Follow-up on Corrective Actions for Violations And Deviations  
Follow-up - Corrective Actions - Violations and Deviations (1 Sample)  
On March 28, 2019, the inspectors reviewed the licensees response to  
NOV 05000446/2018011-01, "Failure to Maintain a Quality Record Complete and Accurate  
in All Material Respects," and determined that the reason for the violation, corrective actions  
taken and planned to address recurrence, and the date when full compliance will be  
achieved for this violation is adequately addressed and captured on the docket.  


INSPECTION RESULTS
  Inadequate Corrective Actions for Failure to Ensure Containment Hatch Closure Capability
15
Cornerstone           Significance                               Cross-cutting       Report
                                                                  Aspect              Section
INSPECTION RESULTS  
Barrier Integrity     Green                                     [H.6] - Design      71111.04
   
                        NCV 05000445; 05000446/2019001-           Margins
Inadequate Corrective Actions for Failure to Ensure Containment Hatch Closure Capability  
                        01
Cornerstone  
                        Closed
Significance  
The inspectors identified a Green non-cited violation of 10 CFR Part 50, Appendix B,
Cross-cutting  
Criterion XVI, Corrective Actions, associated with the licensees failure to take adequate
Aspect
corrective actions for an inadequate containment closure procedure. Specifically, in
Report  
December 2017, the NRC identified that the licensee's procedure for emergency closure of
Section  
the Units 1 and 2 containment equipment hatches was inadequate and the licensee failed to
Barrier Integrity  
take adequate actions to correct the issue prior to the next outage.
Description: In Inspection Report 2017-004, the NRC documented a non-cited violation for an
Green  
inadequate procedure, STI 600.01, "Protecting Plant Equipment and Sensitive Equipment
NCV 05000445; 05000446/2019001-
Controls." This procedure contained instructions for emergency closure of the containment
01
equipment hatch during times when the hatch was open, but the ability to close containment
Closed
was required. The inspectors observed that the bolting pattern and required torque that were
[H.6] - Design
identified in the supporting engineering calculation were not incorporated into the procedure.
Margins
The licensees technical evaluation required four bolts spaced 90 degrees apart and torqued
71111.04
to 30 percent preload values. The procedure did not require bolts to be evenly spaced and
The inspectors identified a Green non-cited violation of 10 CFR Part 50, Appendix B,  
only required the bolts to be snug tight, a licensee term implying full effort on the tool being
Criterion XVI, Corrective Actions, associated with the licensees failure to take adequate  
used. The licensee entered this into their corrective action program. Subsequently, the
corrective actions for an inadequate containment closure procedure. Specifically, in  
licensee performed an evaluation to justify alternate bolt spacing patterns and revised the
December 2017, the NRC identified that the licensee's procedure for emergency closure of  
procedure to include adequate bolting patterns. However, in their evaluation the licensee
the Units 1 and 2 containment equipment hatches was inadequate and the licensee failed to  
stated that no torque requirement existed, and the requirement was only to hold the hatch in
take adequate actions to correct the issue prior to the next outage.  
place.
Description: In Inspection Report 2017-004, the NRC documented a non-cited violation for an  
  The inspectors observed the containment hatch closure training during Refueling
inadequate procedure, STI 600.01, "Protecting Plant Equipment and Sensitive Equipment  
Outage 2RF17. The inspectors observed that the bolt patterns used conformed to the revised
Controls." This procedure contained instructions for emergency closure of the containment  
procedure and evaluation, but that the hatch operators did not appear to apply any torque to
equipment hatch during times when the hatch was open, but the ability to close containment  
the bolts. When the inspectors asked about the bolts, the operators believed that there was
was required. The inspectors observed that the bolting pattern and required torque that were  
no requirement to apply any torque beyond that needed to hold the hatch in place.
identified in the supporting engineering calculation were not incorporated into the procedure.
  The inspectors determined that by not applying any type of torque to the bolts, the licensee
The licensees technical evaluation required four bolts spaced 90 degrees apart and torqued  
was not verifying that the containment equipment hatch could be sealed. A seal is necessary
to 30 percent preload values. The procedure did not require bolts to be evenly spaced and  
to ensure that a release of fission product radioactivity within containment will be restricted
only required the bolts to be snug tight, a licensee term implying full effort on the tool being  
from escaping to the environment in the event of a loss of decay heat removal event when the
used. The licensee entered this into their corrective action program. Subsequently, the  
reactor coolant system was open to the atmosphere.
licensee performed an evaluation to justify alternate bolt spacing patterns and revised the  
The licensee performed another evaluation and concluded that the minimum torque required
procedure to include adequate bolting patterns. However, in their evaluation the licensee  
to ensure a seal with four bolts was 144 ft-lbf. The licensee conducted additional training with
stated that no torque requirement existed, and the requirement was only to hold the hatch in  
all hatch operators on the requirement to ensure a seal on the hatch. They also conducted a
place.  
demonstration with the assigned operators and concluded that the average operator applying
   
full effort would achieve greater than 150 ft-lbf.
The inspectors observed the containment hatch closure training during Refueling  
                                                  15
Outage 2RF17. The inspectors observed that the bolt patterns used conformed to the revised  
procedure and evaluation, but that the hatch operators did not appear to apply any torque to  
the bolts. When the inspectors asked about the bolts, the operators believed that there was  
no requirement to apply any torque beyond that needed to hold the hatch in place.  
   
The inspectors determined that by not applying any type of torque to the bolts, the licensee  
was not verifying that the containment equipment hatch could be sealed. A seal is necessary  
to ensure that a release of fission product radioactivity within containment will be restricted  
from escaping to the environment in the event of a loss of decay heat removal event when the  
reactor coolant system was open to the atmosphere.  
 
The licensee performed another evaluation and concluded that the minimum torque required  
to ensure a seal with four bolts was 144 ft-lbf. The licensee conducted additional training with  
all hatch operators on the requirement to ensure a seal on the hatch. They also conducted a  
demonstration with the assigned operators and concluded that the average operator applying  
full effort would achieve greater than 150 ft-lbf.  
 


Corrective Action(s): The licensee trained the operators on the requirement to ensure the
bolts were adequately torqued and verified through demonstration that the operators could
16
apply enough torque to ensure the hatch would be sealed.
Corrective Action Reference(s): CR-2018-008300, CR-2019-002533
Corrective Action(s): The licensee trained the operators on the requirement to ensure the  
Performance Assessment:
bolts were adequately torqued and verified through demonstration that the operators could  
Performance Deficiency: The inability to assure containment closure during a postulated loss
apply enough torque to ensure the hatch would be sealed.  
of decay heat removal or fuel handling accident was a condition adverse to quality. The
 
failure to correct a condition adverse to quality is a performance deficiency.
Corrective Action Reference(s): CR-2018-008300, CR-2019-002533  
Screening: The inspectors determined the performance deficiency was more than minor
because it was associated with the SSC and barrier performance attribute of the Barrier
Performance Assessment:  
Integrity Cornerstone. It adversely affected the cornerstone objective to provide reasonable
 
assurance that physical design barriers (fuel cladding, reactor coolant system, and
Performance Deficiency: The inability to assure containment closure during a postulated loss  
containment) protect the public from radionuclide releases caused by accidents or events
of decay heat removal or fuel handling accident was a condition adverse to quality. The  
because the finding represented a loss of reasonable assurance of the ability to close the
failure to correct a condition adverse to quality is a performance deficiency.  
containment equipment hatch. Specifically, the failure to assure that personnel would
 
adequately torque the bolts on the hatch sufficient to establish a seal would, in an actual
Screening: The inspectors determined the performance deficiency was more than minor  
event, result in a loss of the containment barrier.
because it was associated with the SSC and barrier performance attribute of the Barrier  
Significance: The inspectors assessed the significance of the finding using Appendix H,
Integrity Cornerstone. It adversely affected the cornerstone objective to provide reasonable  
Containment Integrity SDP. Using Inspection Manual Chapter 0609, Attachment 04, Initial
assurance that physical design barriers (fuel cladding, reactor coolant system, and  
Characterization of Findings, dated October 7, 2016, the inspectors determined the finding
containment) protect the public from radionuclide releases caused by accidents or events  
was associated with the Barrier Integrity cornerstone. Using Inspection Manual
because the finding represented a loss of reasonable assurance of the ability to close the  
Chapter 0609, Appendix G, Attachment 1, Shutdown Operations Significance Determination
containment equipment hatch. Specifically, the failure to assure that personnel would  
Process Phase 1 Initial Screening and Characterization of Findings, Exhibit 4, Barrier
adequately torque the bolts on the hatch sufficient to establish a seal would, in an actual  
Integrity Screening Questions, the inspectors determined the finding degraded the ability to
event, result in a loss of the containment barrier.  
close or isolate containment and required evaluation under Inspection Manual Chapter 0609,
 
Appendix H, Containment Integrity Significance Determination Process, dated
Significance: The inspectors assessed the significance of the finding using Appendix H,  
February 25, 2019. Using the Large Early Release Frequency (LERF) type screening
Containment Integrity SDP. Using Inspection Manual Chapter 0609, Attachment 04, Initial  
process, the inspectors determined the finding was a Type B LERF finding because the
Characterization of Findings, dated October 7, 2016, the inspectors determined the finding  
finding did not affect core damage frequency. The inspectors used
was associated with the Barrier Integrity cornerstone. Using Inspection Manual  
Table 7.3, Phase 1 Screening - Type B Findings at Shutdown, and determined that a
Chapter 0609, Appendix G, Attachment 1, Shutdown Operations Significance Determination  
Phase 2 estimate was required because the containment equipment hatch affected
Process Phase 1 Initial Screening and Characterization of Findings, Exhibit 4, Barrier  
containment isolation, which is a system important to LERF. The inspectors used Table 7.4,
Integrity Screening Questions, the inspectors determined the finding degraded the ability to  
Phase 2 Risk Significance - Type B Findings at Shutdown, to determine the finding was of
close or isolate containment and required evaluation under Inspection Manual Chapter 0609,  
very low safety significance (Green) because it did not meet the threshold for low safety
Appendix H, Containment Integrity Significance Determination Process, dated  
significance (White) for leakage from containment to the environment being greater than
February 25, 2019. Using the Large Early Release Frequency (LERF) type screening  
100 percent containment volume per day through containment penetration seals, isolation
process, the inspectors determined the finding was a Type B LERF finding because the  
valves, or vent and purge systems. Specifically, the licensee was able to demonstrate
finding did not affect core damage frequency. The inspectors used
through calculations that the leakage from the containment hatch being closed, but not
Table 7.3, Phase 1 Screening - Type B Findings at Shutdown, and determined that a
sealed, would be no more than 30 percent of the containment volume per day.
Phase 2 estimate was required because the containment equipment hatch affected  
Cross-cutting Aspect: H.6 - Design Margins: The organization operates and maintains
containment isolation, which is a system important to LERF. The inspectors used Table 7.4,  
equipment within design margins. Margins are carefully guarded and changed only through a
Phase 2 Risk Significance - Type B Findings at Shutdown, to determine the finding was of  
systematic and rigorous process. Special attention is placed on maintaining fission product
very low safety significance (Green) because it did not meet the threshold for low safety  
barriers, defense-in-depth, and safety-related equipment. Specifically, the licensee
significance (White) for leakage from containment to the environment being greater than  
incorrectly assumed that a seal on the containment hatch was not required at the onset of an
100 percent containment volume per day through containment penetration seals, isolation  
                                                16
valves, or vent and purge systems. Specifically, the licensee was able to demonstrate  
through calculations that the leakage from the containment hatch being closed, but not  
sealed, would be no more than 30 percent of the containment volume per day.  
Cross-cutting Aspect: H.6 - Design Margins: The organization operates and maintains  
equipment within design margins. Margins are carefully guarded and changed only through a  
systematic and rigorous process. Special attention is placed on maintaining fission product  
barriers, defense-in-depth, and safety-related equipment. Specifically, the licensee  
incorrectly assumed that a seal on the containment hatch was not required at the onset of an  


accident and that the increased pressure in containment during an accident could be credited
for making a seal on the hatch.
17
Enforcement:
Violation: 10 CFR Part 50, Appendix B, Criterion XVI, "Corrective Action," requires in part
accident and that the increased pressure in containment during an accident could be credited  
that conditions adverse to quality are promptly identified and corrected. Contrary to the
for making a seal on the hatch.  
above, from December 2017 to December 2018, the licensee failed to promptly correct a
condition adverse to quality. Specifically, the licensee failed to implement adequate
Enforcement:  
corrective actions for an inadequate procedure for emergency containment closure to ensure
 
the containment was sealed, an activity affecting quality.
Violation: 10 CFR Part 50, Appendix B, Criterion XVI, "Corrective Action," requires in part  
Enforcement Action: This violation is being treated as a Non-Cited Violation, consistent with
that conditions adverse to quality are promptly identified and corrected. Contrary to the  
Section 2.3.2 of the Enforcement Policy.
above, from December 2017 to December 2018, the licensee failed to promptly correct a  
Failure to Evaluate a Change to the Facility DC Power System
condition adverse to quality. Specifically, the licensee failed to implement adequate  
Cornerstone       SL-IV                                               Cross-cutting Report
corrective actions for an inadequate procedure for emergency containment closure to ensure  
                                                                      Aspect          Section
the containment was sealed, an activity affecting quality.  
Not Applicable NCV 05000445/2019001-02                                 Not             71111.04
                  Closed                                              Applicable
Enforcement Action: This violation is being treated as a Non-Cited Violation, consistent with  
The inspectors identified a Severity Level IV, non-cited violation of 10 CFR 50.59 for the
Section 2.3.2 of the Enforcement Policy.  
licensees failure to obtain a license amendment or perform a written evaluation
demonstrating the basis for not obtaining a license amendment prior to making a change to
Failure to Evaluate a Change to the Facility DC Power System  
the facility as described in the final safety analysis report.
Cornerstone  
Description: The inspectors reviewed the plant configuration of two common Class 1E DC
SL-IV  
power panels that can be powered from either the Unit 1 or Unit 2 Class 1E DC busses. The
Cross-cutting  
inspectors found that the licensee has shared systems for both units that receive power from
Aspect
these panels. The panels also have Unit 1 safety-related systems powered from the panels.
Report  
The inspectors noted that shared systems must meet the requirements of 10 CFR Part 50,
Section  
Appendix A, Criterion 5, which states, in part, that structures, systems, and components
Not Applicable  
important to safety shall not be shared among nuclear power units unless it can be shown
NCV 05000445/2019001-02
that such sharing will not significantly impair their ability to perform their safety functions.
Closed 
The inspectors questioned whether the inclusion of Unit 1 safety-related equipment on the
Not  
common panels constituted acceptable sharing of systems between units.
Applicable
Upon further review, the inspectors determined that the licensee originally committed to
71111.04  
Regulatory Guide (RG) 1.81 to demonstrate compliance with Criterion 5. The licensee, in its
The inspectors identified a Severity Level IV, non-cited violation of 10 CFR 50.59 for the  
Final Safety Analysis Report (FSAR), stated that the DC power sources and electric
licensees failure to obtain a license amendment or perform a written evaluation  
distribution systems were not shared between the two units, and that safety-related loads
demonstrating the basis for not obtaining a license amendment prior to making a change to  
shared between both units are powered from common 125 VDC panels. The NRC in its
the facility as described in the final safety analysis report.  
safety evaluation report concluded that the design as described in the FSAR, with shared
Description: The inspectors reviewed the plant configuration of two common Class 1E DC  
systems being powered from the common panels but no unit-specific safety-related systems
power panels that can be powered from either the Unit 1 or Unit 2 Class 1E DC busses. The  
powered from the common panels, was acceptable.
inspectors found that the licensee has shared systems for both units that receive power from  
In January 2000, the licensee discovered that they had unit-specific safety-related systems
these panels. The panels also have Unit 1 safety-related systems powered from the panels.
from both Units 1 and 2 on the common panels in addition to the previously evaluated shared
The inspectors noted that shared systems must meet the requirements of 10 CFR Part 50,  
systems, contrary to what was described in their FSAR. The licensee entered this design
Appendix A, Criterion 5, which states, in part, that structures, systems, and components  
control issue into the corrective action program. In 2002, the licensee modified the Unit 2
important to safety shall not be shared among nuclear power units unless it can be shown  
systems to align them to Unit 2 power supplies, but left the Unit 1 systems on the common
that such sharing will not significantly impair their ability to perform their safety functions.
panels. The licensee then revised the FSAR to state that they did not comply with RG 1.81,
The inspectors questioned whether the inclusion of Unit 1 safety-related equipment on the  
                                                17
common panels constituted acceptable sharing of systems between units.  
Upon further review, the inspectors determined that the licensee originally committed to  
Regulatory Guide (RG) 1.81 to demonstrate compliance with Criterion 5. The licensee, in its  
Final Safety Analysis Report (FSAR), stated that the DC power sources and electric  
distribution systems were not shared between the two units, and that safety-related loads  
shared between both units are powered from common 125 VDC panels. The NRC in its  
safety evaluation report concluded that the design as described in the FSAR, with shared  
systems being powered from the common panels but no unit-specific safety-related systems  
powered from the common panels, was acceptable.  
In January 2000, the licensee discovered that they had unit-specific safety-related systems  
from both Units 1 and 2 on the common panels in addition to the previously evaluated shared  
systems, contrary to what was described in their FSAR. The licensee entered this design  
control issue into the corrective action program. In 2002, the licensee modified the Unit 2  
systems to align them to Unit 2 power supplies, but left the Unit 1 systems on the common  
panels. The licensee then revised the FSAR to state that they did not comply with RG 1.81,  


but that the existing configuration of Unit 1 systems was an acceptable exception. The
inspectors determined that powering Unit 1 systems from the Unit 2 DC power supply and
18
distribution system constituted a system being shared among units, and that the licensee had
not demonstrated compliance with Criterion 5 for these systems while the panels supplying
but that the existing configuration of Unit 1 systems was an acceptable exception. The  
Unit 1 systems were powered from Unit 2. At the time of the inspection, the common panels
inspectors determined that powering Unit 1 systems from the Unit 2 DC power supply and  
were aligned to Unit 1.
distribution system constituted a system being shared among units, and that the licensee had  
The inspectors determined that the inclusion of Unit 1 systems on panels that shared DC
not demonstrated compliance with Criterion 5 for these systems while the panels supplying  
power systems was a change to the facility as described in the FSAR. The inspectors also
Unit 1 systems were powered from Unit 2. At the time of the inspection, the common panels  
determined that the licensee made the change without performing a written evaluation
were aligned to Unit 1.  
demonstrating that a license amendment would not be required. This impeded the ability of
the agency to perform its regulatory function, requiring disposition using traditional
The inspectors determined that the inclusion of Unit 1 systems on panels that shared DC  
enforcement.
power systems was a change to the facility as described in the FSAR. The inspectors also  
Corrective Action(s): The licensee entered this violation into their corrective action program.
determined that the licensee made the change without performing a written evaluation  
Corrective Action Reference(s): CR-2019-001711
demonstrating that a license amendment would not be required. This impeded the ability of  
Performance Assessment: The inspectors determined this violation was associated with a
the agency to perform its regulatory function, requiring disposition using traditional  
minor performance deficiency.
enforcement.  
Enforcement:
The ROPs significance determination process does not specifically consider the regulatory
Corrective Action(s): The licensee entered this violation into their corrective action program.  
process impact in its assessment of licensee performance. Therefore, it is necessary to
address this violation which impedes the NRCs ability to regulate using traditional
Corrective Action Reference(s): CR-2019-001711  
enforcement to adequately deter non-compliance.
Severity: The violation was determined to be Severity Level IV using section 6.1 of the NRC
Performance Assessment: The inspectors determined this violation was associated with a  
Enforcement Policy, dated May 15, 2018, because it was a violation of 10 CFR 50.59, but did
minor performance deficiency.  
not have a consequence evaluated by the significance determination process as having
Enforcement:  
low-to-moderate or greater safety significance.
The ROPs significance determination process does not specifically consider the regulatory  
Violation: Title 10 CFR 50.59 requires, in part, that if the licensee makes changes to the
process impact in its assessment of licensee performance. Therefore, it is necessary to  
facility as described in the FSAR without obtaining a license amendment, they must maintain
address this violation which impedes the NRCs ability to regulate using traditional  
a written evaluation which provides the basis for determining that the change does not require
enforcement to adequately deter non-compliance.
a licensee amendment. Contrary to the above, in April 2002, the licensee made a change to
the facility as described in the FSAR without obtaining a license amendment, but did not
Severity: The violation was determined to be Severity Level IV using section 6.1 of the NRC  
maintain a written evaluation which provides the basis for determining that the change does
Enforcement Policy, dated May 15, 2018, because it was a violation of 10 CFR 50.59, but did  
not require a licensee amendment.
not have a consequence evaluated by the significance determination process as having  
Enforcement Action: This violation is being treated as a Non-Cited Violation, consistent with
low-to-moderate or greater safety significance.  
Section 2.3.2 of the Enforcement Policy.
                                                18
Violation: Title 10 CFR 50.59 requires, in part, that if the licensee makes changes to the  
facility as described in the FSAR without obtaining a license amendment, they must maintain  
a written evaluation which provides the basis for determining that the change does not require  
a licensee amendment. Contrary to the above, in April 2002, the licensee made a change to  
the facility as described in the FSAR without obtaining a license amendment, but did not  
maintain a written evaluation which provides the basis for determining that the change does  
not require a licensee amendment.  
Enforcement Action: This violation is being treated as a Non-Cited Violation, consistent with  
Section 2.3.2 of the Enforcement Policy.  


Failure to Monitor or Demonstrate Control of Performance Under the Maintenance Rule
Cornerstone           Significance                               Cross-cutting     Report
19
                                                                  Aspect            Section
Mitigating             Green                                     None              71111.12
Failure to Monitor or Demonstrate Control of Performance Under the Maintenance Rule  
Systems                NCV 05000445; 05000446/2019001-03
Cornerstone  
                      Closed
Significance  
The inspectors identified a Green, non-cited violation of 10 CFR 50.65(a)(2), with three
Cross-cutting  
examples, for failure to demonstrate effective control of performance of a maintenance rule
Aspect
scoped system through appropriate preventive maintenance.
Report  
Description: The inspectors identified three examples where the performance of systems,
Section  
structures, and components (SSCs) that were subject to the maintenance rule, was not
Mitigating  
monitored or demonstrated to be effectively controlled through appropriate preventive
Systems
maintenance.
The first example is a violation of 10 CFR 50.65(a)(2) for failure to monitor performance or
Green  
demonstrate effective control of performance for the Class 1E battery chargers. The
NCV 05000445; 05000446/2019001-03
inspectors identified a failure of the 1ED1-1 battery charger to successfully perform a
Closed
maintenance rule function. The battery chargers provide DC power to the class 1E DC
None
busses from the Class 1E AC busses. The vital bus inverters rely on effective control of
71111.12
DC voltage ripple on the battery charger output to allow synchronization with class 1E AC
The inspectors identified a Green, non-cited violation of 10 CFR 50.65(a)(2), with three  
power prior to being placed online. The licensee incorporated a limit of 2 percent voltage
examples, for failure to demonstrate effective control of performance of a maintenance rule  
ripple into the design basis document for the DC system. However, the licensee did not
scoped system through appropriate preventive maintenance.  
perform any testing or preventive maintenance to ensure output voltage ripple remained
Description: The inspectors identified three examples where the performance of systems,  
within limits. As a result, the DC output voltage ripple of the 1ED1-1 battery charger
structures, and components (SSCs) that were subject to the maintenance rule, was not  
exceeded acceptable voltage ripple at some point in its service life, ultimately resulting in a
monitored or demonstrated to be effectively controlled through appropriate preventive  
failure of the supported inverter to return to service on June 5, 2018.
maintenance.  
The licensee determined that the excessive ripple was caused by a failure of a component in
the battery charger, the X-302 printed circuit board (PCB). The PCB had last been replaced
The first example is a violation of 10 CFR 50.65(a)(2) for failure to monitor performance or  
in December 2016 and was scheduled for a 10-year replacement frequency. Subsequent to
demonstrate effective control of performance for the Class 1E battery chargers. The  
that replacement, the licensee documented multiple occurrences where the inverters
inspectors identified a failure of the 1ED1-1 battery charger to successfully perform a  
supported by that charger did not synchronize correctly. The licensee had generated work
maintenance rule function. The battery chargers provide DC power to the class 1E DC  
orders to troubleshoot the inverter but had not completed them prior to the June 2018 failure.
busses from the Class 1E AC busses. The vital bus inverters rely on effective control of  
Following this failure, the licensee performed an evaluation of the event for their maintenance
DC voltage ripple on the battery charger output to allow synchronization with class 1E AC  
rule program. The licensee evaluated the failure as not being a maintenance rule failure
power prior to being placed online. The licensee incorporated a limit of 2 percent voltage  
because the battery charger functions, as written, did not describe providing power to the DC
ripple into the design basis document for the DC system. However, the licensee did not  
busses. The inspectors concluded that the function to provide power to the DC busses was a
perform any testing or preventive maintenance to ensure output voltage ripple remained  
maintenance rule function and that the June 2018 failure was a functional failure.
within limits. As a result, the DC output voltage ripple of the 1ED1-1 battery charger  
Furthermore, because the failure could have been prevented by either performing preventive
exceeded acceptable voltage ripple at some point in its service life, ultimately resulting in a  
maintenance on the battery charger or by completing the troubleshooting work orders, the
failure of the supported inverter to return to service on June 5, 2018.  
failure was maintenance preventable. The June 2018 failure exceeded the established
performance criteria, indicating performance was not being effectively controlled, but the
The licensee determined that the excessive ripple was caused by a failure of a component in  
licensee did not monitor performance or set goals. The licensee entered this issue into the
the battery charger, the X-302 printed circuit board (PCB). The PCB had last been replaced  
corrective action program.
in December 2016 and was scheduled for a 10-year replacement frequency. Subsequent to  
The second example is a violation of 10 CFR 50.65(a)(2) for failure to monitor performance or
that replacement, the licensee documented multiple occurrences where the inverters  
demonstrate effective control of performance for the common low voltage AC power system.
supported by that charger did not synchronize correctly. The licensee had generated work  
The inspectors identified a failure of the common 120 VAC power system to provide Class 1E
orders to troubleshoot the inverter but had not completed them prior to the June 2018 failure.
power to certain important to safety components that are shared between Units 1 and 2. The
Following this failure, the licensee performed an evaluation of the event for their maintenance  
common panels provide power to shared radiation monitors that require Class 1E power to
rule program. The licensee evaluated the failure as not being a maintenance rule failure  
function following an accident, which is covered by the maintenance rule under
because the battery charger functions, as written, did not describe providing power to the DC  
                                                19
busses. The inspectors concluded that the function to provide power to the DC busses was a  
maintenance rule function and that the June 2018 failure was a functional failure.
Furthermore, because the failure could have been prevented by either performing preventive  
maintenance on the battery charger or by completing the troubleshooting work orders, the  
failure was maintenance preventable. The June 2018 failure exceeded the established  
performance criteria, indicating performance was not being effectively controlled, but the  
licensee did not monitor performance or set goals. The licensee entered this issue into the  
corrective action program.  
The second example is a violation of 10 CFR 50.65(a)(2) for failure to monitor performance or  
demonstrate effective control of performance for the common low voltage AC power system.
The inspectors identified a failure of the common 120 VAC power system to provide Class 1E  
power to certain important to safety components that are shared between Units 1 and 2. The  
common panels provide power to shared radiation monitors that require Class 1E power to  
function following an accident, which is covered by the maintenance rule under


10 CFR 50.65(b)(2)(i). The panels can be transferred to non-Class-1E power for
maintenance. Following a planned maintenance activity on Panel XEC1 in October 2016, the
20
licensee was unable to transfer the panel back to its normal Class 1E source due to a failure
of the transfer switch. Because the failure represented an inability to receive power from its
10 CFR 50.65(b)(2)(i). The panels can be transferred to non-Class-1E power for  
Class 1E source, this was a failure to meet its maintenance rule function. The failure was
maintenance. Following a planned maintenance activity on Panel XEC1 in October 2016, the  
maintenance preventable, because the licensee was aware of the potential for these switches
licensee was unable to transfer the panel back to its normal Class 1E source due to a failure  
to fail but did not perform preventive maintenance to address the failures. The licensee
of the transfer switch. Because the failure represented an inability to receive power from its  
incorrectly concluded that the transfer switch failure was not a maintenance preventable
Class 1E source, this was a failure to meet its maintenance rule function. The failure was  
failure of a maintenance rule function, because the common panels were being monitored
maintenance preventable, because the licensee was aware of the potential for these switches  
against plant level performance criteria. The performance of the system cannot be practically
to fail but did not perform preventive maintenance to address the failures. The licensee  
monitored by the use of plant level criteria, because the common low voltage power system
incorrectly concluded that the transfer switch failure was not a maintenance preventable  
could have unlimited maintenance preventable functional failures without ever meeting the
failure of a maintenance rule function, because the common panels were being monitored  
criteria. The licensee entered this issue into the corrective action program.
against plant level performance criteria. The performance of the system cannot be practically  
The third example is a violation of 10 CFR 50.65(a)(2) for failure to monitor performance or
monitored by the use of plant level criteria, because the common low voltage power system  
demonstrate effective control of performance for the inside reactor containment check
could have unlimited maintenance preventable functional failures without ever meeting the  
valves 1(2)CA-0016. Inspectors noted that the performance criteria assigned to the valves
criteria. The licensee entered this issue into the corrective action program.  
was inadequate and that there had been multiple failures of these valves during testing.
These results should have been classified as repeat maintenance preventable functional
The third example is a violation of 10 CFR 50.65(a)(2) for failure to monitor performance or  
failures and caused the system to be classified as 50.65(a)(1), but the system remained in
demonstrate effective control of performance for the inside reactor containment check  
50.65(a)(2) status.
valves 1(2)CA-0016. Inspectors noted that the performance criteria assigned to the valves  
The inspectors noted that the valves were allowed seven failures in a 24-month monitoring
was inadequate and that there had been multiple failures of these valves during testing.  
period. This was determined to be inadequate because the valves were tested on a 30month
These results should have been classified as repeat maintenance preventable functional  
frequency, so the allowed amount of failures could never be exceeded. Additionally, the
failures and caused the system to be classified as 50.65(a)(1), but the system remained in  
inspectors determined that the cause of the valves failures was a known issue, but the
50.65(a)(2) status.  
licensee had not taken action to correct it. Specifically, the valves and system piping are
 
carbon steel and are part of the service air system. The service air system is neither filtered
The inspectors noted that the valves were allowed seven failures in a 24-month monitoring  
nor dried which results in water accumulation in the air system. Water accumulation in the
period. This was determined to be inadequate because the valves were tested on a 30month  
system causes general corrosion in the piping, resulting in wear particles that affect the
frequency, so the allowed amount of failures could never be exceeded. Additionally, the  
valves ability to close. The inspectors determined that the licensee was aware of the failure
inspectors determined that the cause of the valves failures was a known issue, but the  
mechanism, the cause, and a solution for the issue but had prioritized it as a low priority and
licensee had not taken action to correct it. Specifically, the valves and system piping are  
was not considering this when evaluating whether the failures were maintenance preventable.
carbon steel and are part of the service air system. The service air system is neither filtered  
The inspectors determined that the failures were maintenance preventable and as such, were
nor dried which results in water accumulation in the air system. Water accumulation in the  
repeat failures, because the licensee had failed to perform the appropriate modifications to
system causes general corrosion in the piping, resulting in wear particles that affect the  
the system. The licensee entered this issue into the corrective action program.
valves ability to close. The inspectors determined that the licensee was aware of the failure  
In all these cases, the inspectors determined that the failure to demonstrate effective control
mechanism, the cause, and a solution for the issue but had prioritized it as a low priority and  
was caused by incomplete descriptions of the applicable maintenance rule functions, which
was not considering this when evaluating whether the failures were maintenance preventable.
had been developed during initial implementation of the maintenance rule in the 1990s.
The inspectors determined that the failures were maintenance preventable and as such, were  
Corrective Action(s): The licensee entered these three examples into the corrective action
repeat failures, because the licensee had failed to perform the appropriate modifications to  
program and is reviewing the systems performance.
the system. The licensee entered this issue into the corrective action program.  
Corrective Action Reference(s): CR-2018-007884
Performance Assessment:
In all these cases, the inspectors determined that the failure to demonstrate effective control  
Performance Deficiency: The failure to monitor the performance or demonstrate effective
was caused by incomplete descriptions of the applicable maintenance rule functions, which  
control of performance of systems covered by the maintenance rule is a performance
had been developed during initial implementation of the maintenance rule in the 1990s.  
deficiency.
 
                                                20
Corrective Action(s): The licensee entered these three examples into the corrective action  
program and is reviewing the systems performance.  
 
Corrective Action Reference(s): CR-2018-007884  
Performance Assessment:  
 
Performance Deficiency: The failure to monitor the performance or demonstrate effective  
control of performance of systems covered by the maintenance rule is a performance  
deficiency.  


Screening: The inspectors determined the performance deficiency was more than minor
because it was associated with the equipment performance attribute of the Mitigating
21
Systems Cornerstone. It adversely affected the cornerstone objective to ensure the
availability, reliability, and capability of systems that respond to initiating events to prevent
Screening: The inspectors determined the performance deficiency was more than minor  
undesirable consequences (i.e., core damage) because the finding represented a reduction in
because it was associated with the equipment performance attribute of the Mitigating  
the reliability and availability of mitigating systems. Specifically, the failure to monitor the
Systems Cornerstone. It adversely affected the cornerstone objective to ensure the  
performance of the battery chargers resulted in multiple instances of decreased reliability of
availability, reliability, and capability of systems that respond to initiating events to prevent  
the system. The common low voltage power system affected the Emergency Preparedness
undesirable consequences (i.e., core damage) because the finding represented a reduction in  
Cornerstone, and the containment isolation valves affected the Barrier Integrity Cornerstone,
the reliability and availability of mitigating systems. Specifically, the failure to monitor the  
but the Mitigating Systems Cornerstone was selected as the most significant due to the risk
performance of the battery chargers resulted in multiple instances of decreased reliability of  
significance of the battery chargers.
the system. The common low voltage power system affected the Emergency Preparedness  
Significance: The inspectors assessed the significance of the finding using Appendix A,
Cornerstone, and the containment isolation valves affected the Barrier Integrity Cornerstone,  
Significance Determination of Reactor Inspection Findings for At - Power Situations. Using
but the Mitigating Systems Cornerstone was selected as the most significant due to the risk  
Inspection Manual Chapter 0609, Attachment 04, Initial Characterization of Findings, dated
significance of the battery chargers.  
October 7, 2016, the inspectors determined the finding was associated with the Mitigating
 
Systems cornerstone. Using Inspection Manual Chapter 0609, Appendix A, The Significance
Significance: The inspectors assessed the significance of the finding using Appendix A,  
Determination Process (SDP) For Findings At-Power, Exhibit 2, Mitigating Systems
Significance Determination of Reactor Inspection Findings for At - Power Situations. Using  
Screening Questions, the inspectors determined the finding was of very low safety
Inspection Manual Chapter 0609, Attachment 04, Initial Characterization of Findings, dated  
significance (Green) because the finding did not represent an actual loss of function of at
October 7, 2016, the inspectors determined the finding was associated with the Mitigating  
least a single train for greater than its technical specification allowed outage time.
Systems cornerstone. Using Inspection Manual Chapter 0609, Appendix A, The Significance  
Cross-cutting Aspect: No cross-cutting aspect was assigned to this finding because the
Determination Process (SDP) For Findings At-Power, Exhibit 2, Mitigating Systems  
inspectors determined the finding did not reflect present licensee performance.
Screening Questions, the inspectors determined the finding was of very low safety  
Enforcement:
significance (Green) because the finding did not represent an actual loss of function of at  
Violation: 10 CFR 50.65(a)(1), requires, in part, that the holders of an operating license shall
least a single train for greater than its technical specification allowed outage time.  
monitor the performance or condition of structures, systems, or components (SSCs) within the
scope of the rule as defined by 10 CFR 50.65(b), against licensee-established goals, in a
Cross-cutting Aspect: No cross-cutting aspect was assigned to this finding because the  
manner sufficient to provide reasonable assurance that such SSCs are capable of fulfilling
inspectors determined the finding did not reflect present licensee performance.
their intended functions.
10 CFR 50.65(a)(2) states, in part, that monitoring as specified in 10 CFR 50.65(a)(1) is not
Enforcement:  
required where it has been demonstrated that the performance or condition of an SSC is
 
being effectively controlled through the performance of appropriate preventive maintenance,
Violation: 10 CFR 50.65(a)(1), requires, in part, that the holders of an operating license shall  
such that the SSC remains capable of performing its intended function.
monitor the performance or condition of structures, systems, or components (SSCs) within the  
Contrary to the above, as of March 31, 2019, the licensee failed to demonstrate that the
scope of the rule as defined by 10 CFR 50.65(b), against licensee-established goals, in a  
performance of the Class 1E battery chargers, the common 120 VAC power panels, and
manner sufficient to provide reasonable assurance that such SSCs are capable of fulfilling  
containment check valves had been effectively controlled through the performance of
their intended functions.  
appropriate preventive maintenance and did not monitor against licensee-established goals.
Specifically, the licensee failed to identify, and properly account for preventive maintenance
10 CFR 50.65(a)(2) states, in part, that monitoring as specified in 10 CFR 50.65(a)(1) is not  
preventable functional failures of the battery chargers, the common 120 VAC panels, and
required where it has been demonstrated that the performance or condition of an SSC is  
containment check valves occurring from October 2016 to June 2018 which demonstrate that
being effectively controlled through the performance of appropriate preventive maintenance,  
the performance or condition of these SSCs was not being effectively controlled through the
such that the SSC remains capable of performing its intended function.  
performance of appropriate preventive maintenance and, as a result, that goal setting and
monitoring was required.
Contrary to the above, as of March 31, 2019, the licensee failed to demonstrate that the  
Enforcement Action: This violation is being treated as an non-cited violation, consistent with
performance of the Class 1E battery chargers, the common 120 VAC power panels, and  
Section 2.3.2 of the Enforcement Policy.
containment check valves had been effectively controlled through the performance of  
                                                  21
appropriate preventive maintenance and did not monitor against licensee-established goals.
Specifically, the licensee failed to identify, and properly account for preventive maintenance  
preventable functional failures of the battery chargers, the common 120 VAC panels, and  
containment check valves occurring from October 2016 to June 2018 which demonstrate that  
the performance or condition of these SSCs was not being effectively controlled through the  
performance of appropriate preventive maintenance and, as a result, that goal setting and  
monitoring was required.  
Enforcement Action: This violation is being treated as an non-cited violation, consistent with  
Section 2.3.2 of the Enforcement Policy.  


Failure to Control Hazard Barriers During Maintenance
Cornerstone             Significance                             Cross-cutting     Report
22
                                                                Aspect            Section
Mitigating             Green                                   [H.8] -           71111.13
Systems                NCV 05000445/2019001-04                  Procedure
Failure to Control Hazard Barriers During Maintenance  
                        Closed                                  Adherence
Cornerstone  
The inspectors identified a Green, non-cited violation of 10 CFR 50.65(a)4 for failure to
Significance  
implement risk mitigating actions during diesel generator maintenance.
Cross-cutting  
Description: On January 17, 2019, the inspectors observed the licensee performing a
Aspect
maintenance activity to add lube oil to the Unit 1 emergency diesel generator 1-01 sump. In
Report  
order to perform the maintenance, the licensee placed a hose through the normally shut
Section  
door S1-28 from the train A switchgear room to the train A diesel generator room. The door is
Mitigating  
a dogged, two-leaf metal hatch that functions as a barrier for fire, flooding, and medium
Systems
energy line break (MELB) events. Prior to performing the maintenance, the licensee
evaluated the risk of opening the door to allow placement of the hose. The licensee identified
Green  
additional compensatory measures to protect the train A switchgear in an evaluation
NCV 05000445/2019001-04 
documented in Tracking Report (TR) 2019-000001. The licensee determined that the open
Closed 
door did not pose a flood risk and implemented appropriate compensatory measures to
[H.8] -  
mitigate the fire risk. To address the MELB risk, the licensee determined that the open
Procedure  
doorway of the active leaf of door S1-28 could allow a MELB in the diesel generator room to
Adherence  
impact safety-related transformer T1EB3, which provides 480 VAC power to safety-related
71111.13
bus 1EB3. The licensee determined that the transformer would be protected if the workers
The inspectors identified a Green, non-cited violation of 10 CFR 50.65(a)4 for failure to  
maintained door S1-28 open no more than 2 inches, with the door secured to prevent it from
implement risk mitigating actions during diesel generator maintenance.  
opening further. The licensee determined that opening the door for normal ingress and
Description: On January 17, 2019, the inspectors observed the licensee performing a  
egress was acceptable provided the door was secured after personnel passed through. The
maintenance activity to add lube oil to the Unit 1 emergency diesel generator 1-01 sump. In  
evaluation was attached to the work order and a copy was present at the job site.
order to perform the maintenance, the licensee placed a hose through the normally shut  
When the workers began the job, they identified safety concerns with the door being secured
door S1-28 from the train A switchgear room to the train A diesel generator room. The door is  
while personnel were in the diesel generator room. They decided to leave the door open,
a dogged, two-leaf metal hatch that functions as a barrier for fire, flooding, and medium  
assuming that it was acceptable as long as personnel were in the immediate area to close it.
energy line break (MELB) events. Prior to performing the maintenance, the licensee  
When the inspectors arrived at the work site, they noticed the door open with no one passing
evaluated the risk of opening the door to allow placement of the hose. The licensee identified  
through it and questioned the configuration of the door. The inspectors then contacted the
additional compensatory measures to protect the train A switchgear in an evaluation  
control room and the licensee secured the door.
documented in Tracking Report (TR) 2019-000001. The licensee determined that the open  
The licensee determined that crediting actions to close the door post event did not adequately
door did not pose a flood risk and implemented appropriate compensatory measures to  
mitigate the risk of a MELB. As a result of the failure to implement the risk mitigating actions,
mitigate the fire risk. To address the MELB risk, the licensee determined that the open  
the licensee determined that the train A 480 VAC bus 1EB3 was inoperable for
doorway of the active leaf of door S1-28 could allow a MELB in the diesel generator room to  
approximately 3 hours due to the potential for a MELB to spray water on the transformer. The
impact safety-related transformer T1EB3, which provides 480 VAC power to safety-related  
allowable outage time of the bus per Technical Specification 3.8.9 is 8 hours. The licensee
bus 1EB3. The licensee determined that the transformer would be protected if the workers  
determined that the bus did not exceed its allowed outage time due to the hazard barrier
maintained door S1-28 open no more than 2 inches, with the door secured to prevent it from  
being open.
opening further. The licensee determined that opening the door for normal ingress and  
Corrective Action(s): The licensee restored the barrier and entered the issue into the
egress was acceptable provided the door was secured after personnel passed through. The  
corrective action program.
evaluation was attached to the work order and a copy was present at the job site.  
Corrective Action Reference(s): CR-2019-000672
                                              22
When the workers began the job, they identified safety concerns with the door being secured  
while personnel were in the diesel generator room. They decided to leave the door open,  
assuming that it was acceptable as long as personnel were in the immediate area to close it.
When the inspectors arrived at the work site, they noticed the door open with no one passing  
through it and questioned the configuration of the door. The inspectors then contacted the  
control room and the licensee secured the door.  
The licensee determined that crediting actions to close the door post event did not adequately  
mitigate the risk of a MELB. As a result of the failure to implement the risk mitigating actions,  
the licensee determined that the train A 480 VAC bus 1EB3 was inoperable for  
approximately 3 hours due to the potential for a MELB to spray water on the transformer. The  
allowable outage time of the bus per Technical Specification 3.8.9 is 8 hours. The licensee  
determined that the bus did not exceed its allowed outage time due to the hazard barrier  
being open.  
 
Corrective Action(s): The licensee restored the barrier and entered the issue into the  
corrective action program.  
 
Corrective Action Reference(s): CR-2019-000672  


Performance Assessment:
Performance Deficiency: The failure to implement planned risk mitigating actions was a
23
performance deficiency.
Screening: The inspectors determined the performance deficiency was more than minor
Performance Assessment:  
because it was associated with the Configuration Control attribute of the Mitigating Systems
 
cornerstone. It adversely affected the cornerstone objective to ensure the availability,
Performance Deficiency: The failure to implement planned risk mitigating actions was a  
reliability, and capability of systems that respond to initiating events to prevent undesirable
performance deficiency.  
consequences (i.e., core damage) because the finding represented a loss of control of
 
barriers required to ensure the availability of AC power. Specifically, the failure to maintain
Screening: The inspectors determined the performance deficiency was more than minor  
the door in a nearly closed position exposed a Class 1E 480 VAC bus to failure during a
because it was associated with the Configuration Control attribute of the Mitigating Systems  
MELB event, resulting in an electrical distribution train being inoperable for several hours.
cornerstone. It adversely affected the cornerstone objective to ensure the availability,  
Significance: The inspectors assessed the significance of the finding using Appendix K,
reliability, and capability of systems that respond to initiating events to prevent undesirable  
Maintenance Risk Assessment and Risk Management SDP. Using Inspection Manual
consequences (i.e., core damage) because the finding represented a loss of control of  
Chapter 0609, Attachment 04, Initial Characterization of Findings, dated October 7, 2016,
barriers required to ensure the availability of AC power. Specifically, the failure to maintain  
the inspectors determined the finding was associated with the Mitigating Systems
the door in a nearly closed position exposed a Class 1E 480 VAC bus to failure during a  
cornerstone. Using Inspection Manual Chapter 0609, Appendix K, Maintenance Risk
MELB event, resulting in an electrical distribution train being inoperable for several hours.  
Assessment and Risk Management Significance Determination Process, the inspectors
 
determined the finding was associated with risk mitigating actions (RMAs) only. The
Significance: The inspectors assessed the significance of the finding using Appendix K,  
inspectors used Flowcharts 1 and 2 to determine that the finding required a determination of
Maintenance Risk Assessment and Risk Management SDP. Using Inspection Manual  
the incremental core damage probability due to the failure to implement RMAs.
Chapter 0609, Attachment 04, Initial Characterization of Findings, dated October 7, 2016,  
A risk analyst performed a bounding analysis of incremental core damage probability
the inspectors determined the finding was associated with the Mitigating Systems  
assuming that bus 1EB3 was unavailable along with the train A emergency diesel generator
cornerstone. Using Inspection Manual Chapter 0609, Appendix K, Maintenance Risk  
for the entire exposure time when adequate RMAs were not in place. This estimate was
Assessment and Risk Management Significance Determination Process, the inspectors  
bounding because it assumes bus 1EB3 always failed during the exposure time and does not
determined the finding was associated with risk mitigating actions (RMAs) only. The  
incorporate the probabilistic occurrences of fire, flooding, line break, and other events could
inspectors used Flowcharts 1 and 2 to determine that the finding required a determination of  
have rendered bus 1EB3 unavailable, which would result in a lower estimate of incremental
the incremental core damage probability due to the failure to implement RMAs.  
core damage probability. The resulting bounding estimate in the incremental core damage
probability was 8.1E-8. The inspectors determined that the finding was of very low safety
A risk analyst performed a bounding analysis of incremental core damage probability  
significance (Green) because the incremental core damage probability was less than 1E-6
assuming that bus 1EB3 was unavailable along with the train A emergency diesel generator  
and the finding did not affect the large early release probability.
for the entire exposure time when adequate RMAs were not in place. This estimate was  
Cross-cutting Aspect: H.14 - Conservative Bias: Individuals use decision making-practices
bounding because it assumes bus 1EB3 always failed during the exposure time and does not  
that emphasize prudent choices over those that are simply allowable. A proposed action is
incorporate the probabilistic occurrences of fire, flooding, line break, and other events could  
determined to be safe in order to proceed, rather than unsafe in order to stop. Specifically,
have rendered bus 1EB3 unavailable, which would result in a lower estimate of incremental  
the licensee personnel assumed that the controls were not necessary without stopping work
core damage probability. The resulting bounding estimate in the incremental core damage  
and discussing with their supervisor, and did not implement prescribed risk mitigating actions.
probability was 8.1E-8. The inspectors determined that the finding was of very low safety  
Enforcement:
significance (Green) because the incremental core damage probability was less than 1E-6  
Violation: 10 CFR 50.65(a)(4) requires, in part, that the licensee assess and manage the
and the finding did not affect the large early release probability.  
increase in risk that may result from maintenance activities. Contrary to the above, on
January 17, 2019, the licensee failed to manage the increase in risk resulting from a
Cross-cutting Aspect: H.14 - Conservative Bias: Individuals use decision making-practices  
maintenance activity. Specifically, the licensee did not implement planned risk mitigating
that emphasize prudent choices over those that are simply allowable. A proposed action is  
actions that were identified as necessary by the risk assessment.
determined to be safe in order to proceed, rather than unsafe in order to stop. Specifically,  
Enforcement Action: This violation is being treated as a non-cited violation, consistent with
the licensee personnel assumed that the controls were not necessary without stopping work  
Section 2.3.2 of the Enforcement Policy.
and discussing with their supervisor, and did not implement prescribed risk mitigating actions.  
                                                23
Enforcement:  
 
Violation: 10 CFR 50.65(a)(4) requires, in part, that the licensee assess and manage the  
increase in risk that may result from maintenance activities. Contrary to the above, on  
January 17, 2019, the licensee failed to manage the increase in risk resulting from a  
maintenance activity. Specifically, the licensee did not implement planned risk mitigating  
actions that were identified as necessary by the risk assessment.  
Enforcement Action: This violation is being treated as a non-cited violation, consistent with  
Section 2.3.2 of the Enforcement Policy.  


Failure to Follow Procedure When A Degraded Condition Was Identified
Cornerstone           Significance                               Cross-cutting     Report
24
                                                                  Aspect            Section
Mitigating             Green                                     [H.14] -          71111.15
Systems                NCV 05000445; 05000446/2019001-05 Conservative
Failure to Follow Procedure When A Degraded Condition Was Identified  
                      Closed                                    Bias
Cornerstone  
The inspectors identified a Green, non-cited violation of 10 CFR Part 50, Appendix B,
Significance  
Criterion V, Instructions, Procedures, and Drawings, associated with the licensees failure to
Cross-cutting  
follow the requirements of Station Procedure STI-421.01, Initiation of Issue Reports,
Aspect
Revision 0. Specifically, station personnel failed to notify the shift manager of an issue with
Report  
material storage in the protected area. This issue required evaluations and compensatory
Section  
actions for resolution.
Mitigating  
Description: On January 31, 2019, inspectors identified that the licensee had allowed
Systems
material to be stored in a temporary laydown area inside of the protected area. Inspectors
noted that several items appeared to be susceptible to being picked up by tornado driven
Green  
winds, so the inspectors inquired as to how these items had been evaluated for their current
NCV 05000445; 05000446/2019001-05
storage area. The licensee initiated TR-2019-001119 to capture the inspectors questions.
Closed 
As part of TR-2019-001119 the licensee determined that the materials in question had not
[H.14] -
been evaluated for its current storage location. An action was assigned to engineering to
Conservative  
evaluate the materials in question (AI-TR-2019-001119-1). Engineering completed their
Bias  
evaluation on February 4, 2019, and engineering management approved the evaluation on
71111.15
February 6, 2019. The evaluation determined that there were materials in the laydown area
The inspectors identified a Green, non-cited violation of 10 CFR Part 50, Appendix B,  
that were susceptible to being lifted by tornadic winds, and they needed to be strapped down
Criterion V, Instructions, Procedures, and Drawings, associated with the licensees failure to  
in such a way as to increase their weights to a point where they were no longer susceptible.
follow the requirements of Station Procedure STI-421.01, Initiation of Issue Reports,  
Inspectors reviewed AI-TR-2019-001119-1 on February 14, 2019. During their review they
Revision 0. Specifically, station personnel failed to notify the shift manager of an issue with  
determined that the identified condition required an operability review because of the potential
material storage in the protected area. This issue required evaluations and compensatory  
to be in an unanalyzed condition with respect to tornado driven missiles. However, inspectors
actions for resolution.  
noted that an operability review was not performed because the issue had not been reported
Description: On January 31, 2019, inspectors identified that the licensee had allowed  
to the control room by engineering upon discovery on February 4, 2019, as required by
material to be stored in a temporary laydown area inside of the protected area. Inspectors  
Station Procedure STI-421.01, Initiation of Issue Reports, Revision 0, Section 6.1.
noted that several items appeared to be susceptible to being picked up by tornado driven  
Additionally, there was no guidance or actions in place to adequately strap down the material
winds, so the inspectors inquired as to how these items had been evaluated for their current  
to ensure that it did not pose a risk to plant equipment.
storage area. The licensee initiated TR-2019-001119 to capture the inspectors questions.
Inspectors informed the licensee of their observations. The licensee reviewed the issue and
determined that the condition did require an operability review and compensatory actions to
As part of TR-2019-001119 the licensee determined that the materials in question had not  
address it pending further review.
been evaluated for its current storage location. An action was assigned to engineering to  
Corrective Action(s): The licensee performed an operability determination and establish
evaluate the materials in question (AI-TR-2019-001119-1). Engineering completed their  
compensatory measures that established a reasonable expectation of operability pending
evaluation on February 4, 2019, and engineering management approved the evaluation on  
development of additional corrective actions.
February 6, 2019. The evaluation determined that there were materials in the laydown area  
Corrective Action Reference(s): CR-2019-001119
that were susceptible to being lifted by tornadic winds, and they needed to be strapped down  
                                                24
in such a way as to increase their weights to a point where they were no longer susceptible.  
Inspectors reviewed AI-TR-2019-001119-1 on February 14, 2019. During their review they  
determined that the identified condition required an operability review because of the potential  
to be in an unanalyzed condition with respect to tornado driven missiles. However, inspectors  
noted that an operability review was not performed because the issue had not been reported  
to the control room by engineering upon discovery on February 4, 2019, as required by  
Station Procedure STI-421.01, Initiation of Issue Reports, Revision 0, Section 6.1.
Additionally, there was no guidance or actions in place to adequately strap down the material  
to ensure that it did not pose a risk to plant equipment.
Inspectors informed the licensee of their observations. The licensee reviewed the issue and  
determined that the condition did require an operability review and compensatory actions to  
address it pending further review.  
 
Corrective Action(s): The licensee performed an operability determination and establish  
compensatory measures that established a reasonable expectation of operability pending  
development of additional corrective actions.  
 
Corrective Action Reference(s): CR-2019-001119  


Performance Assessment:
Performance Deficiency: The licensees failure to follow the requirements of
25
Procedure STI-421.01 when a degraded condition was identified was a performance
deficiency.
Performance Assessment:  
Screening: The inspectors determined the performance deficiency was more than minor
 
because it was associated with the Protection Against External Factors attribute of the
Performance Deficiency: The licensees failure to follow the requirements of  
Mitigating Systems cornerstone. It affected the cornerstone objective to ensure availability,
Procedure STI-421.01 when a degraded condition was identified was a performance  
reliability, and capability of systems that respond to initiating events to prevent undesirable
deficiency.  
consequences. Specifically, the storage of materials without proper evaluations resulted in
 
the introduction of new and unanalyzed tornadic missiles.
Screening: The inspectors determined the performance deficiency was more than minor  
Significance: The inspectors assessed the significance of the finding using Appendix A,
because it was associated with the Protection Against External Factors attribute of the  
Significance Determination of Reactor Inspection Findings for At - Power Situations. Using
Mitigating Systems cornerstone. It affected the cornerstone objective to ensure availability,  
Exhibit 2, Mitigating Systems Screening Questions, the inspectors determined the finding
reliability, and capability of systems that respond to initiating events to prevent undesirable  
was of very low safety significance (Green) because: (1) it was not a design deficiency; (2) it
consequences. Specifically, the storage of materials without proper evaluations resulted in  
did not represent a loss of system and/or function; (3) it did not represent an actual loss of
the introduction of new and unanalyzed tornadic missiles.  
function of at least a single train for longer than its technical specification allowed outage
 
time; and (4) it did not result in the loss of a high safety significant non-technical specification
Significance: The inspectors assessed the significance of the finding using Appendix A,  
train.
Significance Determination of Reactor Inspection Findings for At - Power Situations. Using  
Cross-cutting Aspect: H.14 - Conservative Bias: Individuals use decision making-practices
Exhibit 2, Mitigating Systems Screening Questions, the inspectors determined the finding  
that emphasize prudent choices over those that are simply allowable. A proposed action is
was of very low safety significance (Green) because: (1) it was not a design deficiency; (2) it  
determined to be safe in order to proceed, rather than unsafe in order to stop. Specifically,
did not represent a loss of system and/or function; (3) it did not represent an actual loss of  
engineering failed to use decision making-practices that emphasize prudent choices over
function of at least a single train for longer than its technical specification allowed outage  
those that are simply allowable.
time; and (4) it did not result in the loss of a high safety significant non-technical specification  
Enforcement:
train.  
Violation: Title 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and
Drawings, requires, in part, that activities affecting quality shall be prescribed by documented
Cross-cutting Aspect: H.14 - Conservative Bias: Individuals use decision making-practices  
instructions, procedures, or drawings, of a type appropriate to the circumstances and shall be
that emphasize prudent choices over those that are simply allowable. A proposed action is  
accomplished in accordance with these instructions, procedures, and drawings.
determined to be safe in order to proceed, rather than unsafe in order to stop. Specifically,  
Contrary to the above, from February 4-27, 2019, an activity affecting quality was not
engineering failed to use decision making-practices that emphasize prudent choices over  
accomplished in accordance procedures appropriate to the circumstances. Specifically,
those that are simply allowable.  
station personnel failed to notify the shift manager of an issue with material storage in the
Enforcement:  
protected area (as required by Station Procedure STI-421.01, Initiation of Issue Reports)
 
which required evaluations and compensatory actions for resolution.
Violation: Title 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and  
Enforcement Action: This violation is being treated as a non-cited violation, consistent with
Drawings, requires, in part, that activities affecting quality shall be prescribed by documented  
Section 2.3.2 of the Enforcement Policy.
instructions, procedures, or drawings, of a type appropriate to the circumstances and shall be  
                                                  25
accomplished in accordance with these instructions, procedures, and drawings.  
 
Contrary to the above, from February 4-27, 2019, an activity affecting quality was not  
accomplished in accordance procedures appropriate to the circumstances. Specifically,  
station personnel failed to notify the shift manager of an issue with material storage in the  
protected area (as required by Station Procedure STI-421.01, Initiation of Issue Reports)  
which required evaluations and compensatory actions for resolution.  
Enforcement Action: This violation is being treated as a non-cited violation, consistent with  
Section 2.3.2 of the Enforcement Policy.  


Failure to Perform Safety Evaluations in Accordance with 10 CFR 50.59
Cornerstone           Significance                             Cross-cutting       Report
26
                                                                Aspect              Section
Mitigating             Green                                   [H.9] - Training    71111.17T
Failure to Perform Safety Evaluations in Accordance with 10 CFR 50.59
Systems                NCV 05000445; 05000446/2019001-
Cornerstone  
                      06
Significance  
                      Closed
Cross-cutting  
The inspectors identified a Green, non-cited violation of 10 CFR 50, Appendix B, Criterion V,
Aspect
Instructions, Procedures, and Drawings, (with four examples) in which the licensee failed to
Report  
complete 50.59 evaluations as required by station procedures.
Section  
Description: The inspectors identified four examples where the licensee failed to perform
Mitigating  
50.59 evaluations as required by procedures and guidance specified in STA-707,
Systems
10 CFR 50.59 and 10 CFR 72.48 Reviews, Revision 21.
Example 1. EV-CR-2017-004743-2, Blow Down the 1-01 Instrument Air Receiver
Green  
In the screen for the compensatory measure to blow down the 1-01 air receiver once per shift,
NCV 05000445; 05000446/2019001-
question 1 of the screening was, Does the proposed activity involve a change to an SSC that
06
adversely affects an UFSAR described design function? The preparer answered the
Closed
question No; the explanation provided had the following statements: The activity is a
[H.9] - Training
Compensatory Measure to blow down the 1-01 Instrument Air Receiver once per shift using
71111.17T
1CI-0012 to remove water from the receiver. The drip trap (CP1- CIMEDT-01) that performs
The inspectors identified a Green, non-cited violation of 10 CFR 50, Appendix B, Criterion V,  
the automatic drain will be repaired IAW WO 5474911. This statement indicates that an
Instructions, Procedures, and Drawings, (with four examples) in which the licensee failed to  
automatic function was replaced with a manual function.
complete 50.59 evaluations as required by station procedures.  
The vendor manual, AP-0293-B, Ingersoll-Rand Compressor Accessories, dated April 1976,
Description: The inspectors identified four examples where the licensee failed to perform  
provides the following guidance on page 7 for liquid carryover, It is important that interstage
50.59 evaluations as required by procedures and guidance specified in STA-707,
separators be drained regularly and we are of the opinion that manual drainage at specified
10 CFR 50.59 and 10 CFR 72.48 Reviews, Revision 21.
intervals with the fact of drainage logged, is the proper method, particularly at higher
pressures. Automatic traps, if used, should have a bypass piped for visual observation and
Example 1. EV-CR-2017-004743-2, Blow Down the 1-01 Instrument Air Receiver  
check on trap operation - the check should be made at stated intervals and the results
logged. Page 12 of the manual provides guidance that drainage of the receiver following the
In the screen for the compensatory measure to blow down the 1-01 air receiver once per shift,  
aftercooler should be drained at least once per shift.
question 1 of the screening was, Does the proposed activity involve a change to an SSC that  
CPNPP 50-59 RM-6, "CPNPP 50.59 Resource Manual," Revision 6, requires that an
adversely affects an UFSAR described design function? The preparer answered the  
evaluation be performed if an automatic function is replaced with a manual action. The
question No; the explanation provided had the following statements: The activity is a  
preparer and reviewer failed to ensure the appropriate Applicability
Compensatory Measure to blow down the 1-01 Instrument Air Receiver once per shift using  
Determination/screen/evaluation was performed and the corresponding Applicability
1CI-0012 to remove water from the receiver. The drip trap (CP1- CIMEDT-01) that performs  
Determination/screen/evaluation form was completed in accordance with guidance provided
the automatic drain will be repaired IAW WO 5474911. This statement indicates that an  
in CPNPP 50-59 RM-6. Screening guidance would require this change to be evaluated prior
automatic function was replaced with a manual function.
to changing from an automatic to a manual function.
Example 2. EV-CR-2018-007384 RCS Pressure Boundary Leakage Test
The vendor manual, AP-0293-B, Ingersoll-Rand Compressor Accessories, dated April 1976,  
This document was to perform a 50.59 review for changes to Procedure OPT-612B, RCS
provides the following guidance on page 7 for liquid carryover, It is important that interstage  
Pressure Boundary Leakage Test for Loop 1 Cold Leg Injection Valves, and
separators be drained regularly and we are of the opinion that manual drainage at specified  
Procedure OPT 613B, RCS Pressure Boundary Leakage Test for Loop 2 Cold Leg Injection
intervals with the fact of drainage logged, is the proper method, particularly at higher  
Valves, to allow the performance of reactor coolant system pressure boundary leakage test
pressures. Automatic traps, if used, should have a bypass piped for visual observation and  
for safety injection loops 1 and 2. The licensee had attempted to perform a flush of the
check on trap operation - the check should be made at stated intervals and the results  
residual heat removal system while in Mode 1, an evolution normally performed in Modes 3,
logged. Page 12 of the manual provides guidance that drainage of the receiver following the  
                                                26
aftercooler should be drained at least once per shift.  
CPNPP 50-59 RM-6, "CPNPP 50.59 Resource Manual," Revision 6, requires that an  
evaluation be performed if an automatic function is replaced with a manual action. The  
preparer and reviewer failed to ensure the appropriate Applicability  
Determination/screen/evaluation was performed and the corresponding Applicability  
Determination/screen/evaluation form was completed in accordance with guidance provided  
in CPNPP 50-59 RM-6. Screening guidance would require this change to be evaluated prior  
to changing from an automatic to a manual function.  
Example 2. EV-CR-2018-007384 RCS Pressure Boundary Leakage Test  
This document was to perform a 50.59 review for changes to Procedure OPT-612B, RCS  
Pressure Boundary Leakage Test for Loop 1 Cold Leg Injection Valves, and  
Procedure OPT 613B, RCS Pressure Boundary Leakage Test for Loop 2 Cold Leg Injection  
Valves, to allow the performance of reactor coolant system pressure boundary leakage test  
for safety injection loops 1 and 2. The licensee had attempted to perform a flush of the  
residual heat removal system while in Mode 1, an evolution normally performed in Modes 3,  


4, or 5. Inadequate procedure changes and review of the planned process resulted in forward
flow through valves 2-8956A and B. This placed the unit in a 24-hour LCO to complete
27
Surveillance Requirement 3.4.14 for valves 2-8956 A and B. Procedures OPT-612B and
OPT-613B needed to be revised to allow performance of this surveillance in Mode 1. The
4, or 5. Inadequate procedure changes and review of the planned process resulted in forward  
activity required component manipulations that isolated one safety injection accumulator and
flow through valves 2-8956A and B. This placed the unit in a 24-hour LCO to complete  
rendered one train of residual heat removal inoperable in order to perform the leak check. A
Surveillance Requirement 3.4.14 for valves 2-8956 A and B. Procedures OPT-612B and  
threaded pipe cap was removed and various normally closed valves were opened to allow
OPT-613B needed to be revised to allow performance of this surveillance in Mode 1. The  
connection of the test rig. The screener and reviewer failed to recognize that these actions
activity required component manipulations that isolated one safety injection accumulator and  
resulted in an "adverse effect" on the plant.
rendered one train of residual heat removal inoperable in order to perform the leak check. A  
CPNPP 50-59-RM6, Section 5.2.2, states, in part, changes that have an adverse effect are
threaded pipe cap was removed and various normally closed valves were opened to allow  
required to be evaluated under 10 CFR 50.59 because they have the potential to increase the
connection of the test rig. The screener and reviewer failed to recognize that these actions  
likelihood of malfunctions, increase consequences, create new accidents, or otherwise meet
resulted in an "adverse effect" on the plant.
the 10 CFR 50.59 evaluation criteria.
CPNPP 50-59-RM6, Section 5.2.1 states, Items to Consider When Deciding Whether an Item
CPNPP 50-59-RM6, Section 5.2.2, states, in part, changes that have an adverse effect are  
is a Change to the Facility: Does the activity decrease the reliability of an SSC design
required to be evaluated under 10 CFR 50.59 because they have the potential to increase the  
function, including either functions whose failure would initiate a transient/accident or
likelihood of malfunctions, increase consequences, create new accidents, or otherwise meet  
functions that are relied upon for mitigation? Does the activity reduce existing redundancy,
the 10 CFR 50.59 evaluation criteria.  
diversity, or defense-in-depth?
The screener and reviewer failed to recognize that, even though technical specifications allow
CPNPP 50-59-RM6, Section 5.2.1 states, Items to Consider When Deciding Whether an Item  
operation with one safety injection accumulator isolated and one train of residual heat
is a Change to the Facility: Does the activity decrease the reliability of an SSC design  
removal inoperable, this resulted in a reduction in the existing redundancy, diversity, and
function, including either functions whose failure would initiate a transient/accident or  
defense-in-depth that required the performance of an evaluation.
functions that are relied upon for mitigation? Does the activity reduce existing redundancy,  
Example 3. Procedure Change to SOP-102B
diversity, or defense-in-depth?  
Section 1 of the screen for the change to SOP-102B, Residual Heat Removal System,
Revision 15, provided the following description in the change justification section: "Modified
The screener and reviewer failed to recognize that, even though technical specifications allow  
Section 5.2 to allow flushing of the RHR System to the RHUT (ref AI-CR-2018-007381-4),
operation with one safety injection accumulator isolated and one train of residual heat  
deleted "Intentionally Left Blank" Pages 3&4 of Attachment 4. Re-sequenced Table of
removal inoperable, this resulted in a reduction in the existing redundancy, diversity, and  
Contents to reflect new page numbering. Added new prerequisite to Section 2.3 to clarify
defense-in-depth that required the performance of an evaluation.  
intent of Section 5.11 and moved 2.3 to previous page." The technical reviewer answered
yes to the question: If change is editorial, THEN circle or mark "YES." Editorial changes, as
Example 3. Procedure Change to SOP-102B  
limited by STA-202, Attachment 8.F, do not require Administrative Review, Technical Review,
NSR, AD, 50.59 Review or 72.48 Review.
Section 1 of the screen for the change to SOP-102B, Residual Heat Removal System,  
The procedure change (in Section 5.2 to allow flushing of the RHR system) actually
Revision 15, provided the following description in the change justification section: "Modified  
manipulated valves in the safety injection system to isolate the safety injection accumulators
Section 5.2 to allow flushing of the RHR System to the RHUT (ref AI-CR-2018-007381-4),  
based on lessons learned when the licensee originally attempted to flush the residual heat
deleted "Intentionally Left Blank" Pages 3&4 of Attachment 4. Re-sequenced Table of  
removal system while in Mode 1. The licensee had failed to recognize that the initial
Contents to reflect new page numbering. Added new prerequisite to Section 2.3 to clarify  
conditions assumed in Procedure SOP-102B had the safety injection accumulators isolated.
intent of Section 5.11 and moved 2.3 to previous page." The technical reviewer answered  
In Mode 1, the safety injection accumulators were in service, and the attempted flush of the
yes to the question: If change is editorial, THEN circle or mark "YES." Editorial changes, as  
residual heat removal system resulted in flow from the accumulators. The purpose of the
limited by STA-202, Attachment 8.F, do not require Administrative Review, Technical Review,  
procedure modification was to isolate the safety injection accumulator to allow a partial flush
NSR, AD, 50.59 Review or 72.48 Review.  
of the residual heat removal system. The preparer, reviewer, and technical reviewer all failed
to identify this aspect of the procedure change. As a result, the adverse effect on the plant, a
The procedure change (in Section 5.2 to allow flushing of the RHR system) actually  
reduction in redundancy to the safety injection system, was not identified, and therefore the
manipulated valves in the safety injection system to isolate the safety injection accumulators  
required 10 CFR 50.59 evaluation was not performed.
based on lessons learned when the licensee originally attempted to flush the residual heat  
                                                27
removal system while in Mode 1. The licensee had failed to recognize that the initial  
conditions assumed in Procedure SOP-102B had the safety injection accumulators isolated.
In Mode 1, the safety injection accumulators were in service, and the attempted flush of the  
residual heat removal system resulted in flow from the accumulators. The purpose of the  
procedure modification was to isolate the safety injection accumulator to allow a partial flush  
of the residual heat removal system. The preparer, reviewer, and technical reviewer all failed  
to identify this aspect of the procedure change. As a result, the adverse effect on the plant, a  
reduction in redundancy to the safety injection system, was not identified, and therefore the  
required 10 CFR 50.59 evaluation was not performed.


Example 4. EV-2002-002026-01-00 Bladder Equivalency Evaluation
On May 28, 2002, the licensee performed an equivalency evaluation for replacement
28
diaphragms for the reactor make up water storage tanks, EV-2002-002026-01-00. In the
evaluation the licensee identified that the new diaphragm was manufactured with a material
Example 4. EV-2002-002026-01-00 Bladder Equivalency Evaluation  
that has a specific gravity greater than 1.0 which will make it heavier than the water in the
tank, and consequently material which tears or breaks off from the diaphragm will sink into
On May 28, 2002, the licensee performed an equivalency evaluation for replacement  
the tank and potentially into the pump suction, which could cause the pump to malfunction.
diaphragms for the reactor make up water storage tanks, EV-2002-002026-01-00. In the  
The licensee determined that this was an equivalent change by crediting proper maintenance
evaluation the licensee identified that the new diaphragm was manufactured with a material  
and inspection to ensure that a failure of the new material does not occur.
that has a specific gravity greater than 1.0 which will make it heavier than the water in the  
Inspectors determined that this was not an equivalent change because the new diaphragm
tank, and consequently material which tears or breaks off from the diaphragm will sink into  
introduced the potential for a new adverse effect (bladder failure could result in material
the tank and potentially into the pump suction, which could cause the pump to malfunction.
sinking and clogging pump suction) and should have been evaluated. CPNPP 50-59-RM6 ,
The licensee determined that this was an equivalent change by crediting proper maintenance  
Section 5.2.2 states in part, changes that have an adverse effect are required to be evaluated
and inspection to ensure that a failure of the new material does not occur.  
under 10 CFR 50.59 because they have the potential to increase the likelihood of
malfunctions, increase consequences, create new accidents, or otherwise meet the 10 CFR
Inspectors determined that this was not an equivalent change because the new diaphragm  
50.59 evaluation criteria.
introduced the potential for a new adverse effect (bladder failure could result in material  
Corrective Action(s): The licensee entered these issues into the corrective action program.
sinking and clogging pump suction) and should have been evaluated. CPNPP 50-59-RM6 ,
Corrective Action Reference(s): IR-2019-001271, IR-2019-001317, IR-2019-001428,
Section 5.2.2 states in part, changes that have an adverse effect are required to be evaluated  
IR-2019-001430
under 10 CFR 50.59 because they have the potential to increase the likelihood of  
Performance Assessment:
malfunctions, increase consequences, create new accidents, or otherwise meet the 10 CFR  
Performance Deficiency: The inspectors determined that not conducting required
50.59 evaluation criteria.  
10 CFR 50.59 evaluations was a performance deficiency within the licensee's ability to
 
foresee and correct. Specifically, the licensee failed to perform 10 CFR 50.59 evaluations for
Corrective Action(s): The licensee entered these issues into the corrective action program.  
the compensatory measure for the instrument air system, the procedure change for the
 
reactor coolant system pressure boundary leakage test for safety injection loops 1 and 2, the
Corrective Action Reference(s): IR-2019-001271, IR-2019-001317, IR-2019-001428,
procedure change for the residual heat removal system flush, and replacement diaphragms
IR-2019-001430  
for the reactor make up water storage tanks.
Screening: The inspectors determined the performance deficiency was more than minor
Performance Assessment:  
because it was associated with the Human Performance attribute of the Mitigating Systems
 
Cornerstone and adversely impacted the cornerstone objective of ensuring the availability,
Performance Deficiency: The inspectors determined that not conducting required
reliability, and capability of systems that respond to initiating events to prevent undesirable
10 CFR 50.59 evaluations was a performance deficiency within the licensee's ability to  
consequences.
foresee and correct. Specifically, the licensee failed to perform 10 CFR 50.59 evaluations for  
Significance: The inspectors assessed the significance of the finding using Appendix A,
the compensatory measure for the instrument air system, the procedure change for the  
Significance Determination of Reactor Inspection Findings for At - Power Situations. The
reactor coolant system pressure boundary leakage test for safety injection loops 1 and 2, the  
inspectors assessed the significance of the finding using Inspection Manual Chapter 0609.04,
procedure change for the residual heat removal system flush, and replacement diaphragms  
and Inspection Manual Chapter 0609, Appendix A, Exhibit 2. The inspectors determined that
for the reactor make up water storage tanks.  
this finding was of very low safety significance (Green), because the finding did not represent
 
a loss of the emergency core cooling system or the instrument air system safety function, did
Screening: The inspectors determined the performance deficiency was more than minor  
not result in any loss of function beyond the technical specification-allowed outage time, and
because it was associated with the Human Performance attribute of the Mitigating Systems  
did not result in the loss of any non-technical specification trains that were designated as high
Cornerstone and adversely impacted the cornerstone objective of ensuring the availability,  
safety-significance in accordance with the licensees maintenance rule program.
reliability, and capability of systems that respond to initiating events to prevent undesirable  
                                                28
consequences.
 
Significance: The inspectors assessed the significance of the finding using Appendix A,  
Significance Determination of Reactor Inspection Findings for At - Power Situations. The  
inspectors assessed the significance of the finding using Inspection Manual Chapter 0609.04,  
and Inspection Manual Chapter 0609, Appendix A, Exhibit 2. The inspectors determined that  
this finding was of very low safety significance (Green), because the finding did not represent  
a loss of the emergency core cooling system or the instrument air system safety function, did  
not result in any loss of function beyond the technical specification-allowed outage time, and  
did not result in the loss of any non-technical specification trains that were designated as high  
safety-significance in accordance with the licensees maintenance rule program.  


Cross-cutting Aspect: H.9 - Training: The organization provides training and ensures
knowledge transfer to maintain a knowledgeable, technically competent workforce and instill
29
nuclear safety values. Specifically, the licensee failed to provide training to maintain a
knowledgeable, technically sound workforce and instill nuclear safety values when
Cross-cutting Aspect: H.9 - Training: The organization provides training and ensures  
implementing the change process.
knowledge transfer to maintain a knowledgeable, technically competent workforce and instill  
Enforcement:
nuclear safety values. Specifically, the licensee failed to provide training to maintain a  
Violation: Title 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and
knowledgeable, technically sound workforce and instill nuclear safety values when  
Drawings, states Activities affecting quality shall be prescribed by documented instructions,
implementing the change process.  
procedures, or drawings, of a type appropriate to the circumstances and shall be
Enforcement:  
accomplished in accordance with these instructions, procedures, or drawings. Contrary to the
 
above, from May 2002, to February 2019, the team identified four examples where the
Violation: Title 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and  
licensee failed to follow the requirements of Procedure CPNPP 50.59-RM6, "CPNPP 50.59
Drawings, states Activities affecting quality shall be prescribed by documented instructions,  
Resource Manual," Revision 6. The procedure required a 10CFR 50.59 evaluation to be
procedures, or drawings, of a type appropriate to the circumstances and shall be  
performed if an activity reduces existing redundancy, diversity, or defense in depth or if an
accomplished in accordance with these instructions, procedures, or drawings. Contrary to the  
automatic function is replaced with a manual action. Specifically, the licensee implemented
above, from May 2002, to February 2019, the team identified four examples where the  
manual compensatory actions when the automatic trap for the instrument air system failed,
licensee failed to follow the requirements of Procedure CPNPP 50.59-RM6, "CPNPP 50.59  
Resource Manual," Revision 6. The procedure required a 10CFR 50.59 evaluation to be  
performed if an activity reduces existing redundancy, diversity, or defense in depth or if an  
automatic function is replaced with a manual action. Specifically, the licensee implemented  
manual compensatory actions when the automatic trap for the instrument air system failed,  
made procedure changes that reduced the redundancy, diversity, reliability, and defense-in-
made procedure changes that reduced the redundancy, diversity, reliability, and defense-in-
depth of the emergency core cooling systems, and installed new material in the plant with a
depth of the emergency core cooling systems, and installed new material in the plant with a  
different adverse effect without performing 10 CFR 50.59 evaluations as required.
different adverse effect without performing 10 CFR 50.59 evaluations as required.  
Enforcement Action: This violation is being treated as a non-cited violation, consistent with
Section 2.3.2 of the Enforcement Policy.
Enforcement Action: This violation is being treated as a non-cited violation, consistent with  
Inadequate Maintenance Instructions Result in Loss of Assessment Capability
Section 2.3.2 of the Enforcement Policy.  
Cornerstone             Significance                             Cross-cutting     Report
                                                                  Aspect            Section
Emergency               Green                                     [H.8] -          71152
Inadequate Maintenance Instructions Result in Loss of Assessment Capability  
Preparedness            NCV 05000445; 05000446/2019001-07 Procedure
Cornerstone  
                        Closed                                    Adherence
Significance  
The inspectors reviewed a self-revealed Green, non-citied violation of 10 CFR 50,
Cross-cutting  
Appendix B, Criterion V, "Instruction, Procedures, and Drawings", that occurred due to
Aspect
inadequate maintenance instructions for safety-related radiation monitors which resulted in a
Report  
major loss of assessment capability.
Section  
Description: On December 5, 2017, the licensee was performing maintenance on the control
Emergency  
room south ventilation intake radiation monitor under Work Order (WO) 5063234 when they
Preparedness
received audible and visible alarms in the control room indicating a loss of multiple radiation
monitors. The crew evaluated the indications and determined a major loss of assessment
Green  
capability occurred due to the unplanned loss of the main steam line radiation monitors for
NCV 05000445; 05000446/2019001-07
steam lines 1 and 3, and the station service water (SSW) radiation monitors. The loss of
Closed 
these radiation monitors impacted emergency action levels for radiation effluent. This event
[H.8] -
was reported to the NRC as Event Report No. 53105.
Procedure  
The inspectors reviewed the circumstances of this event including the licensees evaluation
Adherence  
and corrective actions. The licensees radiation monitoring system consists of four
71152
communication loops of 20 to 30 radiation monitors each. The loops pass inputs via each
The inspectors reviewed a self-revealed Green, non-citied violation of 10 CFR 50,  
successive monitor to the plant computer system, which then provides required indications to
Appendix B, Criterion V, "Instruction, Procedures, and Drawings", that occurred due to  
the control room and emergency response facilities (ERFs). The licensee determined that the
inadequate maintenance instructions for safety-related radiation monitors which resulted in a  
loss of the affected radiation monitors was due to taking the control room south ventilation
major loss of assessment capability.  
                                                29
Description: On December 5, 2017, the licensee was performing maintenance on the control  
room south ventilation intake radiation monitor under Work Order (WO) 5063234 when they  
received audible and visible alarms in the control room indicating a loss of multiple radiation  
monitors. The crew evaluated the indications and determined a major loss of assessment  
capability occurred due to the unplanned loss of the main steam line radiation monitors for  
steam lines 1 and 3, and the station service water (SSW) radiation monitors. The loss of  
these radiation monitors impacted emergency action levels for radiation effluent. This event  
was reported to the NRC as Event Report No. 53105.  
The inspectors reviewed the circumstances of this event including the licensees evaluation  
and corrective actions. The licensees radiation monitoring system consists of four  
communication loops of 20 to 30 radiation monitors each. The loops pass inputs via each  
successive monitor to the plant computer system, which then provides required indications to  
the control room and emergency response facilities (ERFs). The licensee determined that the  
loss of the affected radiation monitors was due to taking the control room south ventilation  


intake radiation monitor out of service without first installing jumpers in the communication
loop to bypass the monitor. This resulted in a failure of all other monitors in the affected loop
30
to provide indication to the plant computer system.
The inadequate maintenance resulted in the simultaneous communications failure of
intake radiation monitor out of service without first installing jumpers in the communication  
approximately 27 radiation monitors. In addition to the monitors that met the criteria for the
loop to bypass the monitor. This resulted in a failure of all other monitors in the affected loop  
report, the inspectors noted the following other monitors that affected emergency
to provide indication to the plant computer system.  
classification:
    *   Unit 1 main steam line radiation monitors for main steam lines 1 and 3
The inadequate maintenance resulted in the simultaneous communications failure of  
    *   both Unit 1 SSW radiation monitors and all Unit 1 component cooling water radiation
approximately 27 radiation monitors. In addition to the monitors that met the criteria for the  
        monitors, their credited backup for the SSW monitors
report, the inspectors noted the following other monitors that affected emergency  
    *   the Unit 1 failed fuel monitor
classification:  
    *   all Unit 1 refueling cavity monitors
    *   the Unit 1 containment radiation monitors for particulate, iodine, and gaseous activity
*  
    *   the fuel building vent exhaust monitor
Unit 1 main steam line radiation monitors for main steam lines 1 and 3  
The licensee implemented compensatory measures for the affected monitors while restoring
them to service. The main steam line radiation monitors affected the ability to declare a
*  
General Emergency for high steam line radiation, but the licensee determined that a General
both Unit 1 SSW radiation monitors and all Unit 1 component cooling water radiation  
Emergency declaration could have been made using other emergency action levels. The
monitors, their credited backup for the SSW monitors  
inspectors did not identify any concerns with the licensees conclusion regarding emergency
classification.
*  
The inspectors determined that the workers did not install the jumpers because WO 5063234
the Unit 1 failed fuel monitor  
did not contain instructions to install the jumpers. The licensee had relied on the knowledge
of a few experienced technicians who were aware that the jumpers needed to be installed
*  
prior to removing a monitor from service. However, the workers performing WO 5063234 on
all Unit 1 refueling cavity monitors  
the control room south ventilation intake radiation monitor on December 5 were not aware of
the need to install jumpers.
*  
The inspectors determined that licensee Procedure STI-606.03, Work Planning, Section 6.2
the Unit 1 containment radiation monitors for particulate, iodine, and gaseous activity  
requires that work packages identify where jumpers need to be installed. The inspectors
concluded that the work instructions in WO 5063234 were inadequate. The control room
*  
south ventilation intake radiation monitor is safety-related, and therefore, the work instructions
the fuel building vent exhaust monitor  
were quality related instructions.
Corrective Action(s): The licensee stopped maintenance, implemented compensatory
The licensee implemented compensatory measures for the affected monitors while restoring  
measures, and restored the monitors to service.
them to service. The main steam line radiation monitors affected the ability to declare a  
Corrective Action Reference(s): CR-2019-002535
General Emergency for high steam line radiation, but the licensee determined that a General  
                                                30
Emergency declaration could have been made using other emergency action levels. The  
inspectors did not identify any concerns with the licensees conclusion regarding emergency  
classification.  
The inspectors determined that the workers did not install the jumpers because WO 5063234  
did not contain instructions to install the jumpers. The licensee had relied on the knowledge  
of a few experienced technicians who were aware that the jumpers needed to be installed  
prior to removing a monitor from service. However, the workers performing WO 5063234 on  
the control room south ventilation intake radiation monitor on December 5 were not aware of  
the need to install jumpers.  
The inspectors determined that licensee Procedure STI-606.03, Work Planning, Section 6.2  
requires that work packages identify where jumpers need to be installed. The inspectors  
concluded that the work instructions in WO 5063234 were inadequate. The control room  
south ventilation intake radiation monitor is safety-related, and therefore, the work instructions  
were quality related instructions.  
 
Corrective Action(s): The licensee stopped maintenance, implemented compensatory  
measures, and restored the monitors to service.  
 
Corrective Action Reference(s): CR-2019-002535  


Performance Assessment:
Performance Deficiency: The failure to prescribe adequate work instructions for a quality
31
related activity is a performance deficiency.
Screening: The inspectors determined the performance deficiency was more than minor
Performance Assessment:  
because it was associated with the facilities and equipment attribute of the Emergency
 
Preparedness Cornerstone. It adversely affected the cornerstone objective to ensure that the
Performance Deficiency: The failure to prescribe adequate work instructions for a quality  
licensee is capable of implementing adequate measures to protect the health and safety of
related activity is a performance deficiency.  
the public in the event of a radiological emergency. Specifically, it resulted in the failure of
 
multiple pieces of equipment credited for maintaining the licensees emergency plan with
Screening: The inspectors determined the performance deficiency was more than minor  
respect to emergency planning standard four, which requires a standard emergency
because it was associated with the facilities and equipment attribute of the Emergency  
classification and action level scheme to be in use.
Preparedness Cornerstone. It adversely affected the cornerstone objective to ensure that the  
Significance: The inspectors assessed the significance of the finding using Appendix B,
licensee is capable of implementing adequate measures to protect the health and safety of  
Emergency Preparedness SDP. Using table 5.4-1, Significance Examples
the public in the event of a radiological emergency. Specifically, it resulted in the failure of  
Section 50.47(b)(4), the finding was determined to be of very low safety significance (Green)
multiple pieces of equipment credited for maintaining the licensees emergency plan with  
because it was not a degraded risk significant planning standard function. The planning
respect to emergency planning standard four, which requires a standard emergency  
standard function was not degraded because, although an emergency action level (EAL) was
classification and action level scheme to be in use.  
rendered ineffective such that a General Emergency would not have been declared for a
 
particular off-normal event, other EALs could have been used to make an appropriate
Significance: The inspectors assessed the significance of the finding using Appendix B,  
declaration.
Emergency Preparedness SDP. Using table 5.4-1, Significance Examples  
Cross-cutting Aspect: H.8 - Procedure Adherence: Individuals follow processes, procedures,
Section 50.47(b)(4), the finding was determined to be of very low safety significance (Green)  
and work instructions. Specifically, individuals did not follow the work planning procedure
because it was not a degraded risk significant planning standard function. The planning  
when preparing work instructions for maintenance on the radiation monitors.
standard function was not degraded because, although an emergency action level (EAL) was  
Enforcement:
rendered ineffective such that a General Emergency would not have been declared for a  
Violation: Title 10 CFR 50, Appendix B, Criterion V, "Instruction, Procedures, and Drawings,"
particular off-normal event, other EALs could have been used to make an appropriate  
requires in part that activities affecting quality shall be prescribed by documented instructions
declaration.  
of a type appropriate to the circumstances. Contrary to the above, on December 5, 2017, the
licensee failed to prescribe activities affecting quality by documented instructions of a type
Cross-cutting Aspect: H.8 - Procedure Adherence: Individuals follow processes, procedures,  
appropriate to the circumstances. Specifically, the licensee prescribed maintenance on a
and work instructions. Specifically, individuals did not follow the work planning procedure  
safety-related radiation monitor with instructions that did not identify jumpers required to
when preparing work instructions for maintenance on the radiation monitors.  
maintain the function of the radiation monitoring system.
Enforcement:  
Enforcement Action: This violation is being treated as a non-cited violation, consistent with
 
Section 2.3.2 of the Enforcement Policy.
Violation: Title 10 CFR 50, Appendix B, Criterion V, "Instruction, Procedures, and Drawings,"  
Failure to Establish Adequate Procedural Guidance for Flushing Lithium at Power
requires in part that activities affecting quality shall be prescribed by documented instructions  
Cornerstone           Significance                                 Cross-cutting   Report
of a type appropriate to the circumstances. Contrary to the above, on December 5, 2017, the  
                                                                    Aspect          Section
licensee failed to prescribe activities affecting quality by documented instructions of a type  
Mitigating             Green                                       [H.11] -         71152
appropriate to the circumstances. Specifically, the licensee prescribed maintenance on a  
Systems                NCV 05000446/2019001-08                      Challenge the
safety-related radiation monitor with instructions that did not identify jumpers required to  
                      Closed                                      Unknown
maintain the function of the radiation monitoring system.  
The inspectors reviewed a Green, self-revealing non-cited violation of 10 CFR Part 50,
Appendix B, Criterion V, Instructions, Procedures, and Drawings, associated with the
Enforcement Action: This violation is being treated as a non-cited violation, consistent with  
licensees failure to establish an adequate procedure for flushing lithium from the residual
Section 2.3.2 of the Enforcement Policy.  
heat removal system. This resulted in safety injection Accumulators 2-01 and 2-02 discharge
to the safety injection test header causing level drops in both accumulators, and
Failure to Establish Adequate Procedural Guidance for Flushing Lithium at Power  
                                                  31
Cornerstone  
Significance  
Cross-cutting  
Aspect
Report  
Section  
Mitigating  
Systems
Green  
NCV 05000446/2019001-08 
Closed
[H.11] -  
Challenge the  
Unknown  
71152
The inspectors reviewed a Green, self-revealing non-cited violation of 10 CFR Part 50,  
Appendix B, Criterion V, Instructions, Procedures, and Drawings, associated with the  
licensees failure to establish an adequate procedure for flushing lithium from the residual  
heat removal system. This resulted in safety injection Accumulators 2-01 and 2-02 discharge  
to the safety injection test header causing level drops in both accumulators, and  


Accumulator 2-01 pressure dropped to below the operability limit resulting in an unplanned
component inoperability.
32
Description: On November 2, 2018, with Unit 2 in Mode 1 operations the licensee performed
an evolution to flush lithium from the residual heat removal system. The licensee used
Accumulator 2-01 pressure dropped to below the operability limit resulting in an unplanned  
Station Procedure SOP-102A, Residual Heat Removal System, Revision 20, Section 5.11, to
component inoperability.  
perform this evolution. During the flush safety injection Accumulators 2-01 and 2-02 levels
Description: On November 2, 2018, with Unit 2 in Mode 1 operations the licensee performed  
dropped by 6 percent due to the accumulators discharging to the safety injection test header,
an evolution to flush lithium from the residual heat removal system. The licensee used  
and Accumulator 2-01s pressure dropped to below the operability limit resulting in an
Station Procedure SOP-102A, Residual Heat Removal System, Revision 20, Section 5.11, to  
unplanned component inoperability. Operators stopped the activity and restored level and
perform this evolution. During the flush safety injection Accumulators 2-01 and 2-02 levels  
pressure in the accumulators. Condition Report CR-2018-007381 was written to capture the
dropped by 6 percent due to the accumulators discharging to the safety injection test header,  
issue in the corrective action program.
and Accumulator 2-01s pressure dropped to below the operability limit resulting in an  
During the licensees investigation of the event it was determined that Procedure SOP-102A,
unplanned component inoperability. Operators stopped the activity and restored level and  
section 5.11, was not the correct procedure for this evolution because it was not intended for
pressure in the accumulators. Condition Report CR-2018-007381 was written to capture the  
use in the mode of operation. The licensee identified two causes for why an incorrect
issue in the corrective action program.  
procedure was used; inadequate coordination and incorrect assumptions. Inadequate
coordination because operations, chemistry and engineering had used an informal selection
During the licensees investigation of the event it was determined that Procedure SOP-102A,  
process which lacked rigor when selecting a procedure to perform an infrequently performed
section 5.11, was not the correct procedure for this evolution because it was not intended for  
task, and this resulted in no further challenge or verifications of the adequacy of this
use in the mode of operation. The licensee identified two causes for why an incorrect  
procedure. The licensee also identified that the work scheduling process does not require
procedure was used; inadequate coordination and incorrect assumptions. Inadequate  
operations procedures to be reviewed for impact. Inadequate assumptions because of the
coordination because operations, chemistry and engineering had used an informal selection  
belief by operations, chemistry and engineering that procedure SOP-102A provided
process which lacked rigor when selecting a procedure to perform an infrequently performed  
appropriate instructions for the at-power lithium flush.
task, and this resulted in no further challenge or verifications of the adequacy of this  
Inspectors reviewed the licensees evaluation and concluded that it identified reasonable
procedure. The licensee also identified that the work scheduling process does not require  
causes and adequately addressed the identified causes.
operations procedures to be reviewed for impact. Inadequate assumptions because of the  
Corrective Action(s): The licensee immediately stopped the activity, refilled and
belief by operations, chemistry and engineering that procedure SOP-102A provided  
re-pressurized the safety injection accumulators. Subsequent corrective actions were to
appropriate instructions for the at-power lithium flush.  
revise the work control process to require formal reviews for infrequently performed
non-repetitive activities.
Inspectors reviewed the licensees evaluation and concluded that it identified reasonable  
Corrective Action Reference(s): CR-2018-007381
causes and adequately addressed the identified causes.  
Performance Assessment:
 
Performance Deficiency: The licensees failure to establish an adequate procedure for
Corrective Action(s): The licensee immediately stopped the activity, refilled and  
flushing lithium from the residual heat removal system was a performance deficiency.
re-pressurized the safety injection accumulators. Subsequent corrective actions were to  
Screening: The inspectors determined the performance deficiency was more than minor
revise the work control process to require formal reviews for infrequently performed  
because it was associated with the equipment performance attribute of the Mitigating
non-repetitive activities.  
Systems Cornerstone. It adversely affected the cornerstone objective to ensure the
 
availability, reliability, and capability of systems that respond to initiating events to prevent
Corrective Action Reference(s): CR-2018-007381  
undesirable consequences. Specifically, the use of an inadequate procedure for flushing
lithium resulted in an inoperable safety injection accumulator.
Performance Assessment:  
Significance: The inspectors assessed the significance of the finding using Appendix A,
 
Significance Determination of Reactor Inspection Findings for At - Power Situations. Using
Performance Deficiency: The licensees failure to establish an adequate procedure for  
Exhibit 2, Mitigating Systems Screening Questions, the inspectors determined the finding
flushing lithium from the residual heat removal system was a performance deficiency.  
was of very low safety significance (Green) because: (1) it was not a design deficiency; (2) it
 
did not represent a loss of system and/or function; (3) it did not represent an actual loss of
Screening: The inspectors determined the performance deficiency was more than minor  
                                                  32
because it was associated with the equipment performance attribute of the Mitigating  
Systems Cornerstone. It adversely affected the cornerstone objective to ensure the  
availability, reliability, and capability of systems that respond to initiating events to prevent  
undesirable consequences. Specifically, the use of an inadequate procedure for flushing  
lithium resulted in an inoperable safety injection accumulator.
 
Significance: The inspectors assessed the significance of the finding using Appendix A,  
Significance Determination of Reactor Inspection Findings for At - Power Situations. Using  
Exhibit 2, Mitigating Systems Screening Questions, the inspectors determined the finding  
was of very low safety significance (Green) because: (1) it was not a design deficiency; (2) it  
did not represent a loss of system and/or function; (3) it did not represent an actual loss of  


function of at least a single train for longer than its technical specification allowed outage
time; and (4) it did not result in the loss of a high safety significant non-technical specification
33
train.
Cross-cutting Aspect: H.11 - Challenge the Unknown: Individuals stop when faced with
function of at least a single train for longer than its technical specification allowed outage  
uncertain conditions. Risks are evaluated and managed before proceeding. Specifically,
time; and (4) it did not result in the loss of a high safety significant non-technical specification  
station personnel failed to stop when faced with uncertain conditions and ensure that risks
train.  
were evaluated and managed before proceeding.
Enforcement:
Cross-cutting Aspect: H.11 - Challenge the Unknown: Individuals stop when faced with  
Violation: Title 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and
uncertain conditions. Risks are evaluated and managed before proceeding. Specifically,  
Drawings requires, in part, that activities affecting quality shall be prescribed by documented
station personnel failed to stop when faced with uncertain conditions and ensure that risks  
instructions, procedures, or drawings, of a type appropriate to the circumstances and shall be
were evaluated and managed before proceeding.  
accomplished in accordance with these instructions, procedures, and drawings.
Contrary to the above, on November 2, 2018, an activity affecting quality was not prescribed
Enforcement:  
by documented instructions, procedures, or drawings, of a type appropriate to the
 
circumstances. Specifically, Station Procedure SOP-102A, Residual Heat Removal System,
Violation: Title 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and  
Revision 20, Section 5.11, provided inadequate guidance for flushing lithium from the residual
Drawings requires, in part, that activities affecting quality shall be prescribed by documented  
heat removal system with the reactor in Mode 1 operation.
instructions, procedures, or drawings, of a type appropriate to the circumstances and shall be  
Enforcement Action: This violation is being treated as a non-cited violation, consistent with
accomplished in accordance with these instructions, procedures, and drawings.  
Section 2.3.2 of the Enforcement Policy.
                      Licensee-Identified Non-Cited Violation                           71111.18
Contrary to the above, on November 2, 2018, an activity affecting quality was not prescribed  
This violation of very low safety significance was identified by the licensee and has been
by documented instructions, procedures, or drawings, of a type appropriate to the  
entered into the licensee corrective action program and is being treated as a non-cited
circumstances. Specifically, Station Procedure SOP-102A, Residual Heat Removal System,  
violation, consistent with Section 2.3.2 of the Enforcement Policy.
Revision 20, Section 5.11, provided inadequate guidance for flushing lithium from the residual  
Violation: 10 CFR Part 50, Appendix B, Criterion III, Design Control, requires in part that
heat removal system with the reactor in Mode 1 operation.  
measures shall be established to assure that applicable regulatory requirements and the
design basis are correctly translated into specifications, drawings, procedures, and
Enforcement Action: This violation is being treated as a non-cited violation, consistent with  
instructions. Contrary to the above, from initial construction to December 2018, the licensee
Section 2.3.2 of the Enforcement Policy.  
failed to correctly translate the design basis into specifications and procedures. Specifically,
the licensee failed to ensure the design basis for nitrogen accumulator pressure for the
Licensee-Identified Non-Cited Violation  
pressurizer power operated relief valves (PORV) was correctly translated into the
71111.18  
specification for minimum allowable pressure, resulting in a non-conservative low pressure
This violation of very low safety significance was identified by the licensee and has been  
alarm setpoint. As a result, for a period of approximately 30 hours, one Unit 1 PORV would
entered into the licensee corrective action program and is being treated as a non-cited  
not have been able to cycle for the required number of operations to mitigate an overpressure
violation, consistent with Section 2.3.2 of the Enforcement Policy.  
event when required.
Significance: Green.
Violation: 10 CFR Part 50, Appendix B, Criterion III, Design Control, requires in part that  
Using Inspection Manual Chapter 0609, Attachment 04, Initial Characterization of Findings,
measures shall be established to assure that applicable regulatory requirements and the  
dated October 7, 2016, Inspection Manual Chapter 0609, Appendix G, Shutdown Operations
design basis are correctly translated into specifications, drawings, procedures, and  
Significance Determination Process, dated May 9, 2014, and Appendix G Attachment 1,
instructions. Contrary to the above, from initial construction to December 2018, the licensee  
Phase 1 Initial Screening and Characterization of Findings, Exhibit 4, Barrier Integrity
failed to correctly translate the design basis into specifications and procedures. Specifically,  
Screening Questions, the inspectors determined the finding affected the Barrier Integrity
the licensee failed to ensure the design basis for nitrogen accumulator pressure for the  
Cornerstone and required a detailed risk evaluation because the finding involved the
pressurizer power operated relief valves (PORV) was correctly translated into the  
unavailability of a PORV during low temperature overpressure (LTOP) operations.
specification for minimum allowable pressure, resulting in a non-conservative low pressure  
                                                  33
alarm setpoint. As a result, for a period of approximately 30 hours, one Unit 1 PORV would  
not have been able to cycle for the required number of operations to mitigate an overpressure  
event when required.  
Significance: Green.  
Using Inspection Manual Chapter 0609, Attachment 04, Initial Characterization of Findings,  
dated October 7, 2016, Inspection Manual Chapter 0609, Appendix G, Shutdown Operations  
Significance Determination Process, dated May 9, 2014, and Appendix G Attachment 1,  
Phase 1 Initial Screening and Characterization of Findings, Exhibit 4, Barrier Integrity  
Screening Questions, the inspectors determined the finding affected the Barrier Integrity  
Cornerstone and required a detailed risk evaluation because the finding involved the  
unavailability of a PORV during low temperature overpressure (LTOP) operations.  


  A senior risk analyst performed a bounding detailed risk evaluation and assumed that the
   
PORV not being able to cycle the full credited amount of times prevented the PORV from
34
fulfilling its LTOP system function. The analyst used the frequency estimate for overpressure
excursion events from NUREG-0933, Resolution of Generic Safety Issues: Issue 94:
A senior risk analyst performed a bounding detailed risk evaluation and assumed that the  
Additional Low Temperature Overpressure Protection for Light Water Reactors, to estimate
PORV not being able to cycle the full credited amount of times prevented the PORV from  
the initiating event frequency. Other influential assumptions used by the senior reactor
fulfilling its LTOP system function. The analyst used the frequency estimate for overpressure  
analyst included an exposure time of approximately 30 hours and that the licensee
excursion events from NUREG-0933, Resolution of Generic Safety Issues: Issue 94:
maintained the availability of a single additional relief valve (with its associated failure rate
Additional Low Temperature Overpressure Protection for Light Water Reactors, to estimate  
estimated from the 2016 data update to NUREG/CR-6928, Industry-Average Performance
the initiating event frequency. Other influential assumptions used by the senior reactor  
for Components and Initiating Events at U.S. Commercial Nuclear Power Plants) with
analyst included an exposure time of approximately 30 hours and that the licensee  
capability sufficient to mitigate an LTOP event as described in the final safety analysis report.
maintained the availability of a single additional relief valve (with its associated failure rate  
Using these assumptions, the senior reactor analyst determined that a bounding increase in
estimated from the 2016 data update to NUREG/CR-6928, Industry-Average Performance  
core damage frequency for this issue was 8.9E-8 per year and was, therefore, of very low
for Components and Initiating Events at U.S. Commercial Nuclear Power Plants) with  
safety significance (Green).
capability sufficient to mitigate an LTOP event as described in the final safety analysis report.  
  Corrective Action Reference(s):CR-2018-008757
Using these assumptions, the senior reactor analyst determined that a bounding increase in  
EXIT MEETINGS AND DEBRIEFS
core damage frequency for this issue was 8.9E-8 per year and was, therefore, of very low  
The inspectors verified no proprietary information was retained or documented in this report.
safety significance (Green).  
    *     On February 8, 2019, the inspector presented the Evaluations of Changes, Tests and
   
          Experiments inspection results to Mr. Tom McCool and other members of the licensee
Corrective Action Reference(s):CR-2018-008757  
          staff.
    *     On February 13, 2019, the inspector presented the Evaluations of Changes, Tests and
          Experiments inspection results to Mr. Tim Hope and other members of the licensee staff.
EXIT MEETINGS AND DEBRIEFS  
    *     On April 2, 2019, the inspector presented the quarterly resident inspector inspection
          results to Steven Sewell and other members of the licensee staff.
The inspectors verified no proprietary information was retained or documented in this report.  
                                                  34
*  
On February 8, 2019, the inspector presented the Evaluations of Changes, Tests and  
Experiments inspection results to Mr. Tom McCool and other members of the licensee  
staff.  
*  
On February 13, 2019, the inspector presented the Evaluations of Changes, Tests and  
Experiments inspection results to Mr. Tim Hope and other members of the licensee staff.  
*  
On April 2, 2019, the inspector presented the quarterly resident inspector inspection  
results to Steven Sewell and other members of the licensee staff.  


DOCUMENTS REVIEWED
71111.04 - Equipment Alignment
35
Condition Reports
CR-2000-000142           CR-2017-011443         CR-2018-008300     CR-2019-000653
DOCUMENTS REVIEWED  
CR-2019-000672           CR-2019-002533         TR-2017-011236     TR-2017-011749
Procedures
71111.04 - Equipment Alignment  
Number         Title                                                             Revision
STI-600.01     Protecting Plant Equipment and Sensitive Equipment Controls       1
Condition Reports  
SOP-605A       125 VDC Switchgear and Distribution Systems, Batteries and       12
CR-2000-000142  
                Battery Chargers
CR-2017-011443  
Drawings
CR-2018-008300  
Number               Title                                                       Revision
CR-2019-000653  
E1-0020 Sh. K         125V DC One Line Diagram                                   CP-24
CR-2019-000672  
E1-0020 Sh. L         125V DC One Line Diagram                                   CP-23
CR-2019-002533  
Miscellaneous
TR-2017-011236  
Documents                                                                     Revision
TR-2017-011749  
Number               Title                                                     or Date
FDA-2000-00142       Final Design Authorization                               02
Procedures  
Calculations                                                               Revision
Number  
Number             Title                                                 or Date
MM-90-2671         Technical Evaluation                                   11/28/1990
Title  
71111.12 - Maintenance Effectiveness
Condition Reports
Revision  
CR-2015-008236           CR-2016-000049         CR-2016-007907     CR-2017-000594
STI-600.01  
CR-2017-0010477           CR-2017-004704         CR-2018-003921     CR-2018-003945
Protecting Plant Equipment and Sensitive Equipment Controls  
CR-2018-004761           CR-2019-002622         TR-2016-000169     TR-2016-002742
1  
TR-2016-008960           TR-2018-004761
SOP-605A  
Work Orders
125 VDC Switchgear and Distribution Systems, Batteries and  
5380904     5517474         5144575     5220567     5331282     5347463       5377428
Battery Chargers  
                                              35
12
Drawings
Number  
Title  
Revision  
E1-0020 Sh. K  
125V DC One Line Diagram  
CP-24  
E1-0020 Sh. L  
125V DC One Line Diagram  
CP-23  
Miscellaneous
Documents  
Number  
Title  
Revision
or Date  
FDA-2000-00142  
Final Design Authorization  
02  
Calculations  
Number  
Title  
Revision
or Date  
MM-90-2671  
Technical Evaluation  
11/28/1990  
71111.12 - Maintenance Effectiveness  
Condition Reports  
CR-2015-008236  
CR-2016-000049  
CR-2016-007907  
CR-2017-000594  
CR-2017-0010477  
CR-2017-004704  
CR-2018-003921  
CR-2018-003945  
CR-2018-004761  
CR-2019-002622  
TR-2016-000169  
TR-2016-002742  
TR-2016-008960  
TR-2018-004761  
Work Orders  
5380904  
5517474  
5144575  
5220567  
5331282  
5347463  
5377428  


Miscellaneous
Documents                                                                       Revision
36
Number               Title                                                     or Date
DBD-EE-044           DC Power Systems                                           28
Miscellaneous
DBD-EE-043           118V AC Uninterruptible Power Supply System               14
Documents  
71111.13 - Maintenance Risk and Emergent Work
Number  
Condition Reports
TR-2019-000001
Work Orders
Title  
5692097     5705947
Procedures
Revision
Number         Title                                                             Revision
or Date  
STA-696         Hazard Barrier Controls                                           3
DBD-EE-044  
71111.17T - Evaluations of Changes, Tests and Experiments
DC Power Systems  
Condition Reports
28  
CR-2017-005150           CR-2017-012952         CR-2018-007381         CR-2018-007384
DBD-EE-043  
TR-2019-001160           CR-2019-001179         CR-2019-001200         CR-2019-001240
118V AC Uninterruptible Power Supply System  
CR-2019-001249           CR-2019-001271         IR-2019-001316         IR-2019-001317
14  
IR-2019-001318           IR-2019-001428         IR-2019-001430         TR-2017-007959
TR-2018-004675
71111.13 - Maintenance Risk and Emergent Work  
Work Orders
5352698     5510637         5510645     5510646       5510663     5510664     5510665
Condition Reports  
5510666     5510588         5510605     5510610       5510611     5510615     5510633
TR-2019-000001  
5510634     5510635         5510636     5351262       5351266     5351253     5383860
5351257     5351268         5346400     5284599       5435995     391842       3905518
Procedures
Number         Title                                                             Revision
ODA-401         Control of Annunciators, Instruments, and Protective Relays       11
Work Orders  
OPT-612B       RCS Pressure Boundary Leakage Test FOR LOOP 1 CL                   3
5692097  
                INJECTION VALVES
5705947  
                                              36
Procedures  
Number  
Title  
Revision  
STA-696  
Hazard Barrier Controls  
3  
71111.17T - Evaluations of Changes, Tests and Experiments  
Condition Reports  
CR-2017-005150  
CR-2017-012952  
CR-2018-007381  
CR-2018-007384  
TR-2019-001160  
CR-2019-001179  
CR-2019-001200  
CR-2019-001240  
CR-2019-001249  
CR-2019-001271  
IR-2019-001316  
IR-2019-001317  
IR-2019-001318  
IR-2019-001428  
IR-2019-001430  
TR-2017-007959  
TR-2018-004675  
Work Orders  
5352698  
5510637  
5510645  
5510646  
5510663  
5510664  
5510665  
5510666  
5510588  
5510605  
5510610  
5510611  
5510615  
5510633  
5510634  
5510635  
5510636  
5351262  
5351266  
5351253  
5383860  
5351257  
5351268  
5346400  
5284599  
5435995  
391842  
3905518  
Procedures  
Number  
Title  
Revision  
ODA-401  
Control of Annunciators, Instruments, and Protective Relays  
11  
OPT-612B  
RCS Pressure Boundary Leakage Test FOR LOOP 1 CL  
INJECTION VALVES  
3


Procedures
Number     Title                                             Revision
37
OPT-613B   RCS PRESSURE BOUNDARY LEAKAGE TEST FOR LOOP 2 CL 3
          INJECTION VALVES
Procedures  
SOP-102B   RESIDUAL HEAT REMOVAL SYSTEM                     15
Number  
SOP-609A   DIESEL GENERATOR SYSTEM                           21
STA-602   TEMPORARY MODIFICATIONS AND TRANSIENT EQUIPMENT   18
Title  
          PLACEMENTS
STA-707   10CFR50.59 AND 10CFR72.48 REVIEWS                 21
Revision  
STA-738   FIRE PROTECTION SYSTEMS/EQUIPMENT IMPAIRMENTS     7
OPT-613B  
STI-422.02 COMPENSATORY ACTIONS & TRANSIENT EQUIPMENT       1
RCS PRESSURE BOUNDARY LEAKAGE TEST FOR LOOP 2 CL  
          PLACEMENTS
INJECTION VALVES  
STI-707.04 10CFR50.59 AND 10CFR72.48 REVIEWS APPLICABILITY   1
3
          DETERMINATIONS
SOP-102B  
TDM-401B   TURBINE/GENERATOR LIMIT CURVES                   5
RESIDUAL HEAT REMOVAL SYSTEM  
ABN-104   RESIDUAL HEAT REMOVAL SYSTEM MALFUNCTION         9
15  
ABN-104   RESIDUAL HEAT REMOVAL SYSTEM MALFUNCTION         8
SOP-609A  
ABN-402   MAIN GENERATOR MALFUNCTION                       13
DIESEL GENERATOR SYSTEM  
ALM-0031A ALARM PROCEDURE 1-ALB-3A                         8
21  
ALM-0031B ALARM PROCEDURE 2-ALB-3A                         4
STA-602  
TDM-401B   TURBINE/GENERATOR LIMIT CURVES                   5
TEMPORARY MODIFICATIONS AND TRANSIENT EQUIPMENT  
Drawings
PLACEMENTS  
Number           Title                                       Revision
18
M2-0235         FLOW DIAGRAM, SPENT FUEL POOL COOLING AND   CP-17
STA-707  
                CLEAN-UP SYSTEM
10CFR50.59 AND 10CFR72.48 REVIEWS  
M2-2225         INSTRUMENTATION AND CONTROL DIAGRAM, FIRE   CP-2
21  
                DETECTION/PROTECTION SYSTEM CHANNELS 4100,
STA-738  
                4102, 4103, 4111
FIRE PROTECTION SYSTEMS/EQUIPMENT IMPAIRMENTS  
COMANCHE 004     UNIT 1 & UNIT 2 ISOPHASE BUS CONTROL PLC   CP-3
7  
                CONTROL PANEL CP1/2-EPIBHX-01P
STI-422.02  
COMANCHE 015     UNIT 1 & UNIT 2 ISOPHASE BUS CONTROL DAMPER CP-1
COMPENSATORY ACTIONS & TRANSIENT EQUIPMENT  
                CONTROL PANEL
PLACEMENTS  
COMANCHE 006     UNIT 1 & UNIT 2 ISOPHASE BUS CONTROL PLC   CP-3
1
                CONTROL PANEL CP1/2-EPIBHX-01P
STI-707.04  
COMANCHE 008     UNIT 1 & UNIT 2 ISOPHASE BUS CONTROL PLC   CP-2
10CFR50.59 AND 10CFR72.48 REVIEWS APPLICABILITY  
                CONTROL PANEL CP1/2-EPIBHX-01P
DETERMINATIONS  
COMANCHE 010     UNIT 1 & UNIT 2 ISOPHASE BUS CONTROL PLC   CP-2
1
                CONTROL PANEL CP1/2-EPIBHX-01P
TDM-401B  
                                      37
TURBINE/GENERATOR LIMIT CURVES  
5  
ABN-104  
RESIDUAL HEAT REMOVAL SYSTEM MALFUNCTION  
9  
ABN-104  
RESIDUAL HEAT REMOVAL SYSTEM MALFUNCTION  
8  
ABN-402  
MAIN GENERATOR MALFUNCTION  
13  
ALM-0031A  
ALARM PROCEDURE 1-ALB-3A  
8  
ALM-0031B  
ALARM PROCEDURE 2-ALB-3A  
4  
TDM-401B  
TURBINE/GENERATOR LIMIT CURVES  
5  
Drawings
Number  
Title  
Revision  
M2-0235  
FLOW DIAGRAM, SPENT FUEL POOL COOLING AND  
CLEAN-UP SYSTEM  
CP-17
M2-2225  
INSTRUMENTATION AND CONTROL DIAGRAM, FIRE  
DETECTION/PROTECTION SYSTEM CHANNELS 4100,  
4102, 4103, 4111  
CP-2
COMANCHE 004  
UNIT 1 & UNIT 2 ISOPHASE BUS CONTROL PLC  
CONTROL PANEL CP1/2-EPIBHX-01P  
CP-3
COMANCHE 015  
UNIT 1 & UNIT 2 ISOPHASE BUS CONTROL DAMPER  
CONTROL PANEL
CP-1  
COMANCHE 006  
UNIT 1 & UNIT 2 ISOPHASE BUS CONTROL PLC  
CONTROL PANEL CP1/2-EPIBHX-01P  
CP-3
COMANCHE 008  
UNIT 1 & UNIT 2 ISOPHASE BUS CONTROL PLC  
CONTROL PANEL CP1/2-EPIBHX-01P  
CP-2
COMANCHE 010  
UNIT 1 & UNIT 2 ISOPHASE BUS CONTROL PLC  
CONTROL PANEL CP1/2-EPIBHX-01P  
CP-2


Drawings
Number         Title                                                   Revision
38
COMANCHE 012   UNIT 1 & UNIT 2 ISOPHASE BUS CONTROL AHUA/AHUB         CP-3
              FAN STRTER PANELS CP1/2-EPIBMC-01 AND CP1/2-
Drawings
              EPIBMC-02
Number  
COMANCHE 014   UNIT 1 & UNIT 2 ISOPHASE BUS CONTROL                   CP-2
COMANCHE 011   UNIT 1 & UNIT 2 ISOPHASE BUS CONTROL PLC               CP-2
Title  
              CONTROL PANEL CP1/2-EPIBHX-01P
COMANCHE 013A UNIT 1 AND UNIT 2 ISOPHASE BUS CONTROL INTERNAL         CP-3
Revision  
              WIRING DIAGRAM
COMANCHE 012  
2323-A1-0507   PRIMARY PLANT AUXILIARY ELECTRICAL AND CONTROL CP-1
UNIT 1 & UNIT 2 ISOPHASE BUS CONTROL AHUA/AHUB  
              BUILDING FLOOR PLAN
FAN STRTER PANELS CP1/2-EPIBMC-01 AND CP1/2-
COMANCHE 002   UNIT 1 & UNIT 2 ISOPHASE BUS CONTROL INTERIOR           CP-2
EPIBMC-02  
              PANEL LAYOUT
CP-3
COMANCHE 003   UNIT 1 & UNIT 2 ISOPHASE BUS CONTROL PLC               CP-2
COMANCHE 014  
              CONTROL PANEL CP1/2-EPIBHX-01P
UNIT 1 & UNIT 2 ISOPHASE BUS CONTROL  
COMANCHE 015A UNIT 1 & UNIT 2 ISOPHASE BUS CONTROL DAMPER             CP-1
CP-2  
              CONTROL PANEL
COMANCHE 011  
COMANCHE 015B UNIT 1 & UNIT 2 ISOPHASE BUS CONTROL DAMPER             CP-1
UNIT 1 & UNIT 2 ISOPHASE BUS CONTROL PLC  
              CONTROL PANEL
CONTROL PANEL CP1/2-EPIBHX-01P  
M1-0260       FLOW DIAGRAM - RESIDUAL HEAT REMOVAL SYSTEM             CP-37
CP-2
M1-0261       FLOW DIAGRAM - SAFETY INJECTION SYSTEM SHEET 1         CP-24
COMANCHE 013A UNIT 1 AND UNIT 2 ISOPHASE BUS CONTROL INTERNAL  
              0F 5
WIRING DIAGRAM
M1-0216       FLOW DIAGRAM - COMPRESSED AIR SYSTEM                   CP-45
CP-3  
M1-0250       FLOW DIAGRAM - REACTOR COOLANT SYSTEM                   CP-34
2323-A1-0507  
M1-2300       INSTRUMENTATION AND CONTROL DIAGRAM,                   CP-7
PRIMARY PLANT AUXILIARY ELECTRICAL AND CONTROL  
              VENTILATION - CONTAINMENT, CHANNEL 5400/5403
BUILDING FLOOR PLAN  
Miscellaneous
CP-1
Documents                                                           Revision
COMANCHE 002  
Number       Title                                                 or Date
UNIT 1 & UNIT 2 ISOPHASE BUS CONTROL INTERIOR  
EVAL-2018-007 CPNPP Nuclear Oversight Audit Report - CONFIGURATION 08/16/2018
PANEL LAYOUT
              & DESIGN CONTROL
CP-2  
DBD-ME-013   Design Basis Document - Containment Isolation System 25
COMANCHE 003  
RIR-22946OCR Receipt Inspection Report                             10/06/1983
UNIT 1 & UNIT 2 ISOPHASE BUS CONTROL PLC  
CP-201700626 Comanche Peak Nuclear Power Plant, Docket Nos. 50-445 12/05/2017
CONTROL PANEL CP1/2-EPIBHX-01P  
              and 50-446 and 72-74, 10CFR50.59 Evaluation Summary
CP-2
              Report 020, 10CFR72.48 Evaluation Summary Report 005,
COMANCHE 015A UNIT 1 & UNIT 2 ISOPHASE BUS CONTROL DAMPER  
              and Commitment Material Change Evaluation Report 014
CONTROL PANEL
DBD-ME-014-02 Design Basis Document - Generator and Exciter System 21
CP-1  
                                      38
COMANCHE 015B UNIT 1 & UNIT 2 ISOPHASE BUS CONTROL DAMPER  
CONTROL PANEL
CP-1  
M1-0260  
FLOW DIAGRAM - RESIDUAL HEAT REMOVAL SYSTEM  
CP-37  
M1-0261  
FLOW DIAGRAM - SAFETY INJECTION SYSTEM SHEET 1  
0F 5
CP-24  
M1-0216  
FLOW DIAGRAM - COMPRESSED AIR SYSTEM  
CP-45  
M1-0250  
FLOW DIAGRAM - REACTOR COOLANT SYSTEM  
CP-34  
M1-2300  
INSTRUMENTATION AND CONTROL DIAGRAM,  
VENTILATION - CONTAINMENT, CHANNEL 5400/5403  
CP-7
Miscellaneous
Documents  
Number  
Title  
Revision
or Date  
EVAL-2018-007  
CPNPP Nuclear Oversight Audit Report - CONFIGURATION  
& DESIGN CONTROL
08/16/2018  
DBD-ME-013  
Design Basis Document - Containment Isolation System  
25  
RIR-22946OCR  
Receipt Inspection Report  
10/06/1983  
CP-201700626  
Comanche Peak Nuclear Power Plant, Docket Nos. 50-445  
and 50-446 and 72-74, 10CFR50.59 Evaluation Summary  
Report 020, 10CFR72.48 Evaluation Summary Report 005,  
and Commitment Material Change Evaluation Report 014  
12/05/2017
DBD-ME-014-02  
Design Basis Document - Generator and Exciter System  
21  


Vendor
Documents                                                                     Revision
39
Number             Title                                                     or Date
CP-201600573       EVALUATION OF COMANCHE PEAK UNIT 1 CLASS 2 TO 05/31/2016
Vendor  
                  CLASS 1VALVE UPGRADES
Documents  
CP1/CP2-           Damper Position Monitor                                   08/16/2016
Number  
EPIBHX-01E/01F
CT-27331           MISSILE PROBABILITY ANALYSIS METHODOLOGY                   8
                  FOR LUMINANT GENERATION COMPANY LLC,
Title  
                  COMANCHE PEAK UNITS 1 & 2 WITH SIEMENS
                  RETROFIT TURBINES
Revision
VDRT-5472306       Unit 2 Generator Stator Damage - Monitoring Installation   07/21/2017
or Date  
                  Plan
CP-201600573  
WPT-18067         Transmittal of LTR-SEE-17-189, Flow Evaluation of Forced 10/03/2017
EVALUATION OF COMANCHE PEAK UNIT 1 CLASS 2 TO  
                  Forward Flow through the Residual Heat Removal Pumps at
CLASS 1VALVE UPGRADES
                  Comanche Peak Units 1 & 2
05/31/2016  
Calculations
CP1/CP2-
Number             Title                                                       Revision
EPIBHX-01E/01F
MEB-391             Minimum Allowable Service Water Flow to Diesel Generators   5
Damper Position Monitor  
ME-CA-0229-2188     Component Cooling Water Heater Exchanger Fowling Water       8
08/16/2016  
                    Analysis
CT-27331  
71111.18 - Plant Modifications
MISSILE PROBABILITY ANALYSIS METHODOLOGY  
Condition Reports
FOR LUMINANT GENERATION COMPANY LLC,  
CR-2018-008757
COMANCHE PEAK UNITS 1 & 2 WITH SIEMENS  
Work Orders
RETROFIT TURBINES  
5435249       5689179
8
Modifications
VDRT-5472306  
Number                   Title                                                   Revision
Unit 2 Generator Stator Damage - Monitoring Installation  
FDA-2018-000119-01       Final Design Authorization
Plan
Calculations
07/21/2017  
Number                   Title                                                   Revision
WPT-18067  
ME-CA-0000-3342         Air Accumulator Check Valve Leakage - Decay Rate,       3
Transmittal of LTR-SEE-17-189, Flow Evaluation of Forced  
                        Pressure, Time
Forward Flow through the Residual Heat Removal Pumps at  
                                              39
Comanche Peak Units 1 & 2  
10/03/2017
Calculations  
Number  
Title  
Revision  
MEB-391  
Minimum Allowable Service Water Flow to Diesel Generators  
5  
ME-CA-0229-2188 Component Cooling Water Heater Exchanger Fowling Water  
Analysis
8  
71111.18 - Plant Modifications  
Condition Reports  
CR-2018-008757  
Work Orders  
5435249  
5689179  
Modifications
Number  
Title  
Revision  
FDA-2018-000119-01  
Final Design Authorization  
Calculations
Number  
Title  
Revision  
ME-CA-0000-3342  
Air Accumulator Check Valve Leakage - Decay Rate,  
Pressure, Time  
3


71152 - Identification and Resolution of Problems
Condition Reports
40
CR-2017-013243           CR-2018-003808           CR-2019-002535
Work Orders
71152 - Identification and Resolution of Problems  
5540984       5063234
Procedures
Condition Reports  
Number           Title                                         Revision
CR-2017-013243  
STI-606.03       Work Planning                                 3
CR-2018-003808  
Miscellaneous
CR-2019-002535  
Documents
Number           Title                                         Revision
DBD-EE-023       Radiation Monitoring System                   23
Work Orders  
                                              40
5540984  
5063234  
Procedures  
Number  
Title  
Revision  
STI-606.03  
Work Planning  
3  
Miscellaneous  
Documents  
Number  
Title  
Revision  
DBD-EE-023  
Radiation Monitoring System  
23  




ML19130A154
  ML19130A154  
  SUNSI Review           ADAMS         Publicly Available         Non-Sensitive  Keyword:
SUNSI Review  
Complete                  Yes  No    Non-Publicly Available      Sensitive      NRC-002
Complete
By: RDA
By:  RDA
OFFICE        SRI/DRP/A     RI/DRP/A   DRS/EB1         DRS/EB2       DRS/OB         DRS/IPAT
ADAMS  
NAME           JJosey       RKumana     VGaddy           GPick         GWerner       RKellar
Yes  No
SIGNATURE     /RA/         /RA/       /RA/             /RA/         /RA/ CCO for   /RA/
Publicly Available  
DATE           05/07/19     05/03/19   05/02/19         05/08/19     05/03/19       05/06/19
Non-Publicly Available
OFFICE         DRS/RCB       DNMS/RIB   SPE:DRP/A       BC/DRP/A
Non-Sensitive  
  NAME           NMakris       GWarnick   RAlexander       MHaire
  Sensitive
  SIGNATURE     /RA/         /RA/       /RA/             /RA/
Keyword:
  DATE           05/02/19     05/07/19   05/02/19         5/10/2019
NRC-002  
OFFICE
SRI/DRP/A  
RI/DRP/A  
DRS/EB1  
DRS/EB2  
DRS/OB  
DRS/IPAT  
NAME  
JJosey  
RKumana  
VGaddy  
GPick  
GWerner  
RKellar  
SIGNATURE  
/RA/  
/RA/  
/RA/  
/RA/  
/RA/ CCO for  
/RA/  
DATE  
05/07/19  
05/03/19  
05/02/19  
05/08/19  
05/03/19  
05/06/19  
OFFICE  
DRS/RCB  
DNMS/RIB  
SPE:DRP/A  
BC/DRP/A  
   
NAME  
NMakris  
GWarnick  
RAlexander  
MHaire  
   
SIGNATURE  
/RA/  
/RA/  
/RA/  
/RA/  
   
DATE  
05/02/19  
05/07/19  
05/02/19  
5/10/2019
}}
}}

Latest revision as of 02:32, 5 January 2025

NRC Integrated Inspection Report 05000445/2019001 and 05000446/2019001
ML19130A154
Person / Time
Site: Comanche Peak  Luminant icon.png
Issue date: 05/10/2019
From: Mark Haire
NRC/RGN-IV/DRP/RPB-A
To: Peters K
Vistra Operations Company
References
IR 2019001
Download: ML19130A154 (41)
v • d • e


See also: IR 05000445/2019001

Text

May 10, 2019

Mr. Ken Peters, Senior Vice President

and Chief Nuclear Officer

VISTRA Operations Company, LLC

P.O. Box 1002

Glen Rose, TX 76043

SUBJECT:

COMANCHE PEAK NUCLEAR POWER PLANT, UNITS 1 AND 2 - NRC

INTEGRATED INSPECTION REPORT 05000445/2019001 AND

05000446/2019001

Dear Mr. Peters:

On March 31, 2019, the U.S. Nuclear Regulatory Commission (NRC) completed an inspection

at your Comanche Peak Nuclear Power Plant, Units 1 and 2. On April 2, 2019, the NRC

inspectors discussed the results of this inspection with Mr. Steven Sewell and other members of

your staff. The results of this inspection are documented in the enclosed report.

NRC inspectors documented seven findings of very low safety significance (Green) in this

report. These findings involved violations of NRC requirements. Additionally, NRC inspectors

documented one Severity Level IV violation with no associated finding. The NRC is treating

these violations as non-cited violations (NCV) consistent with Section 2.3.2.a of the

Enforcement Policy.

The inspectors also documented a licensee-identified violation which was determined to be of

very low safety significance in this report. 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 violations or significance or severity of the violations documented in this

inspection report, 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 Comanche Peak Nuclear Power Plant.

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 Comanche Peak Nuclear Power Plant.

K. Peters

2

2

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/

Mark S. Haire, Chief

Project Branch A

Division of Reactor Projects

Docket Nos. 50-445 and 50-446

License Nos. NPF-87 and NPF-89

Enclosure:

Inspection Report 05000445/2019001

and 05000446/2019001

3

U.S. NUCLEAR REGULATORY COMMISSION

Inspection Report

Docket Number(s):

05000445 and 05000446

License Number(s):

NPF-87 and NPF-89

Report Number(s):

05000445/2019001 and 05000446/2019001

Enterprise Identifier: I-2019-001-0011

Licensee:

Vistra Operations Company, LLC

Facility:

Comanche Peak Nuclear Power Plant, Units 1 and 2

Location:

Glen Rose, TX 76043

Inspection Dates:

January 1, 2019 to March 31, 2019

Inspectors:

W. Cullum, Reactor Inspector

R. Deese, Senior Reactor Analyst

J. Drake, Senior Reactor Inspector

J. Josey, Senior Resident Inspector

R. Kumana, Resident Inspector

W. Sifre, Senior Reactor Inspector

Approved By:

Mark S. Haire, Chief

Project Branch A

Division of Reactor Projects

4

SUMMARY

The U.S. Nuclear Regulatory Commission (NRC) continued monitoring the licensees

performance by conducting a Quarterly inspection at Comanche Peak Nuclear Power Plant,

Units 1 and 2, in accordance with the Reactor Oversight Process. The Reactor Oversight

Process is the NRCs program for overseeing the safe operation of commercial nuclear power

reactors. Refer to https://www.nrc.gov/reactors/operating/oversight.html for more information.

Findings and violations being considered in the NRCs assessment are summarized in the table

below. A licensee-identified non-cited violation is documented in report section: 71111.18.

List of Findings and Violations

Inadequate Corrective Actions for Failure to Ensure Containment Hatch Closure Capability

Cornerstone

Significance

Cross-cutting

Aspect

Report

Section

Barrier Integrity

Green

NCV 05000445;05000446/2019001-01

Closed

[H.6] - Design

Margins

71111.04

The inspectors identified a Green non-cited violation of 10 CFR Part 50, Appendix B,

Criterion XVI, Corrective Actions, associated with the licensees failure to take adequate

corrective actions for an inadequate containment closure procedure. Specifically, in

December 2017, the NRC identified that the licensee's procedure for emergency closure of

the Unit 1 and 2 containment equipment hatches was inadequate, and the licensee failed to

take adequate actions to correct the issue prior to the next outage.

Failure to Evaluate a Change to the Facility DC Power System

Cornerstone

Significance

Cross-cutting

Aspect

Report

Section

Not Applicable

NCV 05000445/2019001-02

Closed

Not Applicable

71111.04

The inspectors identified a Severity Level IV, non-cited violation of 10 CFR 50.59 for the

licensees failure to obtain a license amendment or perform a written evaluation

demonstrating the basis for not obtaining a license amendment, prior to making a change to

the facility as described in the final safety analysis report.

Failure to Monitor or Demonstrate Control of Performance Under the Maintenance Rule

Cornerstone

Significance

Cross-cutting

Aspect

Report

Section

Mitigating

Systems

Green

NCV 05000445;05000446/2019001-03

Closed

None

71111.12

The inspectors identified a Green non-cited violation of 10 CFR 50.65(a)(2), with

three examples, for failure to demonstrate effective control of performance of a maintenance

rule scoped system through appropriate preventive maintenance.

5

Failure to Control Hazard Barriers During Maintenance

Cornerstone

Significance

Cross-cutting

Aspect

Report

Section

Mitigating

Systems

Green

NCV 05000445/2019001-04

Closed

[H.14] -

Conservative

Bias

71111.13

The inspectors identified a Green non-cited violation of 10 CFR 50.65(a)(4) for failure to

implement risk mitigating actions during diesel generator maintenance.

Failure to Follow Procedure When A Degraded Condition Was Identified

Cornerstone

Significance

Cross-cutting

Aspect

Report

Section

Mitigating

Systems

Green

NCV 05000445;05000446/2019001-05

Closed

[H.14] -

Conservative

Bias

71111.15

The inspectors identified a Green non-cited violation of 10 CFR Part 50, Appendix B,

Criterion V, Instructions, Procedures, and Drawings, associated with the licensees failure to

follow the requirements of Station Procedure STI-421.01, Initiation of Issue Reports,

Revision 0. Specifically, station personnel failed to notify the shift manager of an issue with

material storage in the protected area. This issue required evaluations and compensatory

actions for resolution.

Failure to Perform Safety Evaluations in Accordance with 10 CFR 50.59

Cornerstone

Significance

Cross-cutting

Aspect

Report

Section

Mitigating

Systems

Green

NCV 05000445;05000446/2019001-06

Closed

[H.9] - Training

71111.17T

The inspectors identified a Green, non-cited violation of 10 CFR 50, Appendix B, Criterion V,

Instructions, Procedures, and Drawings, (with four examples) in which the licensee failed to

complete 50.59 evaluations as required by station procedures.

Inadequate Maintenance Instructions Result in Loss of Assessment Capability

Cornerstone

Significance

Cross-cutting

Aspect

Report

Section

Emergency

Preparedness

Green

NCV 05000445;05000446/2019001-07

Closed

[H.8] -

Procedure

Adherence

71152

The inspectors reviewed a self-revealed Green, non-citied violation of 10 CFR 50,

Appendix B, Criterion V, "Instruction, Procedures, and Drawings," that occurred due to

inadequate maintenance instructions for safety-related radiation monitors that resulted in a

major loss of assessment capability.

6

Failure to Establish Adequate Procedural Guidance for Flushing Lithium at Power

Cornerstone

Significance

Cross-cutting

Aspect

Report

Section

Mitigating

Systems

Green

NCV 05000446/2019001-08

Closed

[H.11] -

Challenge the

Unknown

71152

The inspectors reviewed a Green, self-revealed non-cited violation of 10 CFR Part 50,

Appendix B, Criterion V, Instructions, Procedures, and Drawings, associated with the

licensees failure to establish an adequate procedure for flushing lithium from the residual

heat removal system. This resulted in safety injection accumulators 2-01 and 2-02 discharge

to the safety injection test header causing level drops in both accumulators and

accumulator 2-01 pressure dropped to below the operability limit resulting in an unplanned

component inoperability.

Additional Tracking Items

Type

Issue Number

Title

Report

Section

Status

NOV 05000446/2018011-01

Failure to Maintain a Quality

Record Complete and Accurate

in All Material Respects

92702

Closed

LER 05000446/2018-001-00 Unit 2 Automatic Reactor Trip

Due to Turbine Trip, on

March 19, 2019

71153

Closed

7

PLANT STATUS

Unit 1 began the inspection period at or near rated thermal power. On February 1, 2019, the

unit was down powered to 64 percent for turbine testing. The unit was returned to rated thermal

power the same day. On March 22, 2019, the unit began power coast down to a refueling

outage, ending the inspection period at 92 percent power.

Unit 2 began the inspection period in a refueling outage. On January 14, 2019, the unit began a

reactor startup. The unit shut down on January 15, 2019, due to a main turbine primary water

leak. On January 18, 2019, the unit began a reactor startup and reached rated thermal power

on January 22, 2019. On March 2, 2019, the unit was tripped due to a failure of a main

feedwater isolation valve. The unit began a reactor startup the same day and reached rated

thermal power on March 4, 2019. The unit remained at or near rated thermal power for the

remainder of the inspection period.

INSPECTION SCOPES

Inspections were conducted using the appropriate portions of the inspection procedures (IPs) in

effect at the beginning of the inspection unless otherwise noted. Currently approved IPs with

their attached revision histories are located on the public website at http://www.nrc.gov/reading-

rm/doc-collections/insp-manual/inspection-procedure/index.html. Samples were declared

complete when the IP requirements most appropriate to the inspection activity were met

consistent with Inspection Manual Chapter 2515, Light-Water Reactor Inspection Program -

Operations Phase. The inspectors performed plant status activities described in Inspection

Manual Chapter 2515 Appendix D, Plant Status and conducted routine reviews using

IP 71152, Problem Identification and Resolution. The inspectors reviewed selected

procedures and records, observed activities, and interviewed personnel to assess licensee

performance and compliance with Commission rules and regulations, license conditions, site

procedures, and standards.

REACTOR SAFETY

71111.01 - Adverse Weather Protection

Impending Severe Weather Sample (IP Section 03.03) (1 Sample)

The inspectors evaluated readiness for impending adverse weather conditions for severe

thunderstorms on March 13, 2019.

71111.04 - Equipment Alignment

Partial Walkdown (IP Section 02.01) (4 Samples)

The inspectors evaluated system configurations during partial walkdowns of the following

systems/trains:

(1)

Unit 1, safety injection pump 1-01 while 1-02 was out of service for maintenance on

February 5, 2019

(2)

Unit 2, containment hatches on February 13, 2019

8

(3)

Units 1 and 2, common class-1E DC power on March 5, 2019

(4)

Units 1 and 2, seismic monitoring system on March 18, 2019

71111.05Q - Fire Protection

Quarterly Inspection (IP Section 03.01) (5 Samples)

The inspectors evaluated fire protection program implementation in the following selected

areas:

(1)

fire area 2CA, Unit 2 reactor building on January 9, 2019

(2)

fire zones TB201 and TB202, control room emergency lighting battery rooms on

January 14, 2019

(3)

fire zone 1SB2A, Unit 1 safety injection pump 1-01 on March 11, 2019

(4)

fire zone 2SB4, Unit 2 containment spray chemical add tank on March 13, 2019

(5)

fire zone SM157, stairwell in the southeast corner of the safeguards building on

March 26, 2019

71111.06 - Flood Protection Measures

Inspection Activities - Internal Flooding (IP Section 02.02a.) (1 Sample)

The inspectors evaluated internal flooding mitigation protections in the service water intake

structure on March 12, 2019.

71111.11Q - Licensed Operator Requalification Program and Licensed Operator Performance

Licensed Operator Performance in the Actual Plant/Main Control Room (IP Section 03.01)

(2 Samples)

(1)

The inspectors observed and evaluated licensed operator performance in the Control

Room during Unit 2 startup on January 14, 2019.

(2)

The inspectors observed and evaluated licensed operator performance in the Control

Room during Unit 2 startup on January 18, 2019.

Licensed Operator Requalification Training/Examinations (IP Section 03.02) (1 Sample)

The inspectors observed and evaluated a simulator-based loss of coolant accident scenario

on March 27, 2019.

9

71111.12 - Maintenance Effectiveness

Routine Maintenance Effectiveness Inspection (IP Section 02.01) (3 Samples)

The inspectors evaluated the effectiveness of routine maintenance activities associated with

the following equipment and/or safety significant functions:

(1)

common low voltage power distribution failure to align to normal power supply on

February 28, 2019

(2)

Unit 1, battery charger and inverter failures which occurred in June 2018, on

February 28, 2019

(3)

service air check valve failure during surveillance testing on March 14, 2019

71111.13 - Maintenance Risk Assessments and Emergent Work Control

Risk Assessment and Management Sample (IP Section 03.01) (5 Samples)

The inspectors evaluated the risk assessments for the following planned and emergent work

activities:

(1)

Unit 1, risk mitigating actions during emergency diesel generator 1-01 lube oil fill on

January 17, 2019

(2)

Unit 1, risk mitigating actions while safety injection pump 1-02 was out of service on

February 5, 2019

(3)

Unit 1, risk assessment during sequencer undervoltage replacement on

February 13, 2019

(4)

Units 1 and 2, removal of service water pipe tunnel missile shield CPX-SWMEBB-01

on February 28, 2019

(5)

Units 1 and 2, risk mitigating actions with transformer XST2 unavailable on

March 29, 2019

71111.15 - Operability Determinations and Functionality Assessments

Sample Selection (IP Section 02.01) (5 Samples)

The inspectors evaluated the following operability determinations and functionality

assessments:

(1)

CR-2019-000324, Units 1 and 2, environmental qualification of steam generator

atmospheric relief valves on January 10, 2019

(2)

CR-2019-000456, Units 1 and 2, Electroswitch Part 21 relay issue on

January 14, 2019

10

(3)

TR-2019-001119, Units 1 and 2, tornado missile evaluation for equipment storage on

February 13, 2019

(4)

TR-2019-000805, Units 1 and 2, operations support center HVAC sensor failure on

February 14, 2019

(5)

CR-2019-002132, Unit 1, environmental qualification of service water valves with

teflon components on March 12, 2019

71111.17T - Evaluations of Changes, Tests, and Experiments

Sample Selection (IP Section 02.01) (35 Samples)

The inspectors reviewed the following evaluations (items 1 through 8), screenings, and/or

applicability determinations for 10 CFR 50.59 from September 30, 2016, to

January 14, 2019.

(1)

EV-CR-2016-001706-8, Revision1; FDA-2016-000025-01 temporary modification of

2RC-8054A to repair a leak on pressurizer 01 Pressure Transmitter.

(2)

AEV-CR-2016-005587-9; FDA-2016-000142-01, LDCR SA-2016-013 and

LDC R TR-2016-003, Missile Probability Analysis Revision.

(3)

EV-TR-2017-003173-5 ABN-104, Revision 9; PCN-9 addition of alternate residual

heat removal path and use of safety injection pump for core cooling in Mode 6.

(4)

EV-TR-2017-007959-13; Perform 50.59 Evaluation for FDA-2017-000106-02

Generator Repair Plan and 59SC-2017-000106-02.

(5)

EV-2014-013052-9; Modification to change the isolated phase bus cooling fans start

logic to provide seven out of eight dampers open requirement using digital

equipment.

(6)

EV-CR-2016-003267-10; FDA-2016-000075-01 Unit 1 pressurizer instrument

isolation valves class change (LDCR-SA-2016-010).

(7)

EV-TR-2018-004520-14; Evaluate operator action for isolation of faulted battery

charger from its battery per 50.59 screen EV-TR-2018-004520-13.

(8)

EV-CR-2017-004574-2; 59SC - STA-707-1 50.59 screen for 2RF16 changes to

procedures for reactor vessel head and upper internals lifts.

(9)

EV-TR-2015-006849-4; 59SC - Provide 50.59 SC to support DCP-17-000010 to input

FZ locations of raceways and equipment into GENESIS in support of

ME-CA-0000-1086 revision.

(10)

EV-TR-2018-004520-10; 59SC - Perform a 50.59 screen for a compensatory

measure to jumper battery cell.

11

(11)

EV-CR-2014-003412-18; 59SC - Perform 50.59 applicability determination and

screen for additional plugging for component cooling water heat exchanger 2-01 in

2RF14.

(12)

EV-TR-2018-003799-6; Perform 10CFR50.59 review of minor fuel design changes

documented in NF-TB-16-21.

(13)

EV-TR-2018-003700-2; Refer to the attached VDRT package which contains the

requested screen and complete VDRT-5608075 package for valve XWT-0634.

(14)

EV-TR-2018-000169-4; 50.59 screen for backseating of 1MS-0357, SG 1-03

blowdown downstream isolation valve.

(15)

EV-TR-2018-000198-1; Maintenance clearance placed for isolation of 1-LG-2706A

may exceed 90 days.

(16)

EV-TR-2018-000199-1; Maintenance clearance placed for diesel generator starting

compressor solenoid 1-SV-3422-1F may exceed 90 days.

(17)

EV-TR-2018-000600-1; Shift manager clearance placed to isolate TBX-CSFLSI-01

seal water injection filter 01.

(18)

EV-CR-2016-008147-3; Compensatory action of installing scaffolding for medium

energy line break (MELB) barrier.

(19)

EV-CR-2017-007829-1; 59SC - Compensatory actions to install temporary equipment

for flow measurement.

(20)

EV-CR-2017-010212-1; 59SC - Shift manager clearance CP17-0913 due to

feedpump deluge valve not resetting.

(21)

EV-CR-2017-012952-28; 59SC - Shift manager clearance to remove fuses 2-

KXA/0746 and 2-KXB/0746.

(22)

EV-CR-2018-004743-2; 59SC - Compensatory action to blow down the receiver once

per shift.

(23)

EV-TR-2016-005840-10; 59SC - VDRT-5575487 Which includes vendor final

acceptance tests for open phase protection equipment for XST1.

(24)

EV-TR-2017-000041-32; 59SC - VDRT-5397434, Fuel transfer system transfer cart

weldment.

(25)

EV-TR-2017-003173-4; 59SC - Review for revision to ABN-104 based on

EV-TR-2017-003173-3 for loss of residual heat removal events.

(26)

EV-CR-2018-002390-5; 59SC - Changes made under EV-CR-2018-002390-4.

(27)

EV-CR-2018-006758-1; 59SC - Screen for the compensatory action for average

containment temperature.

12

(28)

EV-CR-2018-007384-1; 59SC - Perform 50.59 screen changes to procedures

OPT-612B and OPT-613B.

(29)

EV-CR-2016-007812-1; 59SC - Perform a 10CFR50.59 Review per STA-707 to

update UFSAR Table 9.5-18 to specify tube plugging limit for diesel generator jacket

water coolers for Unit 1 and Unit 2.

(30)

EV-TR-2018-008391-16; 59SC - Perform a 10CFR50.59 Review per STA-707 to plug

tubes in the component cooling water heat exchangers.

(31)

EV-CR-2018-002189-2; 59SC - 50.59 screen for compensatory action to maintain

2-HV-2334A accumulator pressure above 2100psi.

(32)

EV-CR-2016-008215-20; 59SC - 50.59 review of compensatory measures to isolate

suction and discharge pressure indication on CT and SF pumps;

ref: EV-CR-2016-008215-19.

(33)

EV-TR-2016-009344-1; 59SC - Shift Manager Clearance CP16-1381 initiated to

maintain X-PV-3218A isolated following failure of a functional stroke; request a

50.59SC to determine impact on the plant.

(34)

EV-CR-2018-005954-3; 59SC - Seal injection filters housing bolts and potential

excessive torque specification VDRT-5655877.

(35)

EV-TR-2016-010572-2; 59SC - 59SC - Perform a 50.59 screen for hanging shift

manager clearance CP16-1614 on 2-HS-2802A for damage to upper journal bearings

on the motor for Circulating Water Pump Motor 2-03.

71111.18 - Plant Modifications

Temporary Modifications and/or Permanent Modifications (IP Section 03.01 and/or 03.02)

(2 Samples)

The inspectors evaluated the following temporary or permanent modifications:

(1)

Unit 2, pressurizer power operated relief valve accumulator pressure setpoint

modification on February 14, 2019

(2)

bladder addition to safety-related tanks on March 11, 2019

71111.19 - Post Maintenance Testing

Post Maintenance Test Sample (IP Section 03.01) (5 Samples)

The inspectors evaluated the following post maintenance tests:

(1)

Unit 2, diesel generator 2-02 following intercooler crack and jacket water repair on

February 12, 2019

(2)

Unit 2, pressurizer spray valve following actuator rebuild on February 20, 2019

13

(3)

Unit 1, diesel generator 1-01 following fuel injector torqueing on March 13, 2019

(4)

Unit 2, residual heat removal pump 2-02 following pump refurbishment on

March 19, 2019

(5)

Unit 2, auxiliary feedwater pump 2-01 following maintenance on March 20, 2019

71111.20 - Refueling and Other Outage Activities

Refueling/Other Outage Sample (IP Section 03.01) (1 Sample)

The inspectors evaluated refueling outage 2RF17 activities from January 1, 2019, to

January 18, 2019, completing the sample for the refueling outage which started on

December 8, 2018 (see Inspection Report 05000445/2018004; 05000446/2018004 (ADAMS

Accession No. ML19042A345)). Specifically, the inspectors completed Inspection

Procedure 71111.20, Sections 03.01.d through e, during this inspection period.

71111.22 - Surveillance Testing

The inspectors evaluated the following surveillance tests:

Containment Isolation Valve (ISO) (IP Section 03.01) (1 Sample)

Unit 2, service air containment isolation valve test on March 7, 2019

Surveillance Testing (IP Section 03.01) (1 Sample)

Unit 2, OPT-601B auxiliary feedwater flow control valve accumulator pressure drop test on

March 26, 2019

OTHER ACTIVITIES - BASELINE

71151 - Performance Indicator Verification

The inspectors verified licensee performance indicators submittals listed below:

IE01: Unplanned Scrams per 7000 Critical Hours Sample (IP Section 02.01) (2 Samples)

(1)

Unit 1 from January 2018 through December 2018

(2)

Unit 2 from January 2018 through December 2018

IE03: Unplanned Power Changes per 7000 Critical Hours Sample (IP Section 02.02)

(2 Samples)

(1)

Unit 1 from January 2018 through December 2018

(2)

Unit 2 from January 2018 through December 2018

14

IE04: Unplanned Scrams with Complications (USwC) Sample (IP Section 02.03)

(2 Samples)

(1)

Unit 1 from January 2018 through December 2018

(2)

Unit 2 from January 2018 through December 2018

71152 - Problem Identification and Resolution

Annual Follow-up of Selected Issues (IP Section 02.03) (2 Samples)

The inspectors reviewed the licensees implementation of its corrective action program

related to the following issues:

(1)

radiation monitor failures due to failure to install a jumper during maintenance on

February 28, 2019

(2)

safety injection accumulator discharge due to inadequate procedure on

March 29, 2019

71153 - Follow-up of Events and Notices of Enforcement Discretion

Event Report (IP Section 03.02) (1 Sample)

The inspectors evaluated the following licensee event reports which can be accessed at

https://lersearch.inl.gov/LERSearchCriteria.aspx:

(1)

Licensee Event Report 05000446/2018-001-00, "Unit 2 Automatic Reactor Trip Due

to Turbine Trip," on March 19, 2019

The inspectors determined that it was not reasonable to foresee or correct the cause

discussed in the LER; therefore, no performance deficiency was identified. The inspectors

also concluded that no violation of NRC requirements occurred.

OTHER ACTIVITIES - TEMPORARY INSTRUCTIONS, INFREQUENT AND ABNORMAL

92702 - Follow-up on Corrective Actions for Violations And Deviations

Follow-up - Corrective Actions - Violations and Deviations (1 Sample)

On March 28, 2019, the inspectors reviewed the licensees response to

NOV 05000446/2018011-01, "Failure to Maintain a Quality Record Complete and Accurate

in All Material Respects," and determined that the reason for the violation, corrective actions

taken and planned to address recurrence, and the date when full compliance will be

achieved for this violation is adequately addressed and captured on the docket.

15

INSPECTION RESULTS

Inadequate Corrective Actions for Failure to Ensure Containment Hatch Closure Capability

Cornerstone

Significance

Cross-cutting

Aspect

Report

Section

Barrier Integrity

Green

NCV 05000445; 05000446/2019001-

01

Closed

[H.6] - Design

Margins

71111.04

The inspectors identified a Green non-cited violation of 10 CFR Part 50, Appendix B,

Criterion XVI, Corrective Actions, associated with the licensees failure to take adequate

corrective actions for an inadequate containment closure procedure. Specifically, in

December 2017, the NRC identified that the licensee's procedure for emergency closure of

the Units 1 and 2 containment equipment hatches was inadequate and the licensee failed to

take adequate actions to correct the issue prior to the next outage.

Description: In Inspection Report 2017-004, the NRC documented a non-cited violation for an

inadequate procedure, STI 600.01, "Protecting Plant Equipment and Sensitive Equipment

Controls." This procedure contained instructions for emergency closure of the containment

equipment hatch during times when the hatch was open, but the ability to close containment

was required. The inspectors observed that the bolting pattern and required torque that were

identified in the supporting engineering calculation were not incorporated into the procedure.

The licensees technical evaluation required four bolts spaced 90 degrees apart and torqued

to 30 percent preload values. The procedure did not require bolts to be evenly spaced and

only required the bolts to be snug tight, a licensee term implying full effort on the tool being

used. The licensee entered this into their corrective action program. Subsequently, the

licensee performed an evaluation to justify alternate bolt spacing patterns and revised the

procedure to include adequate bolting patterns. However, in their evaluation the licensee

stated that no torque requirement existed, and the requirement was only to hold the hatch in

place.

The inspectors observed the containment hatch closure training during Refueling

Outage 2RF17. The inspectors observed that the bolt patterns used conformed to the revised

procedure and evaluation, but that the hatch operators did not appear to apply any torque to

the bolts. When the inspectors asked about the bolts, the operators believed that there was

no requirement to apply any torque beyond that needed to hold the hatch in place.

The inspectors determined that by not applying any type of torque to the bolts, the licensee

was not verifying that the containment equipment hatch could be sealed. A seal is necessary

to ensure that a release of fission product radioactivity within containment will be restricted

from escaping to the environment in the event of a loss of decay heat removal event when the

reactor coolant system was open to the atmosphere.

The licensee performed another evaluation and concluded that the minimum torque required

to ensure a seal with four bolts was 144 ft-lbf. The licensee conducted additional training with

all hatch operators on the requirement to ensure a seal on the hatch. They also conducted a

demonstration with the assigned operators and concluded that the average operator applying

full effort would achieve greater than 150 ft-lbf.

16

Corrective Action(s): The licensee trained the operators on the requirement to ensure the

bolts were adequately torqued and verified through demonstration that the operators could

apply enough torque to ensure the hatch would be sealed.

Corrective Action Reference(s): CR-2018-008300, CR-2019-002533

Performance Assessment:

Performance Deficiency: The inability to assure containment closure during a postulated loss

of decay heat removal or fuel handling accident was a condition adverse to quality. The

failure to correct a condition adverse to quality is a performance deficiency.

Screening: The inspectors determined the performance deficiency was more than minor

because it was associated with the SSC and barrier performance attribute of the Barrier

Integrity Cornerstone. It adversely affected the cornerstone objective to provide reasonable

assurance that physical design barriers (fuel cladding, reactor coolant system, and

containment) protect the public from radionuclide releases caused by accidents or events

because the finding represented a loss of reasonable assurance of the ability to close the

containment equipment hatch. Specifically, the failure to assure that personnel would

adequately torque the bolts on the hatch sufficient to establish a seal would, in an actual

event, result in a loss of the containment barrier.

Significance: The inspectors assessed the significance of the finding using Appendix H,

Containment Integrity SDP. Using Inspection Manual Chapter 0609, Attachment 04, Initial

Characterization of Findings, dated October 7, 2016, the inspectors determined the finding

was associated with the Barrier Integrity cornerstone. Using Inspection Manual

Chapter 0609, Appendix G, Attachment 1, Shutdown Operations Significance Determination

Process Phase 1 Initial Screening and Characterization of Findings, Exhibit 4, Barrier

Integrity Screening Questions, the inspectors determined the finding degraded the ability to

close or isolate containment and required evaluation under Inspection Manual Chapter 0609,

Appendix H, Containment Integrity Significance Determination Process, dated

February 25, 2019. Using the Large Early Release Frequency (LERF) type screening

process, the inspectors determined the finding was a Type B LERF finding because the

finding did not affect core damage frequency. The inspectors used

Table 7.3, Phase 1 Screening - Type B Findings at Shutdown, and determined that a

Phase 2 estimate was required because the containment equipment hatch affected

containment isolation, which is a system important to LERF. The inspectors used Table 7.4,

Phase 2 Risk Significance - Type B Findings at Shutdown, to determine the finding was of

very low safety significance (Green) because it did not meet the threshold for low safety

significance (White) for leakage from containment to the environment being greater than

100 percent containment volume per day through containment penetration seals, isolation

valves, or vent and purge systems. Specifically, the licensee was able to demonstrate

through calculations that the leakage from the containment hatch being closed, but not

sealed, would be no more than 30 percent of the containment volume per day.

Cross-cutting Aspect: H.6 - Design Margins: The organization operates and maintains

equipment within design margins. Margins are carefully guarded and changed only through a

systematic and rigorous process. Special attention is placed on maintaining fission product

barriers, defense-in-depth, and safety-related equipment. Specifically, the licensee

incorrectly assumed that a seal on the containment hatch was not required at the onset of an

17

accident and that the increased pressure in containment during an accident could be credited

for making a seal on the hatch.

Enforcement:

Violation: 10 CFR Part 50, Appendix B, Criterion XVI, "Corrective Action," requires in part

that conditions adverse to quality are promptly identified and corrected. Contrary to the

above, from December 2017 to December 2018, the licensee failed to promptly correct a

condition adverse to quality. Specifically, the licensee failed to implement adequate

corrective actions for an inadequate procedure for emergency containment closure to ensure

the containment was sealed, an activity affecting quality.

Enforcement Action: This violation is being treated as a Non-Cited Violation, consistent with

Section 2.3.2 of the Enforcement Policy.

Failure to Evaluate a Change to the Facility DC Power System

Cornerstone

SL-IV

Cross-cutting

Aspect

Report

Section

Not Applicable

NCV 05000445/2019001-02

Closed

Not

Applicable

71111.04

The inspectors identified a Severity Level IV, non-cited violation of 10 CFR 50.59 for the

licensees failure to obtain a license amendment or perform a written evaluation

demonstrating the basis for not obtaining a license amendment prior to making a change to

the facility as described in the final safety analysis report.

Description: The inspectors reviewed the plant configuration of two common Class 1E DC

power panels that can be powered from either the Unit 1 or Unit 2 Class 1E DC busses. The

inspectors found that the licensee has shared systems for both units that receive power from

these panels. The panels also have Unit 1 safety-related systems powered from the panels.

The inspectors noted that shared systems must meet the requirements of 10 CFR Part 50,

Appendix A, Criterion 5, which states, in part, that structures, systems, and components

important to safety shall not be shared among nuclear power units unless it can be shown

that such sharing will not significantly impair their ability to perform their safety functions.

The inspectors questioned whether the inclusion of Unit 1 safety-related equipment on the

common panels constituted acceptable sharing of systems between units.

Upon further review, the inspectors determined that the licensee originally committed to

Regulatory Guide (RG) 1.81 to demonstrate compliance with Criterion 5. The licensee, in its

Final Safety Analysis Report (FSAR), stated that the DC power sources and electric

distribution systems were not shared between the two units, and that safety-related loads

shared between both units are powered from common 125 VDC panels. The NRC in its

safety evaluation report concluded that the design as described in the FSAR, with shared

systems being powered from the common panels but no unit-specific safety-related systems

powered from the common panels, was acceptable.

In January 2000, the licensee discovered that they had unit-specific safety-related systems

from both Units 1 and 2 on the common panels in addition to the previously evaluated shared

systems, contrary to what was described in their FSAR. The licensee entered this design

control issue into the corrective action program. In 2002, the licensee modified the Unit 2

systems to align them to Unit 2 power supplies, but left the Unit 1 systems on the common

panels. The licensee then revised the FSAR to state that they did not comply with RG 1.81,

18

but that the existing configuration of Unit 1 systems was an acceptable exception. The

inspectors determined that powering Unit 1 systems from the Unit 2 DC power supply and

distribution system constituted a system being shared among units, and that the licensee had

not demonstrated compliance with Criterion 5 for these systems while the panels supplying

Unit 1 systems were powered from Unit 2. At the time of the inspection, the common panels

were aligned to Unit 1.

The inspectors determined that the inclusion of Unit 1 systems on panels that shared DC

power systems was a change to the facility as described in the FSAR. The inspectors also

determined that the licensee made the change without performing a written evaluation

demonstrating that a license amendment would not be required. This impeded the ability of

the agency to perform its regulatory function, requiring disposition using traditional

enforcement.

Corrective Action(s): The licensee entered this violation into their corrective action program.

Corrective Action Reference(s): CR-2019-001711

Performance Assessment: The inspectors determined this violation was associated with a

minor performance deficiency.

Enforcement:

The ROPs significance determination process does not specifically consider the regulatory

process impact in its assessment of licensee performance. Therefore, it is necessary to

address this violation which impedes the NRCs ability to regulate using traditional

enforcement to adequately deter non-compliance.

Severity: The violation was determined to be Severity Level IV using section 6.1 of the NRC

Enforcement Policy, dated May 15, 2018, because it was a violation of 10 CFR 50.59, but did

not have a consequence evaluated by the significance determination process as having

low-to-moderate or greater safety significance.

Violation: Title 10 CFR 50.59 requires, in part, that if the licensee makes changes to the

facility as described in the FSAR without obtaining a license amendment, they must maintain

a written evaluation which provides the basis for determining that the change does not require

a licensee amendment. Contrary to the above, in April 2002, the licensee made a change to

the facility as described in the FSAR without obtaining a license amendment, but did not

maintain a written evaluation which provides the basis for determining that the change does

not require a licensee amendment.

Enforcement Action: This violation is being treated as a Non-Cited Violation, consistent with

Section 2.3.2 of the Enforcement Policy.

19

Failure to Monitor or Demonstrate Control of Performance Under the Maintenance Rule

Cornerstone

Significance

Cross-cutting

Aspect

Report

Section

Mitigating

Systems

Green

NCV 05000445;05000446/2019001-03

Closed

None

71111.12

The inspectors identified a Green, non-cited violation of 10 CFR 50.65(a)(2), with three

examples, for failure to demonstrate effective control of performance of a maintenance rule

scoped system through appropriate preventive maintenance.

Description: The inspectors identified three examples where the performance of systems,

structures, and components (SSCs) that were subject to the maintenance rule, was not

monitored or demonstrated to be effectively controlled through appropriate preventive

maintenance.

The first example is a violation of 10 CFR 50.65(a)(2) for failure to monitor performance or

demonstrate effective control of performance for the Class 1E battery chargers. The

inspectors identified a failure of the 1ED1-1 battery charger to successfully perform a

maintenance rule function. The battery chargers provide DC power to the class 1E DC

busses from the Class 1E AC busses. The vital bus inverters rely on effective control of

DC voltage ripple on the battery charger output to allow synchronization with class 1E AC

power prior to being placed online. The licensee incorporated a limit of 2 percent voltage

ripple into the design basis document for the DC system. However, the licensee did not

perform any testing or preventive maintenance to ensure output voltage ripple remained

within limits. As a result, the DC output voltage ripple of the 1ED1-1 battery charger

exceeded acceptable voltage ripple at some point in its service life, ultimately resulting in a

failure of the supported inverter to return to service on June 5, 2018.

The licensee determined that the excessive ripple was caused by a failure of a component in

the battery charger, the X-302 printed circuit board (PCB). The PCB had last been replaced

in December 2016 and was scheduled for a 10-year replacement frequency. Subsequent to

that replacement, the licensee documented multiple occurrences where the inverters

supported by that charger did not synchronize correctly. The licensee had generated work

orders to troubleshoot the inverter but had not completed them prior to the June 2018 failure.

Following this failure, the licensee performed an evaluation of the event for their maintenance

rule program. The licensee evaluated the failure as not being a maintenance rule failure

because the battery charger functions, as written, did not describe providing power to the DC

busses. The inspectors concluded that the function to provide power to the DC busses was a

maintenance rule function and that the June 2018 failure was a functional failure.

Furthermore, because the failure could have been prevented by either performing preventive

maintenance on the battery charger or by completing the troubleshooting work orders, the

failure was maintenance preventable. The June 2018 failure exceeded the established

performance criteria, indicating performance was not being effectively controlled, but the

licensee did not monitor performance or set goals. The licensee entered this issue into the

corrective action program.

The second example is a violation of 10 CFR 50.65(a)(2) for failure to monitor performance or

demonstrate effective control of performance for the common low voltage AC power system.

The inspectors identified a failure of the common 120 VAC power system to provide Class 1E

power to certain important to safety components that are shared between Units 1 and 2. The

common panels provide power to shared radiation monitors that require Class 1E power to

function following an accident, which is covered by the maintenance rule under

20

10 CFR 50.65(b)(2)(i). The panels can be transferred to non-Class-1E power for

maintenance. Following a planned maintenance activity on Panel XEC1 in October 2016, the

licensee was unable to transfer the panel back to its normal Class 1E source due to a failure

of the transfer switch. Because the failure represented an inability to receive power from its

Class 1E source, this was a failure to meet its maintenance rule function. The failure was

maintenance preventable, because the licensee was aware of the potential for these switches

to fail but did not perform preventive maintenance to address the failures. The licensee

incorrectly concluded that the transfer switch failure was not a maintenance preventable

failure of a maintenance rule function, because the common panels were being monitored

against plant level performance criteria. The performance of the system cannot be practically

monitored by the use of plant level criteria, because the common low voltage power system

could have unlimited maintenance preventable functional failures without ever meeting the

criteria. The licensee entered this issue into the corrective action program.

The third example is a violation of 10 CFR 50.65(a)(2) for failure to monitor performance or

demonstrate effective control of performance for the inside reactor containment check

valves 1(2)CA-0016. Inspectors noted that the performance criteria assigned to the valves

was inadequate and that there had been multiple failures of these valves during testing.

These results should have been classified as repeat maintenance preventable functional

failures and caused the system to be classified as 50.65(a)(1), but the system remained in

50.65(a)(2) status.

The inspectors noted that the valves were allowed seven failures in a 24-month monitoring

period. This was determined to be inadequate because the valves were tested on a 30month

frequency, so the allowed amount of failures could never be exceeded. Additionally, the

inspectors determined that the cause of the valves failures was a known issue, but the

licensee had not taken action to correct it. Specifically, the valves and system piping are

carbon steel and are part of the service air system. The service air system is neither filtered

nor dried which results in water accumulation in the air system. Water accumulation in the

system causes general corrosion in the piping, resulting in wear particles that affect the

valves ability to close. The inspectors determined that the licensee was aware of the failure

mechanism, the cause, and a solution for the issue but had prioritized it as a low priority and

was not considering this when evaluating whether the failures were maintenance preventable.

The inspectors determined that the failures were maintenance preventable and as such, were

repeat failures, because the licensee had failed to perform the appropriate modifications to

the system. The licensee entered this issue into the corrective action program.

In all these cases, the inspectors determined that the failure to demonstrate effective control

was caused by incomplete descriptions of the applicable maintenance rule functions, which

had been developed during initial implementation of the maintenance rule in the 1990s.

Corrective Action(s): The licensee entered these three examples into the corrective action

program and is reviewing the systems performance.

Corrective Action Reference(s): CR-2018-007884

Performance Assessment:

Performance Deficiency: The failure to monitor the performance or demonstrate effective

control of performance of systems covered by the maintenance rule is a performance

deficiency.

21

Screening: The inspectors determined the performance deficiency was more than minor

because it was associated with the equipment performance attribute of the Mitigating

Systems Cornerstone. It adversely affected the cornerstone objective to ensure the

availability, reliability, and capability of systems that respond to initiating events to prevent

undesirable consequences (i.e., core damage) because the finding represented a reduction in

the reliability and availability of mitigating systems. Specifically, the failure to monitor the

performance of the battery chargers resulted in multiple instances of decreased reliability of

the system. The common low voltage power system affected the Emergency Preparedness

Cornerstone, and the containment isolation valves affected the Barrier Integrity Cornerstone,

but the Mitigating Systems Cornerstone was selected as the most significant due to the risk

significance of the battery chargers.

Significance: The inspectors assessed the significance of the finding using Appendix A,

Significance Determination of Reactor Inspection Findings for At - Power Situations. Using

Inspection Manual Chapter 0609, Attachment 04, Initial Characterization of Findings, dated

October 7, 2016, the inspectors determined the finding was associated with the Mitigating

Systems cornerstone. Using Inspection Manual Chapter 0609, Appendix A, The Significance

Determination Process (SDP) For Findings At-Power, Exhibit 2, Mitigating Systems

Screening Questions, the inspectors determined the finding was of very low safety

significance (Green) because the finding did not represent an actual loss of function of at

least a single train for greater than its technical specification allowed outage time.

Cross-cutting Aspect: No cross-cutting aspect was assigned to this finding because the

inspectors determined the finding did not reflect present licensee performance.

Enforcement:

Violation: 10 CFR 50.65(a)(1), requires, in part, that the holders of an operating license shall

monitor the performance or condition of structures, systems, or components (SSCs) within the

scope of the rule as defined by 10 CFR 50.65(b), against licensee-established goals, in a

manner sufficient to provide reasonable assurance that such SSCs are capable of fulfilling

their intended functions.

10 CFR 50.65(a)(2) states, in part, that monitoring as specified in 10 CFR 50.65(a)(1) is not

required where it has been demonstrated that the performance or condition of an SSC is

being effectively controlled through the performance of appropriate preventive maintenance,

such that the SSC remains capable of performing its intended function.

Contrary to the above, as of March 31, 2019, the licensee failed to demonstrate that the

performance of the Class 1E battery chargers, the common 120 VAC power panels, and

containment check valves had been effectively controlled through the performance of

appropriate preventive maintenance and did not monitor against licensee-established goals.

Specifically, the licensee failed to identify, and properly account for preventive maintenance

preventable functional failures of the battery chargers, the common 120 VAC panels, and

containment check valves occurring from October 2016 to June 2018 which demonstrate that

the performance or condition of these SSCs was not being effectively controlled through the

performance of appropriate preventive maintenance and, as a result, that goal setting and

monitoring was required.

Enforcement Action: This violation is being treated as an non-cited violation, consistent with

Section 2.3.2 of the Enforcement Policy.

22

Failure to Control Hazard Barriers During Maintenance

Cornerstone

Significance

Cross-cutting

Aspect

Report

Section

Mitigating

Systems

Green

NCV 05000445/2019001-04

Closed

[H.8] -

Procedure

Adherence

71111.13

The inspectors identified a Green, non-cited violation of 10 CFR 50.65(a)4 for failure to

implement risk mitigating actions during diesel generator maintenance.

Description: On January 17, 2019, the inspectors observed the licensee performing a

maintenance activity to add lube oil to the Unit 1 emergency diesel generator 1-01 sump. In

order to perform the maintenance, the licensee placed a hose through the normally shut

door S1-28 from the train A switchgear room to the train A diesel generator room. The door is

a dogged, two-leaf metal hatch that functions as a barrier for fire, flooding, and medium

energy line break (MELB) events. Prior to performing the maintenance, the licensee

evaluated the risk of opening the door to allow placement of the hose. The licensee identified

additional compensatory measures to protect the train A switchgear in an evaluation

documented in Tracking Report (TR) 2019-000001. The licensee determined that the open

door did not pose a flood risk and implemented appropriate compensatory measures to

mitigate the fire risk. To address the MELB risk, the licensee determined that the open

doorway of the active leaf of door S1-28 could allow a MELB in the diesel generator room to

impact safety-related transformer T1EB3, which provides 480 VAC power to safety-related

bus 1EB3. The licensee determined that the transformer would be protected if the workers

maintained door S1-28 open no more than 2 inches, with the door secured to prevent it from

opening further. The licensee determined that opening the door for normal ingress and

egress was acceptable provided the door was secured after personnel passed through. The

evaluation was attached to the work order and a copy was present at the job site.

When the workers began the job, they identified safety concerns with the door being secured

while personnel were in the diesel generator room. They decided to leave the door open,

assuming that it was acceptable as long as personnel were in the immediate area to close it.

When the inspectors arrived at the work site, they noticed the door open with no one passing

through it and questioned the configuration of the door. The inspectors then contacted the

control room and the licensee secured the door.

The licensee determined that crediting actions to close the door post event did not adequately

mitigate the risk of a MELB. As a result of the failure to implement the risk mitigating actions,

the licensee determined that the train A 480 VAC bus 1EB3 was inoperable for

approximately 3 hours3.472222e-5 days <br />8.333333e-4 hours <br />4.960317e-6 weeks <br />1.1415e-6 months <br /> due to the potential for a MELB to spray water on the transformer. The

allowable outage time of the bus per Technical Specification 3.8.9 is 8 hours9.259259e-5 days <br />0.00222 hours <br />1.322751e-5 weeks <br />3.044e-6 months <br />. The licensee

determined that the bus did not exceed its allowed outage time due to the hazard barrier

being open.

Corrective Action(s): The licensee restored the barrier and entered the issue into the

corrective action program.

Corrective Action Reference(s): CR-2019-000672

23

Performance Assessment:

Performance Deficiency: The failure to implement planned risk mitigating actions was a

performance deficiency.

Screening: The inspectors determined the performance deficiency was more than minor

because it was associated with the Configuration Control attribute of the Mitigating Systems

cornerstone. It adversely affected the cornerstone objective to ensure the availability,

reliability, and capability of systems that respond to initiating events to prevent undesirable

consequences (i.e., core damage) because the finding represented a loss of control of

barriers required to ensure the availability of AC power. Specifically, the failure to maintain

the door in a nearly closed position exposed a Class 1E 480 VAC bus to failure during a

MELB event, resulting in an electrical distribution train being inoperable for several hours.

Significance: The inspectors assessed the significance of the finding using Appendix K,

Maintenance Risk Assessment and Risk Management SDP. Using Inspection Manual

Chapter 0609, Attachment 04, Initial Characterization of Findings, dated October 7, 2016,

the inspectors determined the finding was associated with the Mitigating Systems

cornerstone. Using Inspection Manual Chapter 0609, Appendix K, Maintenance Risk

Assessment and Risk Management Significance Determination Process, the inspectors

determined the finding was associated with risk mitigating actions (RMAs) only. The

inspectors used Flowcharts 1 and 2 to determine that the finding required a determination of

the incremental core damage probability due to the failure to implement RMAs.

A risk analyst performed a bounding analysis of incremental core damage probability

assuming that bus 1EB3 was unavailable along with the train A emergency diesel generator

for the entire exposure time when adequate RMAs were not in place. This estimate was

bounding because it assumes bus 1EB3 always failed during the exposure time and does not

incorporate the probabilistic occurrences of fire, flooding, line break, and other events could

have rendered bus 1EB3 unavailable, which would result in a lower estimate of incremental

core damage probability. The resulting bounding estimate in the incremental core damage

probability was 8.1E-8. The inspectors determined that the finding was of very low safety

significance (Green) because the incremental core damage probability was less than 1E-6

and the finding did not affect the large early release probability.

Cross-cutting Aspect: H.14 - Conservative Bias: Individuals use decision making-practices

that emphasize prudent choices over those that are simply allowable. A proposed action is

determined to be safe in order to proceed, rather than unsafe in order to stop. Specifically,

the licensee personnel assumed that the controls were not necessary without stopping work

and discussing with their supervisor, and did not implement prescribed risk mitigating actions.

Enforcement:

Violation: 10 CFR 50.65(a)(4) requires, in part, that the licensee assess and manage the

increase in risk that may result from maintenance activities. Contrary to the above, on

January 17, 2019, the licensee failed to manage the increase in risk resulting from a

maintenance activity. Specifically, the licensee did not implement planned risk mitigating

actions that were identified as necessary by the risk assessment.

Enforcement Action: This violation is being treated as a non-cited violation, consistent with

Section 2.3.2 of the Enforcement Policy.

24

Failure to Follow Procedure When A Degraded Condition Was Identified

Cornerstone

Significance

Cross-cutting

Aspect

Report

Section

Mitigating

Systems

Green

NCV 05000445;05000446/2019001-05

Closed

[H.14] -

Conservative

Bias

71111.15

The inspectors identified a Green, non-cited violation of 10 CFR Part 50, Appendix B,

Criterion V, Instructions, Procedures, and Drawings, associated with the licensees failure to

follow the requirements of Station Procedure STI-421.01, Initiation of Issue Reports,

Revision 0. Specifically, station personnel failed to notify the shift manager of an issue with

material storage in the protected area. This issue required evaluations and compensatory

actions for resolution.

Description: On January 31, 2019, inspectors identified that the licensee had allowed

material to be stored in a temporary laydown area inside of the protected area. Inspectors

noted that several items appeared to be susceptible to being picked up by tornado driven

winds, so the inspectors inquired as to how these items had been evaluated for their current

storage area. The licensee initiated TR-2019-001119 to capture the inspectors questions.

As part of TR-2019-001119 the licensee determined that the materials in question had not

been evaluated for its current storage location. An action was assigned to engineering to

evaluate the materials in question (AI-TR-2019-001119-1). Engineering completed their

evaluation on February 4, 2019, and engineering management approved the evaluation on

February 6, 2019. The evaluation determined that there were materials in the laydown area

that were susceptible to being lifted by tornadic winds, and they needed to be strapped down

in such a way as to increase their weights to a point where they were no longer susceptible.

Inspectors reviewed AI-TR-2019-001119-1 on February 14, 2019. During their review they

determined that the identified condition required an operability review because of the potential

to be in an unanalyzed condition with respect to tornado driven missiles. However, inspectors

noted that an operability review was not performed because the issue had not been reported

to the control room by engineering upon discovery on February 4, 2019, as required by

Station Procedure STI-421.01, Initiation of Issue Reports, Revision 0, Section 6.1.

Additionally, there was no guidance or actions in place to adequately strap down the material

to ensure that it did not pose a risk to plant equipment.

Inspectors informed the licensee of their observations. The licensee reviewed the issue and

determined that the condition did require an operability review and compensatory actions to

address it pending further review.

Corrective Action(s): The licensee performed an operability determination and establish

compensatory measures that established a reasonable expectation of operability pending

development of additional corrective actions.

Corrective Action Reference(s): CR-2019-001119

25

Performance Assessment:

Performance Deficiency: The licensees failure to follow the requirements of

Procedure STI-421.01 when a degraded condition was identified was a performance

deficiency.

Screening: The inspectors determined the performance deficiency was more than minor

because it was associated with the Protection Against External Factors attribute of the

Mitigating Systems cornerstone. It affected the cornerstone objective to ensure availability,

reliability, and capability of systems that respond to initiating events to prevent undesirable

consequences. Specifically, the storage of materials without proper evaluations resulted in

the introduction of new and unanalyzed tornadic missiles.

Significance: The inspectors assessed the significance of the finding using Appendix A,

Significance Determination of Reactor Inspection Findings for At - Power Situations. Using

Exhibit 2, Mitigating Systems Screening Questions, the inspectors determined the finding

was of very low safety significance (Green) because: (1) it was not a design deficiency; (2) it

did not represent a loss of system and/or function; (3) it did not represent an actual loss of

function of at least a single train for longer than its technical specification allowed outage

time; and (4) it did not result in the loss of a high safety significant non-technical specification

train.

Cross-cutting Aspect: H.14 - Conservative Bias: Individuals use decision making-practices

that emphasize prudent choices over those that are simply allowable. A proposed action is

determined to be safe in order to proceed, rather than unsafe in order to stop. Specifically,

engineering failed to use decision making-practices that emphasize prudent choices over

those that are simply allowable.

Enforcement:

Violation: Title 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, and drawings.

Contrary to the above, from February 4-27, 2019, an activity affecting quality was not

accomplished in accordance procedures appropriate to the circumstances. Specifically,

station personnel failed to notify the shift manager of an issue with material storage in the

protected area (as required by Station Procedure STI-421.01, Initiation of Issue Reports)

which required evaluations and compensatory actions for resolution.

Enforcement Action: This violation is being treated as a non-cited violation, consistent with

Section 2.3.2 of the Enforcement Policy.

26

Failure to Perform Safety Evaluations in Accordance with 10 CFR 50.59

Cornerstone

Significance

Cross-cutting

Aspect

Report

Section

Mitigating

Systems

Green

NCV 05000445; 05000446/2019001-

06

Closed

[H.9] - Training

71111.17T

The inspectors identified a Green, non-cited violation of 10 CFR 50, Appendix B, Criterion V,

Instructions, Procedures, and Drawings, (with four examples) in which the licensee failed to

complete 50.59 evaluations as required by station procedures.

Description: The inspectors identified four examples where the licensee failed to perform

50.59 evaluations as required by procedures and guidance specified in STA-707,

10 CFR 50.59 and 10 CFR 72.48 Reviews, Revision 21.

Example 1. EV-CR-2017-004743-2, Blow Down the 1-01 Instrument Air Receiver

In the screen for the compensatory measure to blow down the 1-01 air receiver once per shift,

question 1 of the screening was, Does the proposed activity involve a change to an SSC that

adversely affects an UFSAR described design function? The preparer answered the

question No; the explanation provided had the following statements: The activity is a

Compensatory Measure to blow down the 1-01 Instrument Air Receiver once per shift using

1CI-0012 to remove water from the receiver. The drip trap (CP1- CIMEDT-01) that performs

the automatic drain will be repaired IAW WO 5474911. This statement indicates that an

automatic function was replaced with a manual function.

The vendor manual, AP-0293-B, Ingersoll-Rand Compressor Accessories, dated April 1976,

provides the following guidance on page 7 for liquid carryover, It is important that interstage

separators be drained regularly and we are of the opinion that manual drainage at specified

intervals with the fact of drainage logged, is the proper method, particularly at higher

pressures. Automatic traps, if used, should have a bypass piped for visual observation and

check on trap operation - the check should be made at stated intervals and the results

logged. Page 12 of the manual provides guidance that drainage of the receiver following the

aftercooler should be drained at least once per shift.

CPNPP 50-59 RM-6, "CPNPP 50.59 Resource Manual," Revision 6, requires that an

evaluation be performed if an automatic function is replaced with a manual action. The

preparer and reviewer failed to ensure the appropriate Applicability

Determination/screen/evaluation was performed and the corresponding Applicability

Determination/screen/evaluation form was completed in accordance with guidance provided

in CPNPP 50-59 RM-6. Screening guidance would require this change to be evaluated prior

to changing from an automatic to a manual function.

Example 2. EV-CR-2018-007384 RCS Pressure Boundary Leakage Test

This document was to perform a 50.59 review for changes to Procedure OPT-612B, RCS

Pressure Boundary Leakage Test for Loop 1 Cold Leg Injection Valves, and

Procedure OPT 613B, RCS Pressure Boundary Leakage Test for Loop 2 Cold Leg Injection

Valves, to allow the performance of reactor coolant system pressure boundary leakage test

for safety injection loops 1 and 2. The licensee had attempted to perform a flush of the

residual heat removal system while in Mode 1, an evolution normally performed in Modes 3,

27

4, or 5. Inadequate procedure changes and review of the planned process resulted in forward

flow through valves 2-8956A and B. This placed the unit in a 24-hour LCO to complete

Surveillance Requirement 3.4.14 for valves 2-8956 A and B. Procedures OPT-612B and

OPT-613B needed to be revised to allow performance of this surveillance in Mode 1. The

activity required component manipulations that isolated one safety injection accumulator and

rendered one train of residual heat removal inoperable in order to perform the leak check. A

threaded pipe cap was removed and various normally closed valves were opened to allow

connection of the test rig. The screener and reviewer failed to recognize that these actions

resulted in an "adverse effect" on the plant.

CPNPP 50-59-RM6, Section 5.2.2, states, in part, changes that have an adverse effect are

required to be evaluated under 10 CFR 50.59 because they have the potential to increase the

likelihood of malfunctions, increase consequences, create new accidents, or otherwise meet

the 10 CFR 50.59 evaluation criteria.

CPNPP 50-59-RM6, Section 5.2.1 states, Items to Consider When Deciding Whether an Item

is a Change to the Facility: Does the activity decrease the reliability of an SSC design

function, including either functions whose failure would initiate a transient/accident or

functions that are relied upon for mitigation? Does the activity reduce existing redundancy,

diversity, or defense-in-depth?

The screener and reviewer failed to recognize that, even though technical specifications allow

operation with one safety injection accumulator isolated and one train of residual heat

removal inoperable, this resulted in a reduction in the existing redundancy, diversity, and

defense-in-depth that required the performance of an evaluation.

Example 3. Procedure Change to SOP-102B

Section 1 of the screen for the change to SOP-102B, Residual Heat Removal System,

Revision 15, provided the following description in the change justification section: "Modified

Section 5.2 to allow flushing of the RHR System to the RHUT (ref AI-CR-2018-007381-4),

deleted "Intentionally Left Blank" Pages 3&4 of Attachment 4. Re-sequenced Table of

Contents to reflect new page numbering. Added new prerequisite to Section 2.3 to clarify

intent of Section 5.11 and moved 2.3 to previous page." The technical reviewer answered

yes to the question: If change is editorial, THEN circle or mark "YES." Editorial changes, as

limited by STA-202, Attachment 8.F, do not require Administrative Review, Technical Review,

NSR, AD, 50.59 Review or 72.48 Review.

The procedure change (in Section 5.2 to allow flushing of the RHR system) actually

manipulated valves in the safety injection system to isolate the safety injection accumulators

based on lessons learned when the licensee originally attempted to flush the residual heat

removal system while in Mode 1. The licensee had failed to recognize that the initial

conditions assumed in Procedure SOP-102B had the safety injection accumulators isolated.

In Mode 1, the safety injection accumulators were in service, and the attempted flush of the

residual heat removal system resulted in flow from the accumulators. The purpose of the

procedure modification was to isolate the safety injection accumulator to allow a partial flush

of the residual heat removal system. The preparer, reviewer, and technical reviewer all failed

to identify this aspect of the procedure change. As a result, the adverse effect on the plant, a

reduction in redundancy to the safety injection system, was not identified, and therefore the

required 10 CFR 50.59 evaluation was not performed.

28

Example 4. EV-2002-002026-01-00 Bladder Equivalency Evaluation

On May 28, 2002, the licensee performed an equivalency evaluation for replacement

diaphragms for the reactor make up water storage tanks, EV-2002-002026-01-00. In the

evaluation the licensee identified that the new diaphragm was manufactured with a material

that has a specific gravity greater than 1.0 which will make it heavier than the water in the

tank, and consequently material which tears or breaks off from the diaphragm will sink into

the tank and potentially into the pump suction, which could cause the pump to malfunction.

The licensee determined that this was an equivalent change by crediting proper maintenance

and inspection to ensure that a failure of the new material does not occur.

Inspectors determined that this was not an equivalent change because the new diaphragm

introduced the potential for a new adverse effect (bladder failure could result in material

sinking and clogging pump suction) and should have been evaluated. CPNPP 50-59-RM6 ,

Section 5.2.2 states in part, changes that have an adverse effect are required to be evaluated

under 10 CFR 50.59 because they have the potential to increase the likelihood of

malfunctions, increase consequences, create new accidents, or otherwise meet the 10 CFR

50.59 evaluation criteria.

Corrective Action(s): The licensee entered these issues into the corrective action program.

Corrective Action Reference(s): IR-2019-001271, IR-2019-001317, IR-2019-001428,

IR-2019-001430

Performance Assessment:

Performance Deficiency: The inspectors determined that not conducting required

10 CFR 50.59 evaluations was a performance deficiency within the licensee's ability to

foresee and correct. Specifically, the licensee failed to perform 10 CFR 50.59 evaluations for

the compensatory measure for the instrument air system, the procedure change for the

reactor coolant system pressure boundary leakage test for safety injection loops 1 and 2, the

procedure change for the residual heat removal system flush, and replacement diaphragms

for the reactor make up water storage tanks.

Screening: The inspectors determined the performance deficiency was more than minor

because it was associated with the Human Performance attribute of the Mitigating Systems

Cornerstone and adversely impacted the cornerstone objective of ensuring the availability,

reliability, and capability of systems that respond to initiating events to prevent undesirable

consequences.

Significance: The inspectors assessed the significance of the finding using Appendix A,

Significance Determination of Reactor Inspection Findings for At - Power Situations. The

inspectors assessed the significance of the finding using Inspection Manual Chapter 0609.04,

and Inspection Manual Chapter 0609, Appendix A, Exhibit 2. The inspectors determined that

this finding was of very low safety significance (Green), because the finding did not represent

a loss of the emergency core cooling system or the instrument air system safety function, did

not result in any loss of function beyond the technical specification-allowed outage time, and

did not result in the loss of any non-technical specification trains that were designated as high

safety-significance in accordance with the licensees maintenance rule program.

29

Cross-cutting Aspect: H.9 - Training: The organization provides training and ensures

knowledge transfer to maintain a knowledgeable, technically competent workforce and instill

nuclear safety values. Specifically, the licensee failed to provide training to maintain a

knowledgeable, technically sound workforce and instill nuclear safety values when

implementing the change process.

Enforcement:

Violation: Title 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and

Drawings, states 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. Contrary to the

above, from May 2002, to February 2019, the team identified four examples where the

licensee failed to follow the requirements of Procedure CPNPP 50.59-RM6, "CPNPP 50.59

Resource Manual," Revision 6. The procedure required a 10CFR 50.59 evaluation to be

performed if an activity reduces existing redundancy, diversity, or defense in depth or if an

automatic function is replaced with a manual action. Specifically, the licensee implemented

manual compensatory actions when the automatic trap for the instrument air system failed,

made procedure changes that reduced the redundancy, diversity, reliability, and defense-in-

depth of the emergency core cooling systems, and installed new material in the plant with a

different adverse effect without performing 10 CFR 50.59 evaluations as required.

Enforcement Action: This violation is being treated as a non-cited violation, consistent with

Section 2.3.2 of the Enforcement Policy.

Inadequate Maintenance Instructions Result in Loss of Assessment Capability

Cornerstone

Significance

Cross-cutting

Aspect

Report

Section

Emergency

Preparedness

Green

NCV 05000445;05000446/2019001-07

Closed

[H.8] -

Procedure

Adherence

71152

The inspectors reviewed a self-revealed Green, non-citied violation of 10 CFR 50,

Appendix B, Criterion V, "Instruction, Procedures, and Drawings", that occurred due to

inadequate maintenance instructions for safety-related radiation monitors which resulted in a

major loss of assessment capability.

Description: On December 5, 2017, the licensee was performing maintenance on the control

room south ventilation intake radiation monitor under Work Order (WO) 5063234 when they

received audible and visible alarms in the control room indicating a loss of multiple radiation

monitors. The crew evaluated the indications and determined a major loss of assessment

capability occurred due to the unplanned loss of the main steam line radiation monitors for

steam lines 1 and 3, and the station service water (SSW) radiation monitors. The loss of

these radiation monitors impacted emergency action levels for radiation effluent. This event

was reported to the NRC as Event Report No. 53105.

The inspectors reviewed the circumstances of this event including the licensees evaluation

and corrective actions. The licensees radiation monitoring system consists of four

communication loops of 20 to 30 radiation monitors each. The loops pass inputs via each

successive monitor to the plant computer system, which then provides required indications to

the control room and emergency response facilities (ERFs). The licensee determined that the

loss of the affected radiation monitors was due to taking the control room south ventilation

30

intake radiation monitor out of service without first installing jumpers in the communication

loop to bypass the monitor. This resulted in a failure of all other monitors in the affected loop

to provide indication to the plant computer system.

The inadequate maintenance resulted in the simultaneous communications failure of

approximately 27 radiation monitors. In addition to the monitors that met the criteria for the

report, the inspectors noted the following other monitors that affected emergency

classification:

Unit 1 main steam line radiation monitors for main steam lines 1 and 3

both Unit 1 SSW radiation monitors and all Unit 1 component cooling water radiation

monitors, their credited backup for the SSW monitors

the Unit 1 failed fuel monitor

all Unit 1 refueling cavity monitors

the Unit 1 containment radiation monitors for particulate, iodine, and gaseous activity

the fuel building vent exhaust monitor

The licensee implemented compensatory measures for the affected monitors while restoring

them to service. The main steam line radiation monitors affected the ability to declare a

General Emergency for high steam line radiation, but the licensee determined that a General

Emergency declaration could have been made using other emergency action levels. The

inspectors did not identify any concerns with the licensees conclusion regarding emergency

classification.

The inspectors determined that the workers did not install the jumpers because WO 5063234

did not contain instructions to install the jumpers. The licensee had relied on the knowledge

of a few experienced technicians who were aware that the jumpers needed to be installed

prior to removing a monitor from service. However, the workers performing WO 5063234 on

the control room south ventilation intake radiation monitor on December 5 were not aware of

the need to install jumpers.

The inspectors determined that licensee Procedure STI-606.03, Work Planning, Section 6.2

requires that work packages identify where jumpers need to be installed. The inspectors

concluded that the work instructions in WO 5063234 were inadequate. The control room

south ventilation intake radiation monitor is safety-related, and therefore, the work instructions

were quality related instructions.

Corrective Action(s): The licensee stopped maintenance, implemented compensatory

measures, and restored the monitors to service.

Corrective Action Reference(s): CR-2019-002535

31

Performance Assessment:

Performance Deficiency: The failure to prescribe adequate work instructions for a quality

related activity is a performance deficiency.

Screening: The inspectors determined the performance deficiency was more than minor

because it was associated with the facilities and equipment attribute of the Emergency

Preparedness Cornerstone. It adversely affected the cornerstone objective to ensure that the

licensee is capable of implementing adequate measures to protect the health and safety of

the public in the event of a radiological emergency. Specifically, it resulted in the failure of

multiple pieces of equipment credited for maintaining the licensees emergency plan with

respect to emergency planning standard four, which requires a standard emergency

classification and action level scheme to be in use.

Significance: The inspectors assessed the significance of the finding using Appendix B,

Emergency Preparedness SDP. Using table 5.4-1, Significance Examples

Section 50.47(b)(4), the finding was determined to be of very low safety significance (Green)

because it was not a degraded risk significant planning standard function. The planning

standard function was not degraded because, although an emergency action level (EAL) was

rendered ineffective such that a General Emergency would not have been declared for a

particular off-normal event, other EALs could have been used to make an appropriate

declaration.

Cross-cutting Aspect: H.8 - Procedure Adherence: Individuals follow processes, procedures,

and work instructions. Specifically, individuals did not follow the work planning procedure

when preparing work instructions for maintenance on the radiation monitors.

Enforcement:

Violation: Title 10 CFR 50, Appendix B, Criterion V, "Instruction, Procedures, and Drawings,"

requires in part that activities affecting quality shall be prescribed by documented instructions

of a type appropriate to the circumstances. Contrary to the above, on December 5, 2017, the

licensee failed to prescribe activities affecting quality by documented instructions of a type

appropriate to the circumstances. Specifically, the licensee prescribed maintenance on a

safety-related radiation monitor with instructions that did not identify jumpers required to

maintain the function of the radiation monitoring system.

Enforcement Action: This violation is being treated as a non-cited violation, consistent with

Section 2.3.2 of the Enforcement Policy.

Failure to Establish Adequate Procedural Guidance for Flushing Lithium at Power

Cornerstone

Significance

Cross-cutting

Aspect

Report

Section

Mitigating

Systems

Green

NCV 05000446/2019001-08

Closed

[H.11] -

Challenge the

Unknown

71152

The inspectors reviewed a Green, self-revealing non-cited violation of 10 CFR Part 50,

Appendix B, Criterion V, Instructions, Procedures, and Drawings, associated with the

licensees failure to establish an adequate procedure for flushing lithium from the residual

heat removal system. This resulted in safety injection Accumulators 2-01 and 2-02 discharge

to the safety injection test header causing level drops in both accumulators, and

32

Accumulator 2-01 pressure dropped to below the operability limit resulting in an unplanned

component inoperability.

Description: On November 2, 2018, with Unit 2 in Mode 1 operations the licensee performed

an evolution to flush lithium from the residual heat removal system. The licensee used

Station Procedure SOP-102A, Residual Heat Removal System, Revision 20, Section 5.11, to

perform this evolution. During the flush safety injection Accumulators 2-01 and 2-02 levels

dropped by 6 percent due to the accumulators discharging to the safety injection test header,

and Accumulator 2-01s pressure dropped to below the operability limit resulting in an

unplanned component inoperability. Operators stopped the activity and restored level and

pressure in the accumulators. Condition Report CR-2018-007381 was written to capture the

issue in the corrective action program.

During the licensees investigation of the event it was determined that Procedure SOP-102A,

section 5.11, was not the correct procedure for this evolution because it was not intended for

use in the mode of operation. The licensee identified two causes for why an incorrect

procedure was used; inadequate coordination and incorrect assumptions. Inadequate

coordination because operations, chemistry and engineering had used an informal selection

process which lacked rigor when selecting a procedure to perform an infrequently performed

task, and this resulted in no further challenge or verifications of the adequacy of this

procedure. The licensee also identified that the work scheduling process does not require

operations procedures to be reviewed for impact. Inadequate assumptions because of the

belief by operations, chemistry and engineering that procedure SOP-102A provided

appropriate instructions for the at-power lithium flush.

Inspectors reviewed the licensees evaluation and concluded that it identified reasonable

causes and adequately addressed the identified causes.

Corrective Action(s): The licensee immediately stopped the activity, refilled and

re-pressurized the safety injection accumulators. Subsequent corrective actions were to

revise the work control process to require formal reviews for infrequently performed

non-repetitive activities.

Corrective Action Reference(s): CR-2018-007381

Performance Assessment:

Performance Deficiency: The licensees failure to establish an adequate procedure for

flushing lithium from the residual heat removal system was a performance deficiency.

Screening: The inspectors determined the performance deficiency was more than minor

because it was associated with the equipment performance attribute of the Mitigating

Systems Cornerstone. It adversely affected the cornerstone objective to ensure the

availability, reliability, and capability of systems that respond to initiating events to prevent

undesirable consequences. Specifically, the use of an inadequate procedure for flushing

lithium resulted in an inoperable safety injection accumulator.

Significance: The inspectors assessed the significance of the finding using Appendix A,

Significance Determination of Reactor Inspection Findings for At - Power Situations. Using

Exhibit 2, Mitigating Systems Screening Questions, the inspectors determined the finding

was of very low safety significance (Green) because: (1) it was not a design deficiency; (2) it

did not represent a loss of system and/or function; (3) it did not represent an actual loss of

33

function of at least a single train for longer than its technical specification allowed outage

time; and (4) it did not result in the loss of a high safety significant non-technical specification

train.

Cross-cutting Aspect: H.11 - Challenge the Unknown: Individuals stop when faced with

uncertain conditions. Risks are evaluated and managed before proceeding. Specifically,

station personnel failed to stop when faced with uncertain conditions and ensure that risks

were evaluated and managed before proceeding.

Enforcement:

Violation: Title 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, and drawings.

Contrary to the above, on November 2, 2018, an activity affecting quality was not prescribed

by documented instructions, procedures, or drawings, of a type appropriate to the

circumstances. Specifically, Station Procedure SOP-102A, Residual Heat Removal System,

Revision 20, Section 5.11, provided inadequate guidance for flushing lithium from the residual

heat removal system with the reactor in Mode 1 operation.

Enforcement Action: This violation is being treated as a non-cited violation, consistent with

Section 2.3.2 of the Enforcement Policy.

Licensee-Identified Non-Cited Violation

71111.18

This violation of very low safety significance was identified by the licensee and has been

entered into the licensee corrective action program and is being treated as a non-cited

violation, consistent with Section 2.3.2 of the Enforcement Policy.

Violation: 10 CFR Part 50, Appendix B, Criterion III, Design Control, requires in part that

measures shall be established to assure that applicable regulatory requirements and the

design basis are correctly translated into specifications, drawings, procedures, and

instructions. Contrary to the above, from initial construction to December 2018, the licensee

failed to correctly translate the design basis into specifications and procedures. Specifically,

the licensee failed to ensure the design basis for nitrogen accumulator pressure for the

pressurizer power operated relief valves (PORV) was correctly translated into the

specification for minimum allowable pressure, resulting in a non-conservative low pressure

alarm setpoint. As a result, for a period of approximately 30 hours3.472222e-4 days <br />0.00833 hours <br />4.960317e-5 weeks <br />1.1415e-5 months <br />, one Unit 1 PORV would

not have been able to cycle for the required number of operations to mitigate an overpressure

event when required.

Significance: Green.

Using Inspection Manual Chapter 0609, Attachment 04, Initial Characterization of Findings,

dated October 7, 2016, Inspection Manual Chapter 0609, Appendix G, Shutdown Operations

Significance Determination Process, dated May 9, 2014, and Appendix G Attachment 1,

Phase 1 Initial Screening and Characterization of Findings, Exhibit 4, Barrier Integrity

Screening Questions, the inspectors determined the finding affected the Barrier Integrity

Cornerstone and required a detailed risk evaluation because the finding involved the

unavailability of a PORV during low temperature overpressure (LTOP) operations.

34

A senior risk analyst performed a bounding detailed risk evaluation and assumed that the

PORV not being able to cycle the full credited amount of times prevented the PORV from

fulfilling its LTOP system function. The analyst used the frequency estimate for overpressure

excursion events from NUREG-0933, Resolution of Generic Safety Issues: Issue 94:

Additional Low Temperature Overpressure Protection for Light Water Reactors, to estimate

the initiating event frequency. Other influential assumptions used by the senior reactor

analyst included an exposure time of approximately 30 hours3.472222e-4 days <br />0.00833 hours <br />4.960317e-5 weeks <br />1.1415e-5 months <br /> and that the licensee

maintained the availability of a single additional relief valve (with its associated failure rate

estimated from the 2016 data update to NUREG/CR-6928, Industry-Average Performance

for Components and Initiating Events at U.S. Commercial Nuclear Power Plants) with

capability sufficient to mitigate an LTOP event as described in the final safety analysis report.

Using these assumptions, the senior reactor analyst determined that a bounding increase in

core damage frequency for this issue was 8.9E-8 per year and was, therefore, of very low

safety significance (Green).

Corrective Action Reference(s):CR-2018-008757

EXIT MEETINGS AND DEBRIEFS

The inspectors verified no proprietary information was retained or documented in this report.

On February 8, 2019, the inspector presented the Evaluations of Changes, Tests and

Experiments inspection results to Mr. Tom McCool and other members of the licensee

staff.

On February 13, 2019, the inspector presented the Evaluations of Changes, Tests and

Experiments inspection results to Mr. Tim Hope and other members of the licensee staff.

On April 2, 2019, the inspector presented the quarterly resident inspector inspection

results to Steven Sewell and other members of the licensee staff.

35

DOCUMENTS REVIEWED

71111.04 - Equipment Alignment

Condition Reports

CR-2000-000142

CR-2017-011443

CR-2018-008300

CR-2019-000653

CR-2019-000672

CR-2019-002533

TR-2017-011236

TR-2017-011749

Procedures

Number

Title

Revision

STI-600.01

Protecting Plant Equipment and Sensitive Equipment Controls

1

SOP-605A

125 VDC Switchgear and Distribution Systems, Batteries and

Battery Chargers

12

Drawings

Number

Title

Revision

E1-0020 Sh. K

125V DC One Line Diagram

CP-24

E1-0020 Sh. L

125V DC One Line Diagram

CP-23

Miscellaneous

Documents

Number

Title

Revision

or Date

FDA-2000-00142

Final Design Authorization

02

Calculations

Number

Title

Revision

or Date

MM-90-2671

Technical Evaluation

11/28/1990

71111.12 - Maintenance Effectiveness

Condition Reports

CR-2015-008236

CR-2016-000049

CR-2016-007907

CR-2017-000594

CR-2017-0010477

CR-2017-004704

CR-2018-003921

CR-2018-003945

CR-2018-004761

CR-2019-002622

TR-2016-000169

TR-2016-002742

TR-2016-008960

TR-2018-004761

Work Orders

5380904

5517474

5144575

5220567

5331282

5347463

5377428

36

Miscellaneous

Documents

Number

Title

Revision

or Date

DBD-EE-044

DC Power Systems

28

DBD-EE-043

118V AC Uninterruptible Power Supply System

14

71111.13 - Maintenance Risk and Emergent Work

Condition Reports

TR-2019-000001

Work Orders

5692097

5705947

Procedures

Number

Title

Revision

STA-696

Hazard Barrier Controls

3

71111.17T - Evaluations of Changes, Tests and Experiments

Condition Reports

CR-2017-005150

CR-2017-012952

CR-2018-007381

CR-2018-007384

TR-2019-001160

CR-2019-001179

CR-2019-001200

CR-2019-001240

CR-2019-001249

CR-2019-001271

IR-2019-001316

IR-2019-001317

IR-2019-001318

IR-2019-001428

IR-2019-001430

TR-2017-007959

TR-2018-004675

Work Orders

5352698

5510637

5510645

5510646

5510663

5510664

5510665

5510666

5510588

5510605

5510610

5510611

5510615

5510633

5510634

5510635

5510636

5351262

5351266

5351253

5383860

5351257

5351268

5346400

5284599

5435995

391842

3905518

Procedures

Number

Title

Revision

ODA-401

Control of Annunciators, Instruments, and Protective Relays

11

OPT-612B

RCS Pressure Boundary Leakage Test FOR LOOP 1 CL

INJECTION VALVES

3

37

Procedures

Number

Title

Revision

OPT-613B

RCS PRESSURE BOUNDARY LEAKAGE TEST FOR LOOP 2 CL

INJECTION VALVES

3

SOP-102B

RESIDUAL HEAT REMOVAL SYSTEM

15

SOP-609A

DIESEL GENERATOR SYSTEM

21

STA-602

TEMPORARY MODIFICATIONS AND TRANSIENT EQUIPMENT

PLACEMENTS

18

STA-707

10CFR50.59 AND 10CFR72.48 REVIEWS

21

STA-738

FIRE PROTECTION SYSTEMS/EQUIPMENT IMPAIRMENTS

7

STI-422.02

COMPENSATORY ACTIONS & TRANSIENT EQUIPMENT

PLACEMENTS

1

STI-707.04

10CFR50.59 AND 10CFR72.48 REVIEWS APPLICABILITY

DETERMINATIONS

1

TDM-401B

TURBINE/GENERATOR LIMIT CURVES

5

ABN-104

RESIDUAL HEAT REMOVAL SYSTEM MALFUNCTION

9

ABN-104

RESIDUAL HEAT REMOVAL SYSTEM MALFUNCTION

8

ABN-402

MAIN GENERATOR MALFUNCTION

13

ALM-0031A

ALARM PROCEDURE 1-ALB-3A

8

ALM-0031B

ALARM PROCEDURE 2-ALB-3A

4

TDM-401B

TURBINE/GENERATOR LIMIT CURVES

5

Drawings

Number

Title

Revision

M2-0235

FLOW DIAGRAM, SPENT FUEL POOL COOLING AND

CLEAN-UP SYSTEM

CP-17

M2-2225

INSTRUMENTATION AND CONTROL DIAGRAM, FIRE

DETECTION/PROTECTION SYSTEM CHANNELS 4100,

4102, 4103, 4111

CP-2

COMANCHE 004

UNIT 1 & UNIT 2 ISOPHASE BUS CONTROL PLC

CONTROL PANEL CP1/2-EPIBHX-01P

CP-3

COMANCHE 015

UNIT 1 & UNIT 2 ISOPHASE BUS CONTROL DAMPER

CONTROL PANEL

CP-1

COMANCHE 006

UNIT 1 & UNIT 2 ISOPHASE BUS CONTROL PLC

CONTROL PANEL CP1/2-EPIBHX-01P

CP-3

COMANCHE 008

UNIT 1 & UNIT 2 ISOPHASE BUS CONTROL PLC

CONTROL PANEL CP1/2-EPIBHX-01P

CP-2

COMANCHE 010

UNIT 1 & UNIT 2 ISOPHASE BUS CONTROL PLC

CONTROL PANEL CP1/2-EPIBHX-01P

CP-2

38

Drawings

Number

Title

Revision

COMANCHE 012

UNIT 1 & UNIT 2 ISOPHASE BUS CONTROL AHUA/AHUB

FAN STRTER PANELS CP1/2-EPIBMC-01 AND CP1/2-

EPIBMC-02

CP-3

COMANCHE 014

UNIT 1 & UNIT 2 ISOPHASE BUS CONTROL

CP-2

COMANCHE 011

UNIT 1 & UNIT 2 ISOPHASE BUS CONTROL PLC

CONTROL PANEL CP1/2-EPIBHX-01P

CP-2

COMANCHE 013A UNIT 1 AND UNIT 2 ISOPHASE BUS CONTROL INTERNAL

WIRING DIAGRAM

CP-3

2323-A1-0507

PRIMARY PLANT AUXILIARY ELECTRICAL AND CONTROL

BUILDING FLOOR PLAN

CP-1

COMANCHE 002

UNIT 1 & UNIT 2 ISOPHASE BUS CONTROL INTERIOR

PANEL LAYOUT

CP-2

COMANCHE 003

UNIT 1 & UNIT 2 ISOPHASE BUS CONTROL PLC

CONTROL PANEL CP1/2-EPIBHX-01P

CP-2

COMANCHE 015A UNIT 1 & UNIT 2 ISOPHASE BUS CONTROL DAMPER

CONTROL PANEL

CP-1

COMANCHE 015B UNIT 1 & UNIT 2 ISOPHASE BUS CONTROL DAMPER

CONTROL PANEL

CP-1

M1-0260

FLOW DIAGRAM - RESIDUAL HEAT REMOVAL SYSTEM

CP-37

M1-0261

FLOW DIAGRAM - SAFETY INJECTION SYSTEM SHEET 1

0F 5

CP-24

M1-0216

FLOW DIAGRAM - COMPRESSED AIR SYSTEM

CP-45

M1-0250

FLOW DIAGRAM - REACTOR COOLANT SYSTEM

CP-34

M1-2300

INSTRUMENTATION AND CONTROL DIAGRAM,

VENTILATION - CONTAINMENT, CHANNEL 5400/5403

CP-7

Miscellaneous

Documents

Number

Title

Revision

or Date

EVAL-2018-007

CPNPP Nuclear Oversight Audit Report - CONFIGURATION

& DESIGN CONTROL

08/16/2018

DBD-ME-013

Design Basis Document - Containment Isolation System

25

RIR-22946OCR

Receipt Inspection Report

10/06/1983

CP-201700626

Comanche Peak Nuclear Power Plant, Docket Nos. 50-445

and 50-446 and 72-74, 10CFR50.59 Evaluation Summary

Report 020, 10CFR72.48 Evaluation Summary Report 005,

and Commitment Material Change Evaluation Report 014

12/05/2017

DBD-ME-014-02

Design Basis Document - Generator and Exciter System

21

39

Vendor

Documents

Number

Title

Revision

or Date

CP-201600573

EVALUATION OF COMANCHE PEAK UNIT 1 CLASS 2 TO

CLASS 1VALVE UPGRADES

05/31/2016

CP1/CP2-

EPIBHX-01E/01F

Damper Position Monitor

08/16/2016

CT-27331

MISSILE PROBABILITY ANALYSIS METHODOLOGY

FOR LUMINANT GENERATION COMPANY LLC,

COMANCHE PEAK UNITS 1 & 2 WITH SIEMENS

RETROFIT TURBINES

8

VDRT-5472306

Unit 2 Generator Stator Damage - Monitoring Installation

Plan

07/21/2017

WPT-18067

Transmittal of LTR-SEE-17-189, Flow Evaluation of Forced

Forward Flow through the Residual Heat Removal Pumps at

Comanche Peak Units 1 & 2

10/03/2017

Calculations

Number

Title

Revision

MEB-391

Minimum Allowable Service Water Flow to Diesel Generators

5

ME-CA-0229-2188 Component Cooling Water Heater Exchanger Fowling Water

Analysis

8

71111.18 - Plant Modifications

Condition Reports

CR-2018-008757

Work Orders

5435249

5689179

Modifications

Number

Title

Revision

FDA-2018-000119-01

Final Design Authorization

Calculations

Number

Title

Revision

ME-CA-0000-3342

Air Accumulator Check Valve Leakage - Decay Rate,

Pressure, Time

3

40

71152 - Identification and Resolution of Problems

Condition Reports

CR-2017-013243

CR-2018-003808

CR-2019-002535

Work Orders

5540984

5063234

Procedures

Number

Title

Revision

STI-606.03

Work Planning

3

Miscellaneous

Documents

Number

Title

Revision

DBD-EE-023

Radiation Monitoring System

23

ML19130A154

SUNSI Review

Complete

By: RDA

ADAMS

Yes No

Publicly Available

Non-Publicly Available

Non-Sensitive

Sensitive

Keyword:

NRC-002

OFFICE

SRI/DRP/A

RI/DRP/A

DRS/EB1

DRS/EB2

DRS/OB

DRS/IPAT

NAME

JJosey

RKumana

VGaddy

GPick

GWerner

RKellar

SIGNATURE

/RA/

/RA/

/RA/

/RA/

/RA/ CCO for

/RA/

DATE

05/07/19

05/03/19

05/02/19

05/08/19

05/03/19

05/06/19

OFFICE

DRS/RCB

DNMS/RIB

SPE:DRP/A

BC/DRP/A

NAME

NMakris

GWarnick

RAlexander

MHaire

SIGNATURE

/RA/

/RA/

/RA/

/RA/

DATE

05/02/19

05/07/19

05/02/19

5/10/2019

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