April 2, 2003

EA-02-031

EA-03-057

EA-03-059

Mr. Alfred J. Cayia

Site Vice President

Point Beach Nuclear Power Plant

Nuclear Management Company, LLC

6610 Nuclear Road

Two Rivers, WI 54241-9516

SUBJECT: POINT BEACH NUCLEAR PLANT SPECIAL INSPECTIONS:

RESOLUTION OF AUXILIARY FEEDWATER OLD DESIGN ISSUE AND 

PRELIMINARY RED FINDING - AUXILIARY FEEDWATER ORIFICE

PLUGGING ISSUE; NRC INSPECTION REPORT 50-266/02-15(DRP);

50-301/02-15(DRP)

Dear Mr. Cayia:

On March 24, 2003, the results of two special inspections at your Point Beach Nuclear Plant

were discussed with you and members of your staff. The enclosed report presents the results

of those inspections. The inspections were examinations of activities conducted under your

license as they relate to safety and to compliance with the Commission’s rules and regulations

and with the conditions of your license. Within these areas, the inspections consisted of a

selective review of procedures and representative records, observations of activities, and

interviews with personnel.

Initially, a special inspection was conducted September 23-26, 2002, to determine whether a

Red inspection finding associated with the auxiliary feedwater (AFW) system should be treated

as an old design issue as described in NRC Inspection Manual Chapter 0305, “Operating

Reactor Assessment Program.” This finding was discussed in NRC special Inspection

Report 50-266/01-17(DRS); 50-301/01-17(DRS), dated April 3, 2002, and in the NRC’s Final

Significance Determination letter, dated July 12, 2002. On October 29, 2002, while the results

of the September inspection were being reviewed by the NRC, you notified the NRC of a

potential for a common mode failure of the AFW pumps from the plugging by debris of the

pressure reduction orifices in the AFW recirculation lines. A second special inspection was

subsequently conducted, beginning on October 31, 2002, to review the orifice plugging issue

and its relation to the earlier Red inspection finding. 
A. Cayia -2-

Based upon the results of these inspections, we have concluded that the Red inspection

finding, which involved the potential common mode failure of the AFW pumps due to

inadequate operator response to a loss of instrument air (IA), will not be treated as an old

design issue. As detailed in Section 6.06.a of Manual Chapter 0305, there are four criteria that

must be met for the NRC to classify a problem as an old design issue and thus allow the NRC

to not consider the finding in its assessment of Point Beach’s overall performance. 

The inspections identified that the criterion pertaining to corrective action was not met in that

the implementation of corrective action associated with your evaluation of the AFW/IA issue did

not prevent recurrence of another, separate potential common mode failure of the AFW pumps. 

The failure to implement thorough and complete corrective actions became apparent during our

review of the October 2002 AFW recirculation line orifice plugging issue and the identification of

other problems related to AFW design. These problems included the use of a nonsafetyrelated power supply for relays associated with the proper operation of the AFW recirculation

line air-operated flow control valves and the single electrical bus dependencies of three of the

four recirculation line air-operated flow control valves and three of the four service water supply

motor-operated valves. The failure to implement adequate corrective actions for the AFW/IA

issue is a violation of 10 CFR Part 50, Appendix B, Criterion XVI, “Corrective Action.” The other

old design criterion that may not have been met pertained to the AFW/IA Red finding not being

reflective of a current performance deficiency. From our inspections, we concluded that

deficiencies in your engineering program that resulted in the AFW/IA issue were likely

responsible for the recent problem with the AFW recirculation line orifices and other problems

related to AFW design. 

Because the AFW/IA Red finding did not meet the criteria for consideration as an old design

issue, Point Beach is in the Multiple/Repetitive Degraded Cornerstone Column of the Action

Matrix of Manual Chapter 0305. Consequently, your plant will be discussed at the upcoming

Agency Action Review Meeting. We will notify you via separate correspondence of any agency

actions that result from that discussion and as specified in the Action Matrix. 

This report also discusses the potential plugging of the AFW pump recirculation line orifices

during operation of AFW with service water. This issue appears to have high safety

significance. During development of modification packages in 1999, your staff recognized the

potential for these orifices to plug. However, because of the lack of understanding of AFW

design basis, the orifices were installed. In late 2001 and early 2002, the AFW/IA issue

presented an opportunity to correct this lack of understanding, but no action was taken until the

orifice for the “A” motor-driven AFW pump was found partially plugged on October 24, 2002,

after post-maintenance testing of the pump. In February 2003, testing conducted for you by an

independent laboratory demonstrated that the orifices would quickly plug when subjected to

water-borne debris similar to that found in your service water system. The installation of the

orifices is an apparent violation of 10 CFR Part 50, Appendix B, Criterion III, “Design Control.”

This issue was assessed using the NRC’s Significance Determination Process (SDP) and was

preliminarily determined to be Red, an issue with high safety significance that may result in

additional inspection. This issue is of high safety significance because a common mode failure
A. Cayia -3-

of the AFW pumps would result in substantially reduced mitigation capability for safely shutting

down the plant in response to certain accidents. The assumptions and results of our

preliminary SDP analysis are in Section 3.4.B of the attached inspection report.

Your immediate compensatory and corrective actions for the apparent violation were adequate. 

These actions included a revalidation of the design basis of the AFW system, and the revision

of procedures and training of operators so that the AFW system could be operated during

accidents without dependence on pump recirculation flow. The apparent violation is being

considered for escalated enforcement action in accordance with the “General Statement of 

Policy and Procedure for NRC Enforcement Actions” (Enforcement Policy), NUREG-1600. 

The current Enforcement Policy is included on the NRC’s website at www.nrc.gov.

Before the NRC makes a final decision on this matter, we are providing you an opportunity to

request a Regulatory Conference where you would be able to provide your perspectives on the

significance of the findings, the bases for your position, including any revised or new

information associated with your risk analysis, and whether you agree with the apparent

violation. If you choose to request a conference, it should be held within 30 days of the receipt

of this letter and we encourage you to submit your evaluation and any differences with the NRC

evaluations at least one week prior to the conference in an effort to make the conference more

efficient and effective. If a conference is held, it will be open for public observation. The NRC

will also issue a press release to announce the conference. If you decide to submit only a

written response, such submittal should be sent to the NRC within 30 days of the receipt of this

letter.

Please contact Mr. Kenneth Riemer at (630) 829-9757 within seven days of the date of this

letter to notify the NRC of your intentions. If we have not heard from you within 10 days, we will

continue with our significance determination and enforcement decision and you will be advised

by separate correspondence of the results of our deliberations on these matters.

Since the NRC has not made a final determination in this matter, no Notice of Violation is being

issued for the inspection finding related to design control at this time. In addition, please be

advised that the number and characterization of apparent violations described in the enclosed

inspection report may change as a result of further NRC review.

The NRC has determined that the inadequate correction actions taken for the root cause of the

AFW/IA issue is a violation of 10 CFR Part 50, Appendix B, Criterion XVI, “Corrective Action,”

as cited in the enclosed Notice of Violation (Notice). This violation is associated with a

previously identified Red finding (EA-02-031). The circumstances surrounding the violation are

described in detail in the subject inspection report. You are required to respond to this letter

and should follow the instructions specified in the enclosed Notice when preparing your

response.

In accordance with NRC Inspection Manual Chapter 0305, “Operating Reactor Assessment

Program,” Section 06.06.d, the original performance issue (AFW/IA Red finding, EA-02-031)

will remain open and will not be removed from consideration in the assessment program until

the corrective action violation has been corrected.
A. Cayia -4-

Based on the results of these inspections, the NRC has also identified two issues that were

evaluated under the risk Significance Determination Process as having very low risk

significance (Green). The two findings also involved violations of NRC requirements; however,

because the violations were non-willful and non-repetitive and because the findings were

entered into your corrective action program, the NRC is treating these issues as Non-Cited

Violations, in accordance with Section VI.A.1 of the NRC’s Enforcement Policy. 

If you contest the violation in the Notice or the subject or severity of the Non-Cited Violations,

you should provide a response within 30 days of the date of this inspection report, with the

basis for your denial, to the U.S. Nuclear Regulatory Commission, ATTN: Document Control

Desk, Washington, DC 20555-0001, with a copy to the Regional Administrator, U.S. Nuclear

Regulatory Commission - Region III, 801 Warrenville Road, Lisle, IL 60532-4351; the Director,

Office of Enforcement, U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001;

and the Resident Inspector Office at the Point Beach Nuclear Plant facility.

In accordance with 10 CFR 2.790 of the NRC’s "Rules of Practice," a copy of this letter,

its enclosures, and your response will be available electronically for public inspection in the

NRC Public Document Room or from the NRC’s document system (ADAMS). ADAMS is

accessible from the NRC Web site at http://www.usnrc.gov/reading-rm/adams.html (the Public

Electronic Reading Room). To the extent possible, your response should not include any

personal privacy, proprietary, or safeguards information so that it can be made available to the

public without redaction. 

Sincerely,

/RA/

J. E. Dyer

Regional Administrator

Docket Nos. 50-266; 50-301

License Nos. DPR-24; DPR-27

Enclosures: 1. Notice of Violation

2. Inspection Report 50-266/02-15; 50-301/02-15

See Attached Distribution
DOCUMENT NAME: G:\POIN\ML030920128.wpd

To receive a copy of this document, indicate in the box:"C" = Copy without enclosure "E"= Copy with enclosure"N"= No copy

OFFICE RIII RIII RIII RIII RIII

NAME MKunowski:dtp MKunowski

for KRiemer

Klambert for

BClayton

GGrant JDyer

DATE 04/01/03 04/01/03 04/01/03 04/01/03 04/02/03

OFFICIAL RECORD COPY

* OE concurrence via telephone with J. Dixon-Herrity 4/1/03
A. Cayia -5-

cc w/encl: R. Grigg, President and Chief

 Operating Officer, WEPCo

John Paul Cowan, Chief Nuclear Officer

Licensing Manager

D. Weaver, Nuclear Asset Manager

Joseph Jensen, Plant Manager

Gordon P. Arent, Manager, Regulatory Affairs

Jonathan Rogoff, Esquire General Counsel

Mano K. Nazar, Senior Vice President

J. O’Neill, Jr., Shaw, Pittman, 

 Potts & Trowbridge

K. Duveneck, Town Chairman

 Town of Two Creeks

D. Graham, Director

 Bureau of Field Operations

A. Bie, Chairperson, Wisconsin

 Public Service Commission

S. Jenkins, Electric Division

 Wisconsin Public Service Commission

State Liaison Officer
A. Cayia -6-

ADAMS Distribution:

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C. Ariano (hard copy)

DRPIII

DRSIII

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WMD
NOTICE OF VIOLATION

Nuclear Management Company, LLC Docket Nos. 50-266; 50-301 

Point Beach Nuclear Plant License Nos. DPR-24; DPR-27 

EA-03-059

During two NRC inspections conducted between September 23, 2002, and March 24, 2003, a

violation of NRC requirements was identified. In accordance with the "General Statement of

Policy and Procedure for NRC Enforcement Actions," NUREG-1600, the violation is listed

below: 

Criterion XVI, “Corrective Action,” of 10 CFR Part 50, Appendix B, requires, in part, that

conditions adverse to quality be promptly identified and corrected. In the case of significant

conditions adverse to quality, the measures shall assure that the cause of the condition is

determined and corrective action taken to preclude repetition. 

Contrary to the above, as of December 12, 2002, the licensee failed to implement corrective

actions to preclude repetition of a significant condition adverse to quality associated with an

AFW system potential common mode failure. Specifically, the licensee failed to identify

potential common mode failures that existed involving power supplies to the recirculation line

air-operated valve and other system components. In addition, the licensee’s corrective actions

for the potential common mode failure associated with a loss of instrument air did not preclude

repetition. Specifically, the licensee’s corrective actions, to upgrade the safety function of the

air-operated recirculation valve, failed to ensure that successful operation of the recirculation

line air-operated valve was dependent only on safety-related support systems. Following the

corrective actions, successful operation of the valve was still dependent upon nonsafety-related

power to an interposing relay.

This violation is associated with a previously identified Red SDP finding (EA-02-031).

Pursuant to the provisions of 10 CFR 2.201, Nuclear Management Company, LLC, is hereby

required to submit a written statement or explanation to the U.S. Nuclear Regulatory

Commission, ATTN: Document Control Desk, Washington, DC 20555, with a copy to the

Regional Administrator, Region 3, and a copy to the NRC Resident Inspector at the facility that

is the subject of this Notice, within 30 days of the date of the letter transmitting this Notice of

Violation (Notice). This reply should be clearly marked as a "Reply to a Notice of Violation;

EA-03-059" and should include: (1) the reason for the violation, or, if contested, the basis for

disputing the violation or severity level, (2) the corrective steps that have been taken and the

results achieved, (3) the corrective steps that will be taken to avoid further violations, and

(4) the date when full compliance will be achieved. Your response may reference or include

previous docketed correspondence, if the correspondence adequately addresses the required

response. If an adequate reply is not received within the time specified in this Notice, an order

or a Demand for Information may be issued as to why the license should not be modified,

suspended, or revoked, or why such other action as may be proper should not be taken. 

Where good cause is shown, consideration will be given to extending the response time. 

If you contest this enforcement action, you should also provide a copy of your response, with

the basis for your denial, to the Director, Office of Enforcement, United States Nuclear

Regulatory Commission, Washington, DC 20555-0001. 
Notice of Violation -2-

Because your response will be made available electronically for public inspection in the NRC

Public Document Room or from the NRC’s document system (ADAMS), accessible from the

NRC Web site at http://www.usnrc.gov/reading-rm/adams.html, to the extent possible, it should

not include any personal privacy, proprietary, or safeguards information so that it can be made

available to the public without redaction. If personal privacy or proprietary information is

necessary to provide an acceptable response, then please provide a bracketed copy of your

response that identifies the information that should be protected and a redacted copy of your

response that deletes such information. If you request withholding of such material, you must

specifically identify the portions of your response that you seek to have withheld and provide in

detail the bases for your claim of withholding (e.g., explain why the disclosure of information will

create an unwarranted invasion of personal privacy or provide the information required by

10 CFR 2.790(b) to support a request for withholding confidential commercial or financial

information). If safeguards information is necessary to provide an acceptable response, please

provide the level of protection described in 10 CFR 73.21. 

In accordance with 10 CFR 19.11, you may be required to post this Notice within two working

days. 

Dated this 2nd day of April 2003
U.S. NUCLEAR REGULATORY COMMISSION

REGION III

Docket Nos: 50-266; 50-301

License Nos: DPR-24; DPR-27

Report No: 50-266/02-15(DRP); 50-301/02-15(DRP)

Licensee: Nuclear Management Company, LLC

Facility: Point Beach Nuclear Plant

Location: 6610 Nuclear Road

Two Rivers, WI 54241

Dates: September 23 - 26, 2002

October 31, 2002 - March 24, 2003

Inspector: M. Kunowski, Project Engineer

P. Louden, Senior Resident Inspector (Clinton)

Z. Dunham, Resident Inspector (Kewaunee)

M. Morris, Resident Inspector (Point Beach)

K. O’Brien, Senior Reactor Engineer

S. Burgess, Senior Reactor Analyst 

P. Krohn, Senior Resident Inspector (Point Beach)

Approved by: Kenneth Riemer, Chief

Branch 5

Division of Reactor Projects
2

SUMMARY OF FINDINGS

IR 05000266-02-15(DRP); 05000301-02-15(DRP), on 9/23/2002 - 9/26/2002 and 10/31/2002 -

3/24/2003, Nuclear Management Company, LLC; Point Beach Nuclear Plant, Unit 1 and Unit 2. 

Special inspections to evaluate a Red inspection finding for old design issue consideration and

to review potential common mode failure of auxiliary feedwater pumps due to plugging of

recirculation line orifices - Mitigating Systems Cornerstone.

Cornerstone: Mitigating Systems

The Nuclear Regulatory Commission (NRC) performed a special inspection to assess a Red

inspection finding, regarding a potential common mode failure of the auxiliary feedwater (AFW)

system involving the instrument air (IA) system, for consideration as an old design issue. A

second special inspection was conducted to review the plugging of the pressure reduction

orifice in the AFW recirculation line during post-maintenance testing of the P-38A motor-driven

AFW pump on October 24, 2002, and the subsequent determination by the licensee on

October 29, of the potential for the common mode failure of all four AFW pumps due to

plugging of the associated orifices. The second special inspection also reviewed the

relationship between the AFW/IA Red inspection finding and the orifice plugging issue. 

Inspector-Identified Findings

Cornerstone: Mitigating Systems

• To Be Determined. An apparent violation was identified, in part, through a self-revealing

event when decreased auxiliary feedwater pump recirculation flow was noted during postmaintenance testing. Subsequent licensee and NRC review of the event determined that

the licensee had installed incorrectly designed orifices in each of the pump recirculation

lines. The orifices, due to small clearances, were susceptible to plugging. The primary

causes of this finding were inadequacies in the licensee's design process and the

licensee's implementation of the process, including the identification of system design

requirements and the development of supporting safety evaluations. 

The issue has been preliminarily determined to have high safety significance (Red). 

Following installation of the inadequately designed orifices, the entire auxiliary feedwater

system was susceptible to a common mode failure during operations using service water. 

Failure of auxiliary feedwater during several initiating events could lead to core damage. 

The installation of the incorrectly designed orifices in the recirculation lines is an apparent

violation of 10 CFR Part 50, Appendix B, Criterion III, “Design Control.” (Section 3.4)

• Green. The inspectors identified two issues that were treated as one Non-Cited Violation

of 10 CFR Part 50, Appendix B, Criterion VI, “Document Control.” First, emergency and

abnormal procedures in two emergency response facilities were not included as part of

the temporary change distribution process. Second, no controls were in place to ensure

that the scope of distribution of temporary procedure changes was appropriate. 
3

The finding was of very low risk significance because the licensee distributed the

documents to the facilities prior to any facility activation and the need to use the

procedures. (Section 3.3)

• Green. The inspectors identified a Non-Cited Violation of 10 CFR Part 50, Appendix B,

Criterion V, “Instructions, Procedures, and Drawings,” for a procedure which directed the

use of a flow instrument for the turbine-driven AFW pump recirculation line in a range for

which it was not calibrated. 

The finding was of very low risk significance because follow-up calibration indicated that

the instrument was reliable in the range in which it was to be used, and the inspectors

concluded that it could have been used to accurately determine the AFW flow. 

(Section 3.3)

Cross-Cutting Area: Problem Identification and Resolution

• A violation was identified for the licensee's failure to implement adequate corrective

actions to effectively address a previous Red finding and preclude recurrence (Inspection

Report 50-266/01-17; 50-301/01-17). Specifically, the licensee failed to identify potential

common mode failures that existed involving power supplies to the recirculation line airoperated valve and other system components. In addition, the licensee’s corrective

actions for the potential common mode failure associated with a loss of instrument air did

not preclude repetition. Specifically, the licensee’s corrective actions, to upgrade the

safety function of the air-operated recirculation valve, failed to ensure that successful

operation of the recirculation line air-operated valve was dependent only on safety-related

support systems. Following the corrective actions, successful operation of the valve was

still dependent upon nonsafety-related power to an interposing relay. Additionally, the

corrective actions failed to discover a single failure mechanism involving a system orifice

modification.

The issue was more than minor because the failure to implement appropriate corrective

actions resulted in the auxiliary feedwater system continuing to rely on nonsafety-related

support systems and to be susceptible to a single event causing a total system failure. 

The failure of nonsafety-related support systems and single event failures are an

expected condition during several design basis accidents and should not cause a safety

system to fail. The failure of the licensee to implement adequate corrective actions is a

violation of 10 CFR Part 50, Appendix B, Criterion XVI, “Corrective Action.” (Section 3.4)

Licensee-Identified Findings

None.
4

Report Details

1 BACKGROUND

In 2001, the licensee conducted a voluntary upgrade of its Probabilistic Risk Assessment

(PRA) and initially identified a concern about a common mode failure of its four auxiliary

feedwater (AFW) pumps for accident scenarios involving the loss of instrument air (IA). 

The concern was entered into the corrective action program on July 6, 2001, as Condition

Report (CR) 01-2278. After detailed evaluation, the licensee determined on

November 29, 2001, that the potential existed for a common mode failure to occur and

informed the NRC. Subsequently, the licensee provided a written report to the NRC on

January 28, 2002, in Licensee Event Report (LER) 266/2001-005-00. The LER stated

that the identified failure mechanism was associated with inadequate operator actions

using emergency operating procedures (EOPs) in response to the loss of IA to the AFW

recirculation line flow control air-operated valves (AOVs). From December 3, 2001,

through February 28, 2002, an NRC special inspection team reviewed the AFW/IA issue. 

The report of this inspection (50-266/01-17; 50-301/01-17) documented a preliminary

finding of high safety significance (Red) and two apparent violations of 10 CFR Part 50,

Appendix B. On April 29, 2002, a Regulatory Conference was conducted and the Point

Beach licensee (the Nuclear Management Company, LLC (NMC)) agreed that the finding

was Red, but proposed that it was an old design issue (ODI). The ODI designation

referred to the exemption in NRC Inspection Manual Chapter 0305, “Operating Reactor

Assessment Program,” that allowed the NRC to not take actions specified in the Action

Matrix for certain findings. 

In a letter dated July 12, 2002, the NRC issued a Final Significance Determination,

classifying the AFW/IA issue as a Red finding. In addition, a Notice of Violation was

issued, citing both Criterion V, “Instructions, Procedures, and Drawings,” and

Criterion XVI, “Corrective Action,” in one violation of 10 CFR Part 50, Appendix B. The

July 12th letter also discussed the NRC’s decision to perform additional inspection to

determine whether the issue should be treated as an ODI. An initial inspection was

conducted, by two inspectors, from September 23 to September 26, 2002, and a

preliminary meeting to discuss the tentative results of the inspection was held on

October 2. 

On October 29, 2002, while the results of the September inspection were being reviewed

by Region III management, the licensee notified the NRC of a potential for a common

mode failure of the AFW pumps from the plugging by debris of the pressure reduction

orifices in the AFW minimum flow recirculation lines. Flow through the recirculation lines

is required to prevent damage to the pumps when flow to the steam generators (“forward

flow”) is stopped or significantly reduced by reactor operators. The licensee came to this

conclusion after evaluating the failure of recirculation flow on October 24 to meet an

acceptance criterion during post-maintenance testing of the “A” motor-driven AFW

(MDAFW) pump–the “A” pump feeds the “A” steam generators in Unit 1 and Unit 2 and

the “B” MDAFW pump feeds the “B” steam generators in Unit 1 and Unit 2. A special

inspection team, consisting of five inspectors, was dispatched to Point Beach on

October 30 to review this latest AFW issue and its relation to the earlier problem

associated with the vulnerability of the AFW pumps upon a loss of IA. During this

inspection, the licensee identified rust-like debris in the “A” pump orifice and in the
5

“B” pump orifice after reduced flow was observed during post-maintenance testing on

November 6. The licensee concluded that the source of the rust-like debris was discharge

piping high-point vent valves and pump casing vent valves that had been manipulated

during system maintenance. A discussion of the preliminary results of the NRC inspection

were held with the licensee on December 12, 2002. A subsequent discussion was held on

March 24, 2003, after the NRC reviewed the results of orifice testing conducted on

February 21, 2003, for the licensee by an independent laboratory. These studies

indicated that the sand, silt, and zebra mussel shell debris normally found in plant service

water (SW) would quickly plug the orifices.

2 INSPECTION SCOPE 

For the inspection from September 23-26, 2002, and the inspection from October 31,

2002, to March 24, 2003, the inspectors interviewed licensee personnel; reviewed the

documents listed at the end of this inspection report; walked down the IA, AFW, and

related systems; observed licensed operator performance during simulator scenarios

related to the loss of IA and to the plugging of the orifices; and observed licensee

inspections and evaluations of various components during the search for a source of the

rust-like debris found in the orifices. 

The results of the initial inspection (from September 23-26) are combined in this report

with the results of the second inspection (from October 31 to March 24), which was

chartered with eight focus areas:

1. Timeline development relating to contributors and discovery of the potential common

mode failure of the AFW system due to the plugging of the AFW recirculation line

orifices.

2. Assess the adequacy of the licensee’s risk assessment.

3. Assess the adequacy of the licensee’s operability evaluation, and assess the

adequacy of the immediate compensatory actions, including the length of time the

actions are intended to be in place. Review and validate the new procedure

revisions associated with the interim corrective actions to ensure adequacy.

4. Evaluate the adequacy of the modification, and its associated safety analysis, that

installed the current recirculation line orifices.

5. Evaluate the licensee’s efforts in determining and eliminating the source of the

foreign material found in the recirculation line orifice of “A” MDAFW pump on

October 24, 2002. Additionally, evaluate the licensee’s efforts in determining other

potential sources of foreign material that could plug the orifices.

6. Evaluate the licensee’s efforts in determining if other plant components are

susceptible to the same fouling concern.

7. Evaluate the licensee’s re-design options and priority assignments.

8. Identify prior opportunities to have identified the orifice plugging issue.
6

3 INSPECTION RESULTS

3.1 Timeline for the AFW/IA Red Finding and Recirculation Line Orifice Plugging Issue

1979-1986 Numerous correspondence between NRC and Point

Beach regarding post-TMI (Three Mile Island) initiative to

make critical portions of the AFW system safety-related.

1991 Higher flow replacement orifices installed in AFW

recirculation lines per modification MR 88-099*A-D,

developed beginning in 1988 in response to NRC Bulletin

88-04, “Potential Safety-Related Pump Loss.”

1996-1997 Corrective action program documents (condition reports)

written for high noise during AFW operation on

recirculation.

March 1997 The licensee identified that a loss of instrument air to the

discharge flow control valves for the MDAFW pumps could

cause AFW system failure. The licensee reported the

problem in LER 266/97-014-00.

October 1997 The licensee identified a discrepancy with its inservice

testing program and a design basis document concerning

the open safety function of the AFW recirculation valves. 

The issue is documented in Condition Report 97-3363. 

November 2, 2000 New design pressure reduction orifice installed in the

recirculation line of the P-38A (“A”) MDAFW pump, which

provided flow to the “A” steam generator in Unit 1 and

Unit 2. The new design was intended to solve a noise and

vibration problem associated with the previous design.

November 10, 2000 New orifice installed in the recirculation line of the P-38B

(“B”) MDAFW pump, which provided flow to the “B” steam

generator in Unit 1 and Unit 2. Additional holes drilled in

the orifice to increase flow.

March 14, 2001 Additional holes drilled in new orifice for the P-38A pump 

to increase flow.

April 13, 2001 The licensee reviewed foreign material control for the

March 14, 2001, modification after post-modification flow

did not meet expectations. The issue was documented in

CAP013812 (CAPs were corrective action program

documents that replaced condition reports).
7

July 6, 2001 Licensee initially identified a concern about the effect of

the loss of IA on AFW pumps.

November 29, 2001 Licensee reported in accordance with 10 CFR 50.72 the

potential for a common mode failure of the AFW pumps

because of the loss of IA (AFW/IA issue).

December 3, 2001 NRC special inspection to review the AFW/IA issue began.

January 28, 2002 The licensee submitted LER 266/2001-005-00, discussing

the AFW/IA issue.

February 28, 2002 NRC special inspection concluded. A preliminary Red

inspection finding was documented in report

50-266/01-17(DRS); 50-301/01-17(DRS), dated

April 3, 2002.

April 29, 2002 Regulatory Conference held to discuss two apparent

violations and the Red preliminary significance

determination associated with the AFW/IA finding.

May 11, 2002 New orifice installed in the recirculation line of the 2P-29

turbine-driven AFW (TDAFW) pump, which provided flow

to the Unit 2 “A” and “B” steam generators.

May 14, 2002 Licensee issued its root cause evaluation (RCE) of the

AFW/IA issue.

July 12, 2002 Final Significance Determination letter and Notice of

Violation for the AFW/IA finding was issued by NRC.

August 12, 2002 Licensee responded to the Notice of Violation in a letter

describing corrective actions.

September 12, 2002 As part of corrective actions for the AFW/IA issue, the

licensee reclassified the open function of the AFW

recirculation line AOVs as safety-related.

September 26, 2002 Licensee submitted a clarification of its response to the

Notice of Violation.

September 26-29, 2002 NRC special inspection conducted to determine if the

AFW/IA Red finding was an ODI.

October 14, 2002 New orifice installed in the recirculation line of the

1P-29 TDAFW pump, which provided flow to the Unit 1 “A”

and “B” steam generators. 
8

October 24, 2002 During post-maintenance testing of the P-38A MDAFW

pump, recirculation flow of 64.5 gallons per minute (gpm)

was below the 70-gpm acceptance criterion. Rust-like

debris found in 24 of 54 outer holes of the pressure

reduction orifice. The orifice was subsequently cleaned

and the pump re-tested. Recirculation flow was 75 gpm.

October 25, 2002 The P-38B MDAFW pump and the 1P-29 and 2P-29

TDAFW pumps were tested. Recirculation flows met

acceptance criteria.

October 29, 2002 Licensee completed an engineering evaluation and

declared all four AFW pumps inoperable because of the

potential for service water borne-debris to plug the

recirculation line orifices. The pumps were declared

operable about 21⁄2 hours later after special training was

given to reactor operators, temporary information tags

were placed on AFW equipment, and procedure changes

were initiated.

October 31, 2002 NRC special inspection began at Point Beach to review

orifice plugging issue and its relation to the AFW/IA

finding.

November 6, 2002 Boroscopic exam of the P-38B MDAFW pump and

discharge piping was conducted by the licensee. No

problems identified. Subsequent post-maintenance testing

identified that recirculation flow was 68 gpm (70-gpm

acceptance criterion). Rust-like debris found in the orifice. 

The orifice was cleaned and the test was re-run on

November 7. Flow was 73 gpm, satisfying the acceptance

criterion. 

December 12, 2002 Preliminary exit meeting for the special inspection was

held.

December 20, 2002 Licensee contractor completed evaluation of debris found

in the orifices and issued its report. 

December 26, 2002 Licensee submitted LER 266/2002-003-00, discussing the

possible common mode failure of AFW due to partial

clogging of the recirculation orifices.

January 27, 2003 Contractor laboratory began study of plugging potential of

a pressure reduction orifice for the licensee.
9

February 13, 2003 NRC conducted a Significance and Enforcement Review

Panel and concluded that based on the preliminary results

of the most recent special inspection the AFW/IA Red

finding was not an ODI.

February 21, 2003 Final testing of an orifice at the contractor laboratory

indicated that the orifices would plug in less than one

minute when subjected to service water flow with a typical

debris load of sand, silt, and crushed zebra mussel shells.

March 20, 2003 NRC conducted a Significance and Enforcement Review

Panel. The Panel assessed the significance of the

potential plugging of the AFW pump recirculation lines

during operation of AFW with service water. The issue

was preliminarily determined to be Red, an issue with high

safety significance. 

3.2 The Licensee’s Risk Assessment of the Orifice Plugging Issue

Initially, in late October and early November 2002, the licensee assessed plant risk after

making temporary procedure changes (discussed further in Section 3.3) to ensure AFW

forward flow or stopping of an AFW pump in lieu of relying on recirculation flow. The

procedure changes essentially replaced the function of the recirculation line and the flow

control AOV with an operator action to maintain forward flow above the minimum value

required for pump cooling (50 gpm for the MDAFW pumps and 75 gpm for the TDAFW

pumps) or to shut off the pump. The risk assessment changed (improved) daily as the

human error probabilities (HEPs) changed with the completion of procedural changes,

operator aids, and operator training. The on-line risk as calculated by the licensee’s risk

program changed from a high yellow risk to a low yellow risk once all of the procedures

had been revised and operators had been trained. Review by the inspectors determined

that the risk analysis was performed in a systematic and methodical manner and that

appropriate HEP values were used. The HEP analysis was reviewed by a corporate risk

analyst and by an independent contractor throughout the process.

The orifice plugging issue affected all initiating event scenarios, except large-break

loss-of-coolant accident (LLOCA). While the licensee was trying to determine the source

of the rust-like material in the orifices, changes were made to the PRA model that

(1) accounted for the plugging probability from debris in condensate storage tank (CST)

water–the nonsafety-related, normal source of water for AFW–from debris in service

water–the safety-related source for AFW–and from fire water, (2) fine-tuned HEP values

for feed and bleed actions (feed and bleed would be required if the AFW pumps could not

be used for cooling the reactor coolant system; HEP values for feed and bleed were

typically very conservative and were the same for all scenarios even though it is different

for each scenario), and (3) added the water treatment system to the PRA model since the

system could be used for initiating events where loss of offsite power (LOOP) or loss of

instrument air (LOIA) was not involved and make-up to the CST was needed. 
10

For determining a plugging probability, the licensee considered using Point Beach

operating experience with these orifices, because orifices, in general, do not have generic

plugging probabilities and use of this type of orifice was not widespread. In late

December 2002, the licensee concluded that the source of the rust-like material found in

the orifices of the two MDAFW pumps was pump casing and discharge line high-point

vent valves and associated carbon steel piping, where rust-buildup from infrequent use of

the valves would be dislodged during fill and venting operations of the pumps

(Section 3.5). Whereas all four pumps had similar vent valves, it was considered unlikely

that all four pumps would be filled and vented at the same time, potentially plugging the

recirculation line orifices of the four pumps simultaneously. 

In late January and in February 2003, a specially fabricated orifice was tested at a

contractor laboratory in an effort to determine a plugging probability with SW. Definitive

testing occurred on February 21 when a debris mixture of sand, silt, and zebra mussel

shells representative of what would exist in the Point Beach SW system was injected into

a closed loop configuration of piping, an orifice, and a centrifugal pump. The orifice

plugged in much less than one minute of debris being injected into the loop. These

results were contrary to those of a previously performed computational particle fouling

model analysis that indicated that plugging was unlikely because of the particle size

distribution of debris in SW and the shear forces in the holes and channels of the orifices

developed with the minimum flow required through the orifice for pump cooling. 

Based upon the test results, the licensee’s PRA staff determined that a plugging

probability of 1.0 was appropriate for the use of SW as an AFW water supply. The

normally cross-tied CSTs had limited capacity; therefore, for all scenarios within the

24-hour mission time, the licensee eventually had to use another water source. Using the

test results, the licensee’s PRA credited accident sequences where the reactor coolant

pumps were available for forced recirculation and the switchover from AFW to residual

heat removal (RHR) cooling occurred before the CSTs emptied. This was based upon

proceduralized operator actions to go to cold shutdown in lieu of switching over to SW. 

As mentioned previously, the licensee was also able to credit accident sequences where

the water treatment system would be used to refill the CSTs. With this credit given in their

PRA model, the licensee’s preliminary risk analysis determined that the plugging of the

orifices resulted in a risk significant change in core damage frequency. 

3.3 Corrective Actions for the AFW/IA Red Finding and the Orifice Plugging Issue

A. AFW/IA

The licensee determined the root cause for the AFW/IA issue (RCE 01-069) was

deficiencies in the original emergency operating procedure (EOP) validation process,

which was completed in 1985. The EOP validation method used at that time met industry

guidelines and focused specifically on event mitigation responses, but failed to thoroughly

assess the procedure/design/human interface for a loss of IA transient.

Two significant contributing causes were identified: limitations in the PRA model fault

trees which evaluated system performance on design basis functions and only considered

operator actions to mitigate a failure, and earlier evaluations that only focused on

minimum AFW flow requirements to the steam generators to provide decay heat removal. 
11

Other contributing causes identified in the root cause evaluation included failure to

consider human actions during failure modes and effects analysis review on the design

control process; failure to effectively integrate human error reduction methods in

operations; failure to include human error reduction methods into the EOP development

process; and inconsistencies between AFW system descriptions in the Final Safety

Analysis Report, AFW system Design Basis Document, and the In-service Testing

Program document pertaining to the recirculation line AOVs.

In the letter dated August 12, 2002, which responded to the Notice of Violation (NOV)

associated with the Red AFW/IA finding, the licensee described several corrective actions

that had been taken. These included immediate actions to alert operators of the AFW

minimum recirculation flow requirements with control board tags; supplemental briefings

of operators; procedure changes to ensure that AFW minimum recirculation flow was

maintained; and the installation of pneumatic backup supplies for the recirculation line

AOV for each AFW pump.

Many of the corrective actions taken to prevent recurrence of the root cause and those

taken to address the contributing causes had been completed by the date of the NOV

response and more had been completed by the time of the September 23-26 inspection. 

However, from the indepth review of AFW design during the orifice plugging inspection

and the resultant identification of other problems with the AFW system (discussed in

Section 3.4), the NRC inspectors determined that the corrective actions taken for the root

cause of the AFW/IA issue as described in RCE 01-069 were inadequate. The AFW/IA

issue, the self-revealing AFW orifice plugging issue, and the other problems discussed in

Section 3.4, were caused by a fundamental lack of understanding of the design basis of

the AFW system that were not adequately addressed by the corrective actions. 

B. Orifice Plugging Issue

The licensee formed an event resolution team to determine a root cause for the orifice

plugging issue and develop corrective actions. In addition, a large number of procedures

were revised; operators were trained on the issue and on compensatory measures,

including procedure revisions; and components and systems were examined and

evaluated to identify the source of the debris in the orifices. Industry experts were also

contracted with to provide assistance with AFW design basis revalidation, review of the

Point Beach engineering organization and processes, PRA evaluation of the plugging

issue, metallurgical analyses of the debris, and analyses of the plugging potential of the

orifices. 

Two findings of very low safety significance (Green) were identified by the inspectors. 

One finding involved insufficient distribution of abnormal and emergency procedure

temporary changes to all emergency response facilities. The second finding involved the

use of a flow instrument for the TDAFW pump recirculation line in a range for which it had

not been calibrated. These findings are discussed in detail below. Several corrective

actions, such as the AFW design basis revalidation and review of the engineering

organization and processes, had not been completed by the end of the inspection and will

be reviewed during future inspections. Other actions, such as the evaluation of a

replacement design for the orifice and the training of operator crews through simulator

scenarios requiring the use of the revised procedures, were satisfactorily completed. 
12

Because the loss of IA to the AFW recirculation line AOV was a part or a result of an

initiating event, and not considered a separate event, only 4 procedures were revised in

November 2001: EOP-0, Reactor Trip or Safety Injection; EOP-0.1, Reactor Trip

Response; Emergency Contingency Action ECA-0.0, Loss of All AC [Alternating Current]

Power; and Abnormal Operating Procedure AOP-5B, Loss of Instrument Air. These

procedures were changed immediately and a longer term project was undertaken to

systematically evaluate and revise, as necessary, other procedures. However, because

the risk significance of the orifice being plugged was independent of the accident

scenario, 117 procedures (AOPs, EOPs, ECAs, CSPs [Critical Safety Procedures], and

several normal operating procedures) required revision. Also, a factor in the number of

procedure revisions was a change in philosophy after the October 24, 2002, plugging

event whereby operators would be required to stop the AFW pumps when forward flow

was less than 50 gpm for the MDAFW pumps and less than 75 gpm for the TDAFW

pumps. Normally, the operators would close the discharge valves to throttle or stop AFW

flow. Because of the risk of plugging the recirculation line, the operators were instructed

in October 2002 to stop the pumps if there was no dedicated operator observing

recirculation flow, which was only indicated on instruments near the pumps. The licensee

determined that the most effective way to implement the change was to have just-in-time

training and change the fold-out page of the procedures along with specific procedure

changes.

The inspectors reviewed the changes to procedures made by the operations department

in response to the orifice plugging issue and identified four problems: 

 Procedure AOP-10, “Control Room Inaccessibility,” was revised to reflect the

changes in operational requirements for the TDAFW pumps in the “Action/Expected

Response” column, but did not include changes in operational requirements for the

MDAFW pumps in the “Response Not Obtained” column.

 Nuclear Plant Business Unit Procedure (NP) 1.2.3, “Temporary Procedure Change,”

required the initiator of the temporary change to determine the procedure locations

that would receive the change. The operations department selected the following

locations:

• Document Control Distribution Lead for Master File,

• Main Control Room,

• Primary Auxiliary Building Operator Station,

• Operations Department Office,

• Operations Shop,

• Control Room Simulator, and

• Work Control Center.

However, the changes were not distributed to the Technical Support Center (TSC)

and Operations Support Center (OSC) emergency response facilities. As a result,

during an emergency, personnel in these facilities would not have had the same

procedure revisions as the main control room crew, possibly complicating licensee

response to an emergency.
13

 During the recovery phase of an event, operators would exit the emergency and/or

abnormal procedures and return to the normal operating procedures (OPs). The

OPs were not revised to include information about the AFW flow requirements. The

licensee stated that operating instruction (OI)-62 for AFW operations would be used

after leaving the abnormal or emergency procedures. However, by excluding the

AFW orifice information from the OPs, the licensee failed to provide the Duty Shift

Supervisor, the person with overall control of plant operations, with information that

may be needed for decisions affecting plant operations.

 The inspectors compared the AFW “Information Tags” on the control boards and the

local instruments and observed that the tags were not the same. The control board

tags referenced AFW flow, which would include any indication of flow, while the local

instrument tags referenced flow using the AFW pump discharge flow meter. The

tags on the local instruments specified the recirculation flow instrument to be used

because there were no other indications that could have been used in the area. 

Since plant operating philosophy in response to the AFW/IA finding was to consider

recirculation flow not available, the instruction to operators was to secure the AFW

pump if forward flow was less than 50 gpm for the MDAFW pumps and less than

75 gpm for the TDAFW pumps. Given the specific indications available at each

operating station, the inspectors concluded that the difference in information tags

was acceptable.

However, the inspectors noted that the first increment for the TDAFW pump local

discharge flow indicator was 100 gpm and then continued upward in increments of

20 gpm to 400 gpm. This raised a question about the licensee’s ability to accurately

read 75 gpm when the first increment was 100 gpm. The inspectors also reviewed

past calibration records for the instrument and determined that, up until

December 12, 2002, it had been calibrated from 150 gpm to 400 gpm. The

instrument was subsequently calibrated from 50 gpm to 150 gpm during the

weekend of December 13. The inspectors determined that the instrument had not

been calibrated for use in the range in which it was required to be used in the

emergency and abnormal procedures. Therefore, the instrument calibration and

range was not considered as part of the engineering and operations evaluation when

the procedures were revised. 

Analysis

The inspectors determined that two orifice-related procedure issues warranted a

significance evaluation in accordance with NRC Inspection Manual Chapter 0612, “Power

Reactor Inspection Reports,” Appendix B, “Issue Disposition Screening,” dated April 29,

2002. 

First, the inspectors determined that the issue of not having the procedures updated in all

of the emergency facilities was a performance deficiency in that: 1) the temporary

procedure changes were not distributed to all of the facilities that would be required to use

them during a plant emergency, and 2) no controls were in place to ensure that the scope

of distribution of temporary procedure changes was appropriate.
14

Second, the inspectors determined that the issue of insufficient calibration of the AFW

recirculation flow instrument was a performance deficiency in that: 1) the instrument

being relied upon to perform emergency and abnormal actions had not been verified to be

accurate for the range in which it was used, and 2) the instrument calibration procedure

was not designed to assure that the instrument would perform in accordance with the

procedural requirements of maintaining minimum flow through the pump. 

These findings were more than minor since they affected the availability, reliability, and

capability of the AFW system, a mitigating system. Using NRC Inspection Manual

Chapter 0609, Appendix A, “SDP Phase 1 Screening Worksheet for IE, MS, and B

[Initiating Events, Mitigating Systems, and Barrier Integrity] Cornerstones,” the inspectors

used the “Mitigating Systems” column. Based on the answers to the screening questions,

the inspectors concluded that these two orifice-related procedure issues were findings of

very low safety significance (Green).

Enforcement

 

Appendix B, Criterion VI, of 10 CFR Part 50, “Document Control,” requires, in part, that

measures be established to control the issuance of documents and that these measures 

assure that the documents are distributed to and used at the location where the

prescribed activity is performed. Contrary to this, the inspectors determined that the

emergency and abnormal procedures in emergency response facilities had not been

included as part of the temporary procedure change distribution process. Because this

violation was of very low safety significance and was entered into the licensee’s corrective

action program, this violation is being treated as a Non-Cited Violation (NCV

50-266/02-15-01; 50-301/02-15-01) consistent with Section VI.A of the NRC Enforcement

Policy. The issues did not represent an immediate safety concern.

Appendix B, Criterion V, of 10 CFR Part 50, “Instructions, Procedures, and Drawings,”

requires, in part, that the activities affecting quality be prescribed by documented

instructions, procedures, and drawings, including changes thereto. Contrary to this, the

procedure for the calibration of the AFW flow instrumentation was not revised to include

calibration of the instrumentation in the range for which it was required. Since follow-up

calibrations indicated that the instrument was reliable in the range in which it was to be

used, the inspectors determined that the AFW instrument could have been used to

accurately determine the AFW flow and prevent damage to the pump. Because this

violation was of very low safety significance and was entered into the licensee’s corrective

action program, this violation is being treated as a Non-Cited Violation (NCV 50-266/02-

15-02; 50-301/02-15-02) consistent with Section VI.A of the NRC Enforcement Policy. 

The issue did not represent an immediate safety concern.

3.4 Adequacy of the Safety Analysis and Modification for Recirculation Line Orifices

The inspectors reviewed modification packages associated with replacement of each

AFW pump recirculation line orifice and those associated with upgrading the recirculation

line AOV safety classification. As a part of the assessment, the inspectors also reviewed

the associated safety analyses and the plant process for implementing modifications.
15

The inspectors identified an apparent violation associated with the AFW system

modifications and a cited corrective actions violation for current and historical system

deficiencies. One finding for design control was preliminarily determined to be a Red

finding. The second finding for inadequate corrective actions was associated with the 

AFW/IA Red finding.

 A. Description

 A.1 AFW Pump Recirculation Line Orifice Modification (Modifications 99-029*A, B, C, and D)

Background

In 1999, the licensee initiated the development of a modification to replace the pressure

reduction orifices located in the AFW pump recirculation lines. The modification was

developed, in part, to reduce flow noise (cavitation) during routine AFW system operation. 

The modification was also expected to preclude the recurrence of small leaks in

recirculation line welds that the licensee had concluded were caused by cavitation-induced

vibration.

Prior to the proposed 1999 modification, the licensee had replaced the original

construction orifices in 1991, through a modification initiated in 1988. The 1991

replacement effort was undertaken to increase the individual pump recirculation flow

following the licensee’s evaluation of NRC Bulletin 88-04, “Potential Safety-Related Pump

Loss.” The original (1970's) system design included the automatic initiation of pump

recirculation flow, at approximately 30 gpm, following pump startup and whenever pump

forward flow decreased below a setpoint. 

After the modification packages were developed in 1999 - 2000, the licensee staggered

the installation of the orifices. The two MDAFW pump recirculation orifices were installed

in November 2000. The two TDAFW pump orifices were installed in May and October

2002. 

Design Inputs

The inspectors reviewed and compared the modification packages for each pump and

noted only minor differences. One difference was that a full safety evaluation had been

prepared for the MDAFW pump orifice modifications and only a safety screening had

been prepared for the TDAFW pump orifice modifications. This difference was primarily a

result of a change in NRC regulations in the interval between the licensee’s

implementation of these two versions of the modification package. Also, the inspectors

noted that the MDAFW pump modification packages included additional paperwork to

document a further modification to the orifice design, by drilling additional flow holes, to

increase the available flow rate. The TDAFW pump orifice design already included an

adjustment mechanism and did not require the drilling of additional flow holes. 

The inspectors noted that the new (1999) orifice design differed from both the 1970's

original and the 1991 replacement orifice designs. Specifically, both the original and 1991

orifice designs consisted of a series of orifice plates, located within the recirculation piping

and with approximately 0.375-inch-diameter holes in the plate to permit the passage of
16

recirculation flow. The new orifice design consisted of a series of concentric cylinders with

approximate 0.125-inch-diameter holes and varying-sized flow channels. The smallest

dimension of the smallest channels was 0.015-inch. 

In the final design description for the 1999 modifications, the licensee concluded that the

mechanical and flow performance characteristics of the new orifice design were equal to

or better than those of the installed orifice. This conclusion appeared to be based upon

the licensee’s analysis of the pressure drop characteristics of the new orifice design. 

However, the inspectors noted that the modification package did not include a summary of

the parameters compared to support this general conclusion. In addition, the inspectors

noted that the modification package design inputs section did not include a reference to or

discussion of the SW strainer mesh size and its impact on the proposed new orifice

design. The strainer maximum mesh size of approximately 0.125-inch-diameter was

significantly larger than the smallest flow dimension for the new orifice design. As a

result, the inspectors concluded that debris passing through the strainers could have been

expected to plug the narrower flow channels of the orifice when SW was used for AFW

system operation instead of water from the CSTs, the normal but nonsafety-related

source for AFW. The smallest flow channel diameter of the previous orifice design was

0.375-inch.

The inspectors also noted that the design inputs for the orifice installed on

October 14, 2002, for the 1P-29 Unit 1 TDAFW pump, the last of the AFW pumps to be

modified with the new design, had not but should have been updated to include or

consider recent clarifications to the documented AFW system design and safety functions. 

On September 12, 2002, the licensee, as a corrective action for the previous AFW/IA

issue, modified the documented recirculation line AOV design function to overtly require

the valve to be able to open automatically during accident conditions. Previously, the

AFW system design had required a minimum recirculation flow to dissipate pump heat but

only designated the close function of the AOV as safety-related. Furthermore, this design

function was not required throughout an accident, only at the beginning. As a result, the

licensee staff had not considered, in the orifice modification package, the potential for

orifice plugging to be a significant safety impact, although the potential for plugging was

recognized. 

Safety Evaluations

The licensee performed a full safety evaluation (SE 2000-0055) for the MDAFW pump

orifices and a safety screening (SS 2001-0981) for the TDAFW pump orifices to assess

the acceptability of the proposed modifications. Because of a change in the NRC’s

regulations after the safety evaluation was written, only a safety screening was written for

the TDAFW pump orifices.

For both the full safety evaluation and the safety screening, the licensee identified the

current licensing basis design functions of the orifices to include:

(1) ensure adequate flow and pressure drop through the AFW pumps when they were

operated in recirculation mode, thus preventing low flow instabilities and high pump

temperatures;
17

(2) serve to restrict the recirculation flow for the pumps to ensure adequate AFW flow to

the steam generators if the recirculation AOVs failed to close; and

(3) passively maintain the AFW system pressure boundary integrity.

The inspectors reviewed the licensee’s assessment of the modification’s impact on these

design features and concluded that neither the safety evaluation nor the safety screening

correctly determined the impact of the new design orifices on these functions. 

Specifically, in the safety evaluation, the licensee incorrectly concluded: 1) that the new

orifice’s mechanical and performance characteristics were identical to or better than those

of the existing orifice; and 2) that the new orifice design would not result in an increased

possibility of decreased recirculation flow. The inspectors also concluded that the safety

evaluation did not include sufficient detail to objectively compare the mechanical and

performance characteristics of the existing (1991) orifices and the new (1999) orifices. 

The safety evaluation also did not appear to consider the potential for the pump to require

recirculation flow at any point during a design basis event. Instead, the licensee

conjectured that forward flow from the AFW pumps to the steam generators would always

be available to fulfill the recirculation line design functions. In addition, although the

licensee identified the possibility that debris entrained in SW could reduce the recirculation

flow, the licensee concluded that the new orifice design would “reduce” this potential. 

Therefore, based upon a perception that the recirculation flow path was not necessary to

support AFW flow to the steam generators, the licensee concluded that the possibility of

reduced flow was acceptable.

The inspectors identified similar deficiencies with the safety screening. Of note was the

licensee’s conjecture that the “orifices are not explicitly required in an accident analysis to

be able to pass service water, since the recirculation control valve would be closed when

the pump is aligned to a steam generator.” The inspectors determined that this

conclusion did not consider the full range of operator actions, allowed during a design

basis accident, concurrent with the dual automatic open and closed design functioning of

the recirculation AOV. 

A.2 AFW Recirculation Line AOV Safety Upgrade (Modification 02-029)

Background

As a corrective action for the AFW/IA Red finding, the licensee committed to “upgrade”

the design of the recirculation AOV to include a safety-related function to open (licensee

letters to the NRC, dated August 12 and September 26, 2002). The licensee

implemented this commitment through the development and completion, in part, of

Modification 02-029.

Design Inputs

The inspectors reviewed the design inputs for the modification package and determined

that the adequacy of the electrical power for the design change had not been properly

assessed. Specifically, the licensee staff, in the modification package design inputs

section, indicated that the modification did not include any electrical or instrumentation

and control aspects. However, the inspectors determined that proper operation of the
18

recirculation AOV required the availability of safety-related 120-volt alternating current

(Vac) to a relay located electrically between the AFW pump discharge flow sensor and the

AOV solenoid. The current system design powered this relay using nonsafety-related

120-Vac. As a result, under certain design and licensing accident scenarios, the

nonsafety-related power supply to this relay could be lost and the AOV might not be able

to be remotely directed to open. 

The inspectors discussed this issue with licensee staff who validated the issue and

identified immediate compensatory measures. As a followup, the inspectors questioned if

the current AFW system design included other non-realized electrical inadequacies. In

response, the licensee reviewed the current electrical design and identified several

additional design issues: 1) three of the four recirculation AOVs had a single, direct

current, electrical bus dependency; 2) three of the four SW supply valves to the AFW

pumps, had a single, alternating current, electrical bus dependency during certain plant

configurations; 3) manual AFW system-related valves would be necessary following a loss

of a direct current bus concurrent with a faulted steam generator; and 4) one of the four

discharge flow sensors was wired assuming an opposite logic of the other three. In

addition, the licensee determined that a loss of some of the direct current electrical

busses could also result in the control room staff losing some AFW system-related valve

position and flow indications. In response to these additional findings, the licensee staff

initiated appropriate compensatory measures pending final comprehensive corrective

actions.

The inspectors also identified that the modification design did not include an assessment

of the compatibility of the proposed design change to designate the AOV open position as

a safety-related function with the recently installed orifice design. Specifically, the

modification design did not evaluate the implications of AFW system recirculation

operations using service water with the AOV in the open position and the presence of

decreased flow passages in the newly installed orifice.

A.3 Design Change Process

Based upon the licensee’s failure to develop modification packages that adequately

considered recent changes in the plant design, the inspectors reviewed current and past

plant design change process procedures. Specifically, the inspectors reviewed

procedures NP 7.2.1, “Plant Modifications”; NP 7.2.2, “Design Control”; NP 7.2.3,

“Engineering Change Requests”; NP 7.2.6, “Engineering Change Process”; and

NP 7.7.10, “Safety-Related and QA Scope Classification.” Through discussions with the

cognizant licensee staff and review of procedures, the inspectors determined that the

design change process permitted and encouraged the early development of modification

packages; however, the associated procedures did not include adequate provisions to

ensure that the design remained appropriate at the time the modification was installed,

which could have been several years after the package was prepared. In addition, the

inspectors determined that the design change process did not include adequate measures

to ensure that concurrently developed design changes on a single or related systems

would be coordinated to ensure consistent assumptions and interfacing requirements. For

the examples discussed previously, the inspectors determined that some of the design

change packages were developed as much as two years prior to installation and were not

reviewed at the time of installation to confirm that the assumed plant design had not been
19

changed. In one case, the final recirculation line orifice was installed only one month after

the recirculation line AOV upgrade modification was implemented.

A.4 Corrective Actions

As a corrective action to the AFW/IA Red finding, the licensee performed a root cause

evaluation (RCE 01-069). As a result of the inspectors’ findings documented in

Sections A.1 through A.3, a limited review of the RCE and associated corrective actions

for the AFW/IA issue was conducted.

RCE 01-069

The inspectors determined that the corrective actions taken for the root cause identified in

RCE 01-069 were not adequately implemented to prevent recurrence. The inspectors

noted that the RCE problem statement appeared to assume a specific failure mode. That

is, the RCE only questioned why emergency operating procedures existed and contributed

to the AFW/IA issue. As a result, the RCE focused almost exclusively on the emergency

procedure development process and did not assess the adequacy or staff understanding

of the current AFW system design.

The licensee had an independent review of the RCE performed. As a result, the

independent reviewer posed numerous questions regarding the scope and depth of the

RCE. The inspectors reviewed the licensee’s responses to these questions, which were

included as an addendum to the RCE, and determined that the response to many of the

questions did not directly address the underlying question. In several cases, the

questions appeared to be directly related to the issues and findings discussed in

Sections A.1 - A.3 above regarding the licensee’s lack of a clear understanding of the

AFW system design, application of single failure analysis, extent of condition for a similar

failure mode (that is, system operations reliance upon nonsafety-related support systems),

and design configuration control differences.

The independent reviewer also questioned why the RCE did not specifically include

corrective actions associated with upgrading the recirculation AOV open function. The

inspectors determined that integration of the reasoning and rationale for this corrective

action into the RCE would have necessitated a change to several other conclusions

reached in the report.

Although the licensee upgraded the recirculation line AOV open function to safety-related

as a corrective action for the AFW/IA issue, the inspectors determined that the

modification package inadequacies outlined in Section A.2 and the other similar design

deficiencies outlined in Section A.1 were indications that the corrective actions were not

effective in preventing recurrence of this significant condition adverse to quality. While

inadequacies in the RCE may have precluded the identification of the single failure design

deficiencies outlined in Section A.1, the licensee’s failure to successfully implement the

upgraded safety function for the AOV was a further indication of a current lack of

understanding of the AFW system design.
20

B. Analysis

The inspectors identified two issues warranting a significance evaluation in accordance

with Inspection Manual Chapter 0612, “Power Reactor Inspection Reports,” Appendix B,

“Issue Disposition Screening,” issued April 29, 2002.

(1) The first issue involved the licensee’s failure to establish and properly implement

measures to ensure that applicable regulatory requirements and the design basis for

structures, systems, and components important to safety were correctly translated into

specifications, drawings, procedures, and instructions. Specifically, the plant design

change procedures did not establish measures to ensure that modifications, at the time of

installation, would correctly translate applicable regulatory and design requirements. 

Further, Modification Packages 99-029*A, B, C, and D (AFW orifice replacement) and

Modification Package 02-029 (AFW recirculation line AOV safety upgrade), and the

associated safety evaluation or safety screening, did not ensure that the AFW design

requirements for the recirculation lines were appropriately translated into specifications,

drawings, procedures, and instructions. This performance deficiency was determined to

be more than minor consistent with Example 3.a of Appendix E of NRC Inspection Manual

Chapter 0612. That is, the performance deficiency represented multiple failures of the

design change and safety evaluation process that resulted in modifications to the AFW

system that required immediate compensatory measures to ensure continued system

operability and further modifications to correct.

The Region III staff performed a Phase 2 risk assessment, in accordance with NRC

Inspection Manual Chapter 0609, Appendix A, “At Power Operations,” using the

Revision 1 benchmarked Point Beach significance determination process (SDP)

worksheets with the following assumptions:

Assumptions: 

a. Based on the AFW orifice test results, as further described in Section 3.6

of this report, the failure probability of the AFW pumps when SW is used

as a water supply is 1.0. There is no recirculation flow indication in the

control room and no procedural guidance to indicate a potential problem

with the recirculation line if instrument air is still available. AFW pump

recovery is not credited.

b. One CST (of the normally cross-tied two CSTs) is designed for at least 1

hour with a dual unit event at technical specification (TS) minimum level;

however, the plant normally keeps the CST above TS minimum. The

licensee’s best estimated evaluations determined that the CSTs should

last between 4 and 8 hours, depending upon the scenario (single unit vs.

dual unit). 

c. Since the CSTs have limited capacity, for all scenarios within the 24-hour

mission time, the plant eventually has to use another water source. The

Phase 2 SDP credits two alternatives to using raw SW as an AFW pump

suction source.
21

• For those scenarios where the reactor coolant pumps are

available for forced recirculation, credit has been given to

switchover from AFW to RHR cooling before the CSTs empty

based upon the operator’s preference to go to cold shutdown in

lieu of switching over to SW (Initiating Events:

TRANS–Transients, TPCS–Transients Without Power Conversion

System, SGTR–Steam Generator Tube Rupture).

• For those scenarios where the water treatment system is available

for CST refill, credit has been given (TRANS, TPCS, LCCW–Loss

of Component Cooling Water, LDC1–Loss of Single 125Vdc Bus,

SLOCA–Small Loss-of-Coolant Accident, SORV–Stuck-Open

Power-Operated Relief Valve/Safety Relief Valve,

MLOCA–Medium LOCA, SGTR, MSLB–Main Steam Line Break,

ATWS–Anticipated Transient Without Scram). The water

treatment pumps are instrument air dependent and are fed from

Unit 2. Therefore, a LOOP on Unit 1 would still be risk significant;

however, about 1 order of magnitude lower. The use of the water

treatment system is proceduralized (always was) with a dedicated

operator assigned.

d. Duration of condition was 166 days for Unit 2. This is based on the 

timeline where both the MDAFW pump orifices were already installed

(train dependent for each unit) and then the unit-specific TDAFW pump

orifice was installed on May 11, 2002. Both units were susceptible to the

common-cause failure of the AFW pumps for a 10-day duration. Since

the SDP worksheets are for single unit assessments, the worst case,

Unit 2 duration was used.

SDP Worksheet Results

Based on the Phase 2 SDP worksheet results, this issue is considered to be of substantial

safety significance, potentially Red (>10-4). The three most dominant accident sequences

highlighted by the worksheets include the LOIA with the failure of AFW (due to

recirculation line plugging), and the LOOP with a failure of AFW (due to recirculation line

plugging), and the failure to feed and bleed or the failure of containment sump

recirculation. Using the SDP counting rule would indicate that the change in core damage

frequency (CDF) is in the 10-3 range. 

A flood that renders instrument air unavailable would also have a direct impact on the

safety significance of this performance deficiency. The scenario would be LOIA and the

loss of AFW. The licensee performed a flood analysis in support of the previous AFW/IA

Red finding and determined that the risk was 8.5E-6 crediting AFW. Since AFW cannot

be credited for this performance deficiency, the associated risk would be in the high 1E-5

to low 1E-4 range, Yellow to Red.

The potential risk contribution due to LERF (Large Early Release Fraction) was

determined not to affect the CDF since steam generator tube rupture sequences

were not determined to be significantly associated with this finding.
22

The potential risk contribution due to external events (earthquakes) was also determined

to be of high safety significance. The postulated scenario is associated with an

earthquake followed by loss of secondary cooling (AFW). Using the licensee’s analysis

from its Individual Plant Examination of External Events (IPEEE), it was determined that

an initiating event frequency of an earthquake of sufficient magnitude to damage the

CSTs would also result in the loss of offsite power and instrument air. The loss of AFW,

due to the recirculation line plugging, would result in a CDF in the 1E-4 range, Red.

Fire will also be a significant contributor to the CDF because any fire that could affect the

water treatment system would have to be considered. However, because the water

treatment system is not safety-related, the cables are not traced and would take

considerable resources to evaluate. Based on the lack of cable information, a Region III

senior reactor analyst determined that further expenditure of resources to refine the risk

contribution due to fire was not necessary to determine that the performance deficiency

was of high safety significance. The licensee’s preliminary fire risk analysis estimated a

CDF in the low 1E-3 to high 1E-4 range, Red. 

In summary, the internal events, seismic event, flood, and fire analyses indicate that this

finding is of high safety significance (i.e., greater than 10-4, Red). 

(2) The second issue involved the licensee’s failure to implement corrective actions to prevent

recurrence of the AFW/IA issue, a significant condition adverse to quality. The licensee’s

inadequate understanding and implementation of the design basis was demonstrated by

the installation of the AFW orifice replacements in 2000 and 2002. The licensee’s

inadequate corrective actions for the issue did not prevent recurrence as demonstrated by

additional examples of AFW system operations relying upon nonsafety-related support

systems and single failure system vulnerabilities. This performance deficiency was

determined to be more than minor consistent with Example 4.g of Appendix E of NRC

Inspection Manual Chapter 0612. That is, the performance deficiency resulted in a Red

issue not being promptly corrected and in additional examples of inadequate

implementation of the AFW design not being identified until being self-revealed during an

unrelated post-maintenance test and an NRC inspection.

C. Enforcement 

(1) Criterion III, “Design Control,” of 10 CFR 50, Appendix B, requires, in part, that design

control measures be established and implemented to assure that applicable regulatory

requirements and the design basis for structures, systems, and components are correctly

translated into specifications, drawings, procedures, and instructions. As of

December 12, 2002, the inspectors identified three examples of the licensee not meeting

these requirements.

 The licensee failed to establish adequate measures to assure that AFW system

design bases were correctly translated into specifications, drawings, procedures,

and instructions (modification packages) for the installation of the 1P-29 TDAFW

pressure reduction orifice. Specifically, Modification Packages 99-029*A, B, C, and

D to install the revised orifice design were prepared in 1999. By May 2002, three of

the four new orifices had been installed. Subsequently, the licensee developed

Modification Package 02-029, “Safety Upgrade of the AFW System Recirculation
23

Line Air-Operated Flow Control Valve,” to change the design basis of the AFW

system to require that the recirculation line, including the orifice, be able to pass flow

during all required operating conditions. This Modification Package, which was a

design basis change, was implemented on September 12, 2002. On October 14,

the fourth of the four new orifices was installed into the 1P-29 TDAFW recirculation

line (per Modification Package 99-029*C); however, the licensee failed to establish

adequate measures to assure that the design basis change requiring flow during all

operating conditions (Modification Package 02-029) was translated into Modification

Package 99-012*C prior to the installation of the new orifice.

 The licensee failed to correctly translate the AFW system design basis recirculation

line flow requirements into modification packages. Specifically, SW strainer mesh

size was not considered when the new orifice design using 0.125-inch diameter

holes and smaller-sized, inscribed flow channels was incorporated into Modification

Packages 99-029*A, B, C, and D. The SW strainer mesh size of 0.125-inch was

significantly larger than the smallest limiting flow dimensions of the new orifice

design. Consequently, a common mode failure of all AFW trains could have

occurred because debris passing through the SW strainers could plug the holes and

flow channels of the AFW restricting orifices.

 The license failed to correctly translate the AFW system design basis power supply

requirements into Modification Package 02-029, the safety classification upgrade of

the recirculation AOV open function. Specifically, the licensee did not assure that

the upgraded safety design relied only upon a safety-related power source for a

relay associated with the AOV. Instead, the inspectors identified that the AFW

system relied on a single train of nonsafety-related power supply for all trains of the

AOV relays. As a consequence, a common mode failure could have occurred during

a loss of the nonsafety-related power supply.

These three examples of the licensee’s failure to establish the appropriate design control

measures are considered as one apparent violation of Criterion III (AV 50-266/02-15-03;

50-301/02-15-03). Appropriate interim corrective actions have been taken.

(2) Criterion XVI, "Corrective Action," of 10 CFR 50, Appendix B, requires, in part, that

conditions adverse to quality, such as failures, malfunctions, deficiencies, deviations,

defective material and equipment, and non-conformances be promptly identified and

corrected. Criterion XVI further requires that the cause of significant conditions adverse

to quality be determined and corrective actions taken to preclude recurrence. As of

December 12, 2002, the licensee failed to implement corrective actions to preclude

repetition of the associated AFW system potential common mode failure, a significant

condition adverse to quality. Specifically, the licensee failed to identify that the previous

AFW system potential common mode failure, on a loss of instrument air to the

recirculation line AOV concurrent with operator actions (the AFW/IA Red finding), was the

result of system design inadequacies in addition to the identified procedural development

inadequacies. As a result, the licensee failed to identify potential common mode failures

that existed involving power supplies to the AOV and other system components, and

improperly sized orifices. In addition, the licensee’s corrective actions for the potential

common mode failure of the AFW/IA Red finding did not preclude repetition. Specifically,

corrective actions to upgrade the safety function of the recirculation line AOV failed to
24

ensure that successful operation of the AOV was dependent only on safety-related

support systems. Following implementation of the corrective actions, successful operation

of the AOV was still dependent upon nonsafety-related power to an interposing relay. The

failure to implement adequate corrective actions for the AFW/IA Red finding is considered

a violation of Criterion XVI (VIO 50-266/02-15-04; 50-301/02-15-04). Appropriate interim

corrective actions have been taken.

3.5 Source of the Debris in the Orifices

As discussed in Section 3.2, the licensee concluded that the source of the rust-like debris

in the orifices of the two MDAFW pumps was pump casing and discharge line high-point

vent valves and associated carbon steel piping. Because of infrequent use of these

valves, rust would build-up and enter the AFW system when the valves were used for

filling and venting the AFW pump trains after maintenance. This conclusion was reached,

in part, after:

• boroscopic examination of the vent valves and other AFW system components;

• scanning electron microscopy (SEM) characterization of orifice and vent valve debris

size and elemental composition (to determine whether iron, for example, was

present);

• x-ray diffraction analysis (XRD) characterization of orifice and vent valve debris (to

determine, for example, which form of iron was present, such as magnetite,

hematite, or goethite);

• draining and inspection of the two CSTs (the cross-tied, normal source of water for

the AFW pumps). In addition, debris from the tanks were subjected to SEM and

XRD; 

• a computational analysis of particle fouling behavior in an orifice; and

• flushing of the SW/AFW interface deadlegs. Debris removed by flushing was

characterized by SEM and XRD.

Although the licensee correlated the maintenance-related manipulation of the pump

casing and discharge high point vent valves with reduced flow through the “A” MDAFW

pump orifice on October 24, 2002, and the “B” MDAFW pump orifice on November 6,

2002, AFW pump operating and maintenance history had not been reviewed to establish if

these valves had been manipulated, at other times since the orifices were installed in

November 2000, and recirculation was unaffected.

The licensee concluded (in Engineering Evaluation 2002-0031) that the small quantity of

debris found in the CSTs would likely not have affected the ability of the AFW pumps to

perform their safety function because resin and other debris found on the bottom of the

CSTs was not streaming towards the AFW pump suction line (which is about 8" off the

bottom of the tanks) or toward the tank drain when the two tanks were drained, and the

debris found did not float. The licensee also suggested that the many hours that the

MDAFW pumps were operated with CST water during the Unit 1 refueling outage in
25

September 2002 without instances of low recirculation flow supported the contention that

debris in the CSTs was not affecting AFW recirculation line flow. However, information

reviewed by and observations made by the inspectors indicated that the CSTs could not

be definitely ruled out as a source of debris that could affect operation of the AFW pumps

by plugging the associated recirculation orifices:

• The relative large size and quantity of some of the debris, including fragmented and

intact resin beads in one CST and pieces of paint from the inner coating of the other

CST, found at the bottom of the CSTs.

• The turbulence likely created in the CST(s) during the refueling outage performance

of Operating Instruction (OI)-150, Heating the Condensate Storage Tanks, in

support of IT-300/305 (refueling outage surveillance tests of steam generator main

feed line check valves). This OI involved multiple fillings (to overflow) of a CST from

the feedwater system of the operating unit.

• The identification of titanium in some of the debris from the AFW system; titanium is

a constituent of the coating used on the lining of the CST tanks.

• The line used to fill the CSTs from the water treatment system is common with the

suction line of the AFW system from the CSTs. The water treatment system was

the likely source of resins found in the “A” CST. 

3.6 AFW Recirculation Line Testing

The initial testing, performed at Southwest Research Institute in San Antonio, Texas, used

a volume of sand, zebra mussel shells, and silt that was expected to accumulate during

the 30-day period between routine flushings of the SW headers near the AFW pump

suctions. The first test configuration consisted of a positive displacement pump and a

once-through flow scheme. Each of the materials were tested individually and in

combination. The testing showed that when zebra mussel shells hit the orifice, they

broke, pulverized, and clogged the orifice passages.

The initial test configuration demonstrated that the orifices would plug much more quickly

than predicted by the computational analysis. In order to reconcile the differences

between the analytical predictions (i.e., the orifices would not plug since the high

differential pressures would force material through the small orifice passages) and the

initial test configuration results, the licensee modified the test configuration and reperformed testing on February 21, 2003.

The revised test configuration included a single-stage centrifugal pump in a closed-loop

flow system. The impeller tip velocities and impeller/casing clearances of the pump were

similar to those of the Point Beach AFW centrifugal pumps. The same mix of sand, zebra

mussel shells, and silt as used in the initial configuration was used in the revised test, but

the quantity was reduced to 25 percent of the original amount to reflect that there were

four AFW pumps that could be taking suction on SW. In addition, to address a concern

that the size of the zebra mussel shell fragments in the initial test were larger than what

would normally pass through the Point Beach AFW pumps, and thus more readily plug the

test orifice, the revised test was run after the zebra mussel shells were run through the
26

pump about nine times to approximate the comminution of the nine-stage Point Beach

AFW pumps. 

Testing with the revised configuration showed that the orifice plugged more quickly than

with the initial test configuration. According to the licensee, the orifice plugged almost

immediately following the introduction of debris into the test loop.

The initial and revised test loop configurations demonstrated that a small amount of

material could plug the orifices. Neither the initial or revised test results supported the

results of the computational particle fouling model analysis performed for the licensee in

December 2002. 

3.7 Susceptibility of Other Plant Components

The pressure reducing orifices in the recirculation lines of the MDAFW pumps consisted

of several nested cylinders installed in a valve body. Each cylinder had holes and

channels spread throughout the cylinder wall. The opening of the channels was smaller

than the opening of the holes. The design was intended to, and successfully did, reduce

the cavitation and noise that was inherent in the design of the previously installed orifice. 

The orifices for the TDAFW pumps were similar, but consisted of fewer cylinders and had

an adjustment mechanism to cover or uncover holes, as needed. 

Following the partial plugging of the orifice in the “A” MDAFW pump recirculation line, the

licensee evaluated other equipment to determine if a similar potential problem existed. 

The evaluation included a search of the plant equipment database, a review of piping and

instrument drawings (P&IDs), interviews with knowledgeable plant personnel, and a

limited walkdown of components. The evaluation identified 61 components that

functioned as flow restriction devices, of which 48 were in safety-related applications. 

However, none of the orifices associated with safety-related applications were of similar

design and none were experiencing problems with plugging. In nonsafety-related

applications, a similar design orifice was installed in the outlet of each of the steam

generator blowdown heat exchangers to the steam generator blowdown tank. According

to the licensee, operators reported that these orifices routinely (up to weekly) needed to

be cleaned because of plugging. 

3.8 Orifice Re-Design Options

The inspectors reviewed the design of the replacement AFW recirculation line orifice. The

licensee incorporated lessons-learned for the incorrect modification efforts completed in

1991, 2000, and 2002 into the new design. Specifically, the inspectors noted that the

engineering staff identified critical design input assumptions that were not included in the

previous design including: 1) a need to correlate the SW strainer mesh opening size

(0.125-inch) and the orifice opening size, 2) the maximum flow rate that would ensure an

adequate ongoing flow to the steam generators and proper closing of the recirculation line

AOV, 3) a minimum flow rate allowed that would ensure pump stability and heat up during

all response scenarios, and 4) the correct maximum pressure drop across the orifice to

preclude cavitation and to limit flow noise.
27

The new orifices were a 9-stage plate design with a 0.281-inch minimum opening size in

the orifice for the MDAFW pumps and a 0.313-inch minimum opening size in the orifice for

the TDAFW pumps. A carbon-steel version of the new orifice was laboratory tested under

the same conditions as the previous orifice. Whereas the old orifice plugged almost

immediately when subjected to debris-laden flow (Section 3.6), the replacement orifice did

not plug. The replacement orifices were installed at Point Beach and successfully tested

in early March 2003. Also, the appropriate procedures were revised to reflect the new

orifices. With the change in orifices and the revision of the procedures, the normal

baseline daily risk level as calculated by the licensee returned from slightly elevated yellow

risk to green risk. 

3.9 Prior Opportunities to Have Identified the Problem With the Orifices

The inspectors determined that the licensee had several prior opportunities to identify the

self-revealed problem with the AFW recirculation orifices. Recent opportunities included: 

1) during development of the AFW/IA RCE, 2) during investigation and resolution of

comments made by an independent reviewer of the RCE, and 3) during development of

the modification package to upgraded the safety function of the recirculation AOV. There

were also earlier opportunities during development of the 1999 orifice modification

packages. The inspectors identified that a lack of clear understanding of the system

design was evident during preparation of the modification packages. In addition, plant

staff and outside reviewers raised issues regarding the AFW system design throughout

the 1990’s which could have served as a prior opportunity, including the 1991 initial

modification of the orifice. Also, as part of its root cause evaluation of the orifice plugging

issue (RCE000191), the licensee identified a more recent prior opportunity. After

additional holes were drilled on March 14, 2001, into the orifice in the P-38A recirculation

line in an attempt to increase flow, the resultant increase in flow was lower than expected

by the licensee. Suspecting foreign material exclusion (FME) control problems during the

hole drilling, the licensee wrote a corrective action document (CAP013812) and reviewed

the controls that had been in-place. The controls were found acceptable and no debris

was identified in the orifice upon disassembly. The CAP was closed without further

action. In its root cause evaluation, the licensee concluded that the focus of the CAP on

FME had been too narrow and should have addressed the low flow condition in general. 

One other opportunity was in June 2001, when an alewife (small fish) bloom resulted in

fish parts in the SW system. As part of the response to this problem, the licensee

inspected the Y-strainers on the SW supply lines to the AFW pump bearing coolers;

however, the vulnerability of components other than the AFW pump bearing coolers, such

as the orifices of the MDAFW recirculation lines, apparently was not evaluated. 

4 CONCLUSIONS

4.1 Old Design Issue Evaluation

The inspectors evaluated the AFW/IA Red finding against the four criteria (questions)

contained in NRC Inspection Manual Chapter 0305, “Operating Reactor Assessment

Program,” for consideration of a finding as an old design issue, as stated below:
28

 Was the issue licensee identified as a result of a voluntary initiative such as a design

basis reconstitution?

Yes. The AFW system issue was identified by the licensee in 2001 while conducting

a voluntary update of its PRA model.

 Was or will the performance issue be corrected, including immediate corrective

actions and long-term corrective action to prevent recurrence, within a reasonable

time following identification?

No. As discussed in Section 3.3, corrective actions taken for the AFW/IA issue were

not adequate and should have included a detailed review of the AFW system design

basis. As a result of the orifice plugging problem, the licensee had undertaken such

a review. This review has already identified potential concerns with excessive

localized temperatures for components of the TDAFW pump overspeed trip starters

and with the setpoint tolerances for the main steam safety valves not being included

in an AFW ISI acceptance criteria calculation (the safety valve issue is discussed

further in Inspection Report 50-266/03-02; 50-301/03-02, Section 1R15.1). 

 Was it not likely that the issue would have been identified by routine licensee efforts,

such as normal surveillance or quality assurance activities?

Yes. The inspectors determined that this issue would not likely have been identified

by routine licensee efforts. The issue was identified through integrated PRA

modeling techniques that used procedures, system design, human error, and timing

elements not previously analyzed at the station. 

 Does the finding reflect a current performance deficiency associated with existing

licensee programs, policy, or procedure?

Likely. Some of the problems in the engineering and corrective action programs that

contributed to the AFW/IA issue appeared to have factored into the more recent

orifice issue, including the lack of understanding of AFW design and narrowly

focused evaluation of corrective action program items, and limited implementation of

corrective actions.

The inspectors concluded, based on the results of the two special inspections, that the

AFW/IA Red finding did not meet all of the four criteria in NRC Inspection Manual

Chapter 0305, and, as such, was not an old design issue. 

4.2 Orifice Plugging Issue

Laboratory tests conducted for the licensee demonstrated that the orifices in the

recirculation lines of the AFW pumps would quickly plug if the service water system was

the source of water for the pumps, as it would be during various accidents. The two

examples of orifice plugging after AFW system maintenance and the identification of

debris in the AFW system that may have come from the CSTs indicated the possibility

that the orifices may also have been vulnerable to plugging with water from the CSTs, the

nonsafety-related, normal source of water for the AFW system.
29

5 OTHER

5.1 (Closed) LER 266/2001-005-00: PRA Assessment of Auxiliary Feedwater System

Reveals Procedural Vulnerability Related to Loss of Instrument Air. The LER described

the identification by the licensee of the potential inoperability of multiple AFW pumps upon

loss of instrument air due to inadequate recirculation (pump cooling) flow. Licensee

corrective actions listed in the LER were reviewed as part of the initial NRC response to

this issue (Inspection Report 50-266/01-17(DRS); 50-301/01-17(DRS) and as part of the

current inspections. As discussed in Sections 3.3 and 4.1, NRC inspectors during the

current inspections concluded that inadequate corrective actions were taken for the

AFW/IA issue, discussed in both the LER and RCE 01-069. Subsequent licensee

corrective actions for this problem, which included a revalidation of AFW design basis, will

be reviewed as part of VIO 50-266/02-15-04; 50-301/02-15-04. 

5.2 (Closed) LER 266/2002-003-00: Possible Common Mode Failure of AFW Due to Partial

Clogging of Recirculation Orifices. The LER described the initial event, the immediate

compensatory actions to ensure AFW system operability, and interim and long-term

corrective actions. As part of the investigation of the problem, the licensee conducted a

root cause evaluation (RCE), which preliminarily concluded that the design of the orifice

was inadequate for the specific application in the AFW recirculation lines and was the

result of erroneous conclusions in the safety evaluation written, as part of the plant

modification process, for the installation of the orifices. These erroneous conclusions

resulted in information on important design functions of the AFW recirculation lines being

omitted from the safety evaluation. The RCE also discussed the reclassification of the

open function of the AFW recirculation line AOVs as safety-related on September 12,

2002, done as part of the corrective actions for the AFW/IA Red finding. The RCE

concluded that the reclassification, done through the modification process, was another

unavailed opportunity to evaluate the susceptibility of the recirculation line orifices to

plugging. Time pressures resulting from inadequate planning, combined with an

infrequently performed activity–the safety function upgrade of the AOV opening–may have

contributed to the inadequate review of recirculation line components conducted as part of

the upgrade. In the LER, the licensee stated that a supplement would be submitted to

provide the results of ongoing analysis and evaluation of the susceptibility of the orifices to

plugging and to provide an assessment of the safety significance of the plugging issue. 

6 MANAGEMENT MEETINGS

Exit Meeting Summary

The inspectors presented the preliminary results of the September 23-26 inspection to

Messrs. J. P. Cowan and A. J. Cayia, and other members of licensee management on

October 2, 2002. The preliminary results of the October 31st inspection were presented to

Mr. Cayia and other members of licensee management on December 12. A final exit

meeting was held with licensee management on March 24, 2003. The licensee

acknowledged the findings presented. Information related to the design of the plugged

AFW flow orifice was identified by the licensee as possibly proprietary; this information

was not included in the inspection report. 
30

PARTIAL LIST OF PERSONS CONTACTED

Licensee

R. Amundson Operations Training Specialist

G. Arent Kewaunee/Point Beach Regulatory Affairs Manager 

L. Armstrong Design Engineering Manager

A. Cayia Site Vice President

J. Cowan Senior Vice President - Operations (NMC)

B. Day Performance Assessment Manager

F. Flentje Senior Regulatory Compliance Specialist

J. Flessner Engineering Projects Supervisor (Root Cause Team Leader)

J. Freels Engineering Director

D. Hettick Performance Improvement Manager

R. Hopkins Kewaunee-Point Beach Oversight Supervisor

J. Jensen Plant Manager (current)

T. Kendall Engineering Analysis Supervisor

J. Masterlark PRA Engineer

L. Peterson Engineering Projects Manager

K. Peveler Kewaunee-Point Beach Nuclear Oversight Manager

S. Pfaff Corrective Action Program Supervisor

J. Pruitt Nuclear Oversight Assessor

M. Reddemann NMC Vice President - Engineering

E. Schmidt AFW System Engineer

P. Smith Operations Training Coordinator

D. Schoon Operations Manager

J. Strharsky Assistant Operations Manager

T. Vandenbosch EOP Coordinator 

R. Wood Engineering Programs Supervisor 

T. Taylor Plant Manager/Site Assessment Manager

S. Thomas Radiation Protection Manager

T. Webb Regulatory Affairs Manager

E. Weinkam NMC Director of Regulatory Services

W. Zipp System Engineering Supervisor

NRC

J. Dyer Regional Administrator

G. Grant Director, Division of Reactor Projects

P. Krohn Point Beach Senior Resident Inspector

R. Lanksbury Chief, Reactor Projects Branch 5

K. Riemer Chief, Reactor Projects Branch 5

D. Spaulding Project Manager, Office of Nuclear Reactor Regulation 
31

ITEMS OPENED, CLOSED, AND DISCUSSED

Opened

50-266/02-15-01; 50-

301/02-15-01

NCV NCV of 10 CFR Part 50, Appendix B, Criterion VI, for

the failure to distribute temporary procedure changes

to procedure sets in emergency response facilities. 

(Section 3.3)

50-266/02-15-02; 50-

301/02-15-02

NCV NCV of 10 CFR Part 50, Appendix B, Criterion V, for

inadequate procedure for calibration of auxiliary

feedwater flow meter. (Section 3.3)

50-266/02-15-03; 50-

301/02-15-03

AV Apparent violation of 10 CFR Part 50, Appendix B,

Criterion III, for the failure to establish the appropriate

design control measures for the installation of orifices

to the AFW recirculation lines. (Section 3.4)

50-266/02-15-04; 50-

301/02-15-04

VIO Violation of 10 CFR Part 50, Appendix B, Criterion

XVI, for the failure to identify the root cause and

implement corrective actions for the AFW/IA issue, a

significant condition adverse to quality, so as to

prevent recurrence. (Section 3.4)

Closed

50-266/02-15-01; 50-

301/02-15-01

NCV NCV of 10 CFR Part 50, Appendix B, Criterion VI, for

the failure to distribute temporary procedure changes

to procedure sets in emergency response facilities. 

(Section 3.3)

50-266/02-15-02; 50-

301/02-15-02

NCV NCV of 10 CFR Part 50, Appendix B, Criterion V, for

inadequate procedure for calibration of auxiliary

feedwater flow meter. (Section 3.3)

266/2001-005-00 LER PRA Assessment of Auxiliary Feedwater System

Reveals Procedural Vulnerability Related to Loss of

Instrument Air. (Section 5.1)

266/2002-003-00 LER Possible Common Mode Failure of AFW Due to

Partial Clogging of Recirculation Orifices. 

(Section 5.2)

Discussed

None
32

LIST OF ACRONYMS USED

AFW Auxiliary Feedwater

AOV Air-Operated Valve

AV Apparent Violation

CDF Change in Core Damage Frequency

CAP Corrective Action Program

CR Condition Report

CSP Critical Safety Procedure

CST Condensate Storage Tank

ECA Emergency Contingency Action

EOP Emergency Operating Procedure

DRP Division of Reactor Projects

DRS Division of Reactor Safety

FME Foreign Material Exclusion

gpm Gallons Per Minute

HEP Human Error Probability

IA Instrument Air

I&C Instrument and Control

IT Inservice Test

LER Licensee Event Report

LLOCA Large-Break Loss-of-Coolant Accident

LOIA Loss of Instrument Air

LOOP Loss of Offsite Power

MC Manual Chapter

MDAFW Motor-Driven Auxiliary Feedwater 

NMC Nuclear Management Company, LLC

NP Nuclear Plant Business Unit Procedure

NPM Point Beach Memorandum

NRC Nuclear Regulatory Commission

ODI Old Design Issue

OI Operating Instruction

OP Operating Procedure

PARS Publicly Available Records System

PBNP Point Beach Nuclear Plant

P&ID Piping and Instrumentation Diagram

PRA Probabilistic Risk Assessment

RCE Root Cause Evaluation

RHR Residual Heat Removal

SDP Significance Determination Process

SE Safety Evaluation

SEM Scanning Electron Microscopy

SEN Significant Event Notice

SGTR Steam Generator Tube Rupture

SS Safety Screening

SW Service Water

TDAFW Turbine-Driven Auxiliary Feedwater

TRANS Transients

TPCS Transients Without Power Conversion System
33

TS Technical Specification 

Vac Volts Alternating Current

Vdc Volts Direct Current

VIO Violation

XRD X-Ray Diffraction Analysis
34

LIST OF DOCUMENTS REVIEWED

AFW Pump Normal Operation and Testing Pre-Job Briefing Requirements

Abnormal Operating Procedure AOP 3, Steam Generator Tube Leak, Unit 1, Revision 4

AOP 5B, Loss of Instrument Air, Revision 21, June 3, 2002

AOP 10, Control Room Inaccessibility, Unit 0, Revision 0

AOP 10A, Safe Shutdown - Local Control, Unit 0, Revision 33

AOP 10B, Safe to Cold Shutdown in Local Control, Unit 1, Revision 3

AOP 23, Establishing Alternate AFW Suction Supply, Unit 1, Revision 0

Bechtel Corporation Auxiliary Feedwater Pumps Bid Specification, May 4, 1967

Calculation N-91-063-00-A, P38A and B Recirc Line System Characteristics, July 2, 1991

Calculation N-91-069-00-A, Impact of Higher Capacity Recirculation System for Electric Motor

Driven AFW Pumps, June 6, 1991

Calculation 2001-0056, TDAFP Mini Recirc Valve Instrument Air Accumulator Sizing, March 20,

2002

Calculation 2002-002, Nitrogen Backup System for MDAFP Discharge Valves and Minimum Flow

Recirculation Valves, January 28, 2002

Calculation 2002-0044, AFW Pump Required Recirculation Flow, November 13, 2002

Control Room Log Entries (2002): October 23, 4:00 a.m. to October 30, 11:18 p.m.

November 5, 2:07 p.m. to November 7, 6:15 a.m.;

November 6, 12:25 p.m. to November 7, 5:00 a.m.

Corrective Action Program (CAP) 004254, Blockage of Service Water Line, May 10, 2000

CAP001625, SCAQ Action - Potential Common Mode Failure Mechanism Affecting Welds in

AFW Pump, May 24, 1999

CAP001763; ISI Scoping of AF-117, AF-4035, Classification of AFW Recirc Lines; January 2,

2002

CAP005091, Cooling Flow to P-38B AFP [Auxiliary Feedwater Pump] Inadequate, April 8, 2001

CAP005432, Blockage of Emergency Diesel Generator Cooler Tubes, July 23, 2001

CAP013812, Foreign Material Exclusion (FME) for Aux Feed Work, April 13, 2001
35

CAP014171, Unit 2 First Off Check Valve Flow Indicator Failure, July 3, 2001

CAP017144, Six-inch Elbow Removed From West Service Water Header Had Approximately

60-70 percent Blockage Due to Silt Buildup, April 2, 1997

CAP023470, Service Water Piping Blockage, June 14, 1996

CAP026633, Zebra Mussels Cause FME [Foreign Material Exclusion] Problems in Service

Water System, September 13, 1999

CAP026917, Review of QA-Scope Flow Restricting Devices at PBNP

CAP028186, Biofouling Inspection Discrepancies Identified in Response to GL [NRC Generic

Letter] 89-13, Action 1, May 26, 1999

CAP028370, PORVs Ability to Limit RCS Pressure Response During an ATWS Event

Questioned, June 3, 2002

CAP029261, Appendix R Classification Discrepancies in AFW Common Recirc Line,

September 10, 2002

CAP029335, AFW Red Finding Assist Visit, September 16, 2002

CAP029344, Expanded Extent of Condition Review for AFW Red Finding, September 16, 2002

CAP029404, AOP-9A Has Little Guidance for System Blockage, September 18, 2002

CAP029908, P-38A, Motor Driven AFW Pump Has Inadequate Recirc Flow During IT-10,

October 24, 2002

CAP029928, No Parts Were Identified or Available to Perform Maintenance on RO-04008,

October 25, 2002

CAP029952, Possible Common Mode Failure of Aux Feed Recirculation Lines, October 29,

2002

CAP029983, AFW DBD Description of Recirc Orifice Flow Rate Bases in Error, November 2,

2002

CAP029999, Training Needs Analysis of AFW Mini-Recirc Line Plugging Recommendations,

November 4, 2002

CAP030009, Required Information Missing on record Procedure, November 5, 2002

CAP030011, Inconsistencies Noted in Annotating NA on Procedural Steps, November 5, 2002

CAP030012, AFW Pump Recirc Orifice Debris Sample Fidelity, November 5, 2002

CAP030014, P-38B Aux Feed Pump Low Recirc Flow, November 6, 2002
36

CAP030015, Five-day Delay in Identifying Common Mode Failure of Auxiliary Feedwater

Pumps, November 6, 2002

CAP030024, Temporary Changes Made to the AOP/EOPs Are Not Being Distributed to All

Locations, November 6, 2002

CAP030026, RCE 01-069 Extent of Condition Assessment Inadequate, November 6, 2002

CAP030030, Work Order Preparation and Approval Prior to Work, November 6, 2002

CAP030031, Arms Across RP [Radiation Protection] Boundary, November 6, 2002

CAP030032, P-38B Recirculation Orifice, RO-4015, Unable to be Maintained/Cleaned,

November 7, 2002

CAP030034, NP 1.1.8 Issued Without Training Being Performed, November 7, 2002

CAP030040, Power Supply to AFW Pump Recirc Valves Not Safety Related, November 7,

2002

CAP030045, Discrepancies in AFW PRA Model and Notebook, November 7, 2002

CAP030048, Lack of Specific Detail in Response to On-Line Safety Assessment Changes,

November 8, 2002

CAP030052, Unplanned YELLOW - Requires CAP Per NP 10.3.7, November 8, 2002

CAP030124, Potential Process Deficiency - Temporary Procedure Changes, November 13,

2002

CAP030178, AFW Recirculation Valve DPIS [Differential Pressure Indicating Switch] Device

Differences, November 19, 2002

CAP030227, Service Water (SW) to Auxiliary Feedwater (AFW) Pump Suction Power Supply

Issues, November 22, 2002

CAP030937, Station Blackout Procedure (ECA 0.0) Deficiency, January 30, 2003

CAP031257, Potential MS-2082 Motor Starter Equipment Too Warm for Equipment

Specifications, February 21, 2003

CA002964, Per Operability Evaluation Section 6, Provide Results and Details of Related

Investigations and Failure Testing to SECA for Completion of Consolidation RCE 99-081,

May 27, 1999

CA002965, In Coordination With EWR 99-031, Evaluate a Resolution and Process an

Appropriate Design Modification Request to Provide Adequate Pressure Reduction in the

AF Recirculation Lines, September 14, 1999
37

CA002966, Per RCE 99-081, SEP Is Requested to Conduct Engineering Training, as Deemed

Appropriate, on the Modification Aspects of the RCE, Particularly the Design Deficiency Related

to the Inadequate Specification of the Orifice Differential Breakdown Pressure, March 16, 2000

CA003702, Review the Description of the AFW Recirculation Line Function in the FSAR,

DBD-01, and the IST Program for Consistency and Accuracy, and Initiate Revisions as

Required, February 5, 2002

CA004388, Review Operator Action Assumptions in PRA Model for Validity for Top Risk -

Significant Systems Prior to USNRC Regulatory Conference on 4/29/2002, April 26, 2002

CA004279, Re-Open Evaluation of SEN 174, Ensuring That Questions About Procedures for

Ensuring Adequate Pump Flow is Maintained, Are Fully Addressed, Including Pumps Other

Than AFP’s, April 11, 2002

CA006836, Assess Foreign Material Exclusion Controls For Aux Feed Work, April 19, 2001

CA018338, The Process to Implement the Revised Service Water Treatment Strategy Has

Been Written Into New Procedure OI 155. Track Completion and Issuance of Procedure. 

February 29, 200.

CA026897, Write and Hang Info Tags on the Pump Handswitches, October 31, 2002

CA026898, Make Changes to Affected AOPs, EOPs, and Other Critical Procedures to Ensure

that Minimum Forward Flow is Maintained, or the Affected Pump is Stopped, October 31, 2002

CA026900, Ensure That the PRA Work to Evaluate the Risk Significance of this Potential

Common Mode Failure is Completed Expeditiously, October 31, 2002

CA026902, Redesign the Recirc Line Orifices to Make Use of an Orifice Design That Has

Aperture Size of >1/8" (basis: service water zurn strainer size is 1/8"), October 31, 2002

CA026908, Complete the Interim Administrative Controls, Operator Training, and EOP and

AOP Changes to Establish Appropriate Operator Guidance for All Accident Sequences of

Interest, October 31, 2002

CA026909, Independently Evaluate the Procedure Changes Being Made to the EOPs and

AOPs and Assess Their Adequacy to Provide Adequate Operator Guidance, October 31, 2002

CA026911, Evaluate Hydraulic System Response to Determine if the Orifices Could Become

Plugged, October 31, 2002

CA026912, Develop a Test Plan to Evaluate Plugging of a Spare Orifice, October 31, 2002

CA026917, Identify All Other Applications of This Type of Orifice, October 31, 2002

CA026958, Ensure Compliance with Procedure NP 10.3.7, “On-line Safety Assessment,” While

at Elevated Risk Due to the Potential for Common Mode Plugging of AFW Recirc Orifices,

November 4, 2002
38

CA026962, Perform an Incident Investigation, November 4, 2002

Condition Evaluation (CE) 010821, Perform a Condition Evaluation, per CAP029928, in

Accordance with NP 5.3.1, October 29, 2002

CR 97-3363, IST Program Design Basis for AFW Minimum flow Recirculation Valves,

October 15, 1997

CR 01-2278, Auxiliary Feedwater Probabilistic Risk Assessment (PRA) Model for Loss of

Instrument Air, July 6, 2001

CR 01-3595, Potential Common Failure Mode For All Auxiliary Feed Pumps Under Certain

Initiating Events, November 29, 2001

Critical Safety Procedure CSP-C.1, Response to Inadequate Core Cooling, Unit 1, Revision 22

CSP-C.1, Response to Inadequate Core Cooling, Unit 2, Revision 22

CSP-C.2, Response to Degraded Core Cooling, Unit 1, Revision 19

CSP-C.2, Response to Degraded Core Cooling, Unit 2, Revision 19

CSP-H.1, Response to Loss of Secondary Heat Sink, Unit 1, Revision 21

CSP-H.1, Response to Loss of Secondary Heat Sink, Unit 2, Revision 22

CSP-H.2, Response to Steam Generator Overpressure, Unit 1, Revision 9

CSP-H.2, Response to Steam Generator Overpressure, Unit 2, Revision 8

CSP-S.1, Response to Nuclear Power Generation/ATWS [Anticipated Transient Without

Scram], Unit 1, Revision 22

CSP-S.1, Response to Nuclear Power Generation/ATWS, Unit 2, Revision 23

Design Basis Document (DBD)-01, Auxiliary Feedwater System Design Basis Document,

Revision 0, April 4, 1994; Revision 1; March 31, 2000; Revision 2; June 7, 2002; and

Revision 3; September 19, 2002

Draft 10 CFR 50.59 Screening and Safety Evaluation Provided to the Onsite Review Committee 

for Approval, “Aux. Feed Water Pump P-38A and P-38B Minimum Flow Recirc Line Flow Orifice

Replacement.”

Elementary Wiring Diagram, Turbine Driven Auxiliary Feedwater Pump Mini-Recirc. Control

Valve 1AF-4002, EAFS00000114, May 1, 2001

Elementary Wiring Diagram, Turbine Driven Auxiliary Feedwater Pump Mini-Recirc. Control

Valve 2AF-4002, EAFS00000211, May 1, 2001
39

Emergency Contingency Action ECA-0.0, Loss of All AC [Alternating Current] Power, Unit 1,

Revision 31

ECA-2.1, Uncontrolled Depressurization of Both Steam Generators, Unit 2, Revision 30

ECA-3.1, SGTR With Loss of Reactor Coolant-Subcooled Recovery Desired, Unit 1,

Revision 30

ECA-3.2, SGTR With Loss of Reactor Coolant-Saturated Recovery Desired, Unit 2, Revision 25

Emergency Operating Procedure EOP-0, Reactor Trip and Safety Injection, Unit 1, Revision 38

EOP-0, Reactor Trip and Safety Injection, Unit 2, Revision 39

EOP-0.1, Reactor Trip Response, Unit 1, Revision 27

EOP 0.1, Reactor Trip Response, Revision 27C, June 24, 2002

EOP-0.1, Reactor Trip Response, Unit 2, Revision 26

EOP-0.2, Natural Circulation Cooldown, Unit 1, Revision 22

EOP-1, Loss of Reactor or Secondary Coolant, Unit 1, Revision 32

EOP-1, Loss of Reactor or Secondary Coolant, Unit 2, Revision 32

EOP-2, Faulted Steam Generator Isolation, Unit 1, Revision 16

EOP-2, Faulted Steam Generator Isolation, Unit 2, Revision 16

EOP-3, Steam Generator Tube Rupture, Unit 1, Revision 32

EOP-3, Steam Generator Tube Rupture, Unit 2, Revision 32

Engineering Evaluation 2002-0031, Foreign Material in RO-4008, December 5, 2002

Excerpt From Wisconsin Electric Company Document NPC 28077, Revision 2, September 14,

1981

Fax message from Flowserve Corporation to Licensee Regarding Feedpump Recirculation

Minimum Flow Element, August 25, 1999 

Flowserve Corporation Drawing of the Valtek Mark I Channel Stream Pressure Reducing

Device, Drawing Number 94-16219, December 21, 2000

Flowserve Corporation Drawing of the Globe Control Valve Socket Ends, Stainless Steel Valtek

Mark One Channel Stream with Adjustable Pressure Reducing Device, May 3, 2002

FSAR Section 10.2, Auxiliary Feedwater System (AF), June 2001 and June 2002
40

Individual Plant Examination of External Events, Wisconsin Electric Power Company,

June 30, 1995 

Inservice Test IT-08A, Cold Start of Turbine-Driven Auxiliary Feed Pump and Valve Test

(Quarterly) Unit 1, Revision 29

IT-09A, Cold Start of Turbine-Driven Auxiliary Feed Pump and Valve Test (Quarterly) Unit 2, 

Revision 29

IT-10, Test of Electric-Driven Auxiliary Feed Pumps and Valves (Quarterly), Unit 0, Revision 45

IT-10A, Test of Electric-Driven Auxiliary Feed Pumps and Valves With Flow to Unit 1 Steam

Generators (Quarterly), Revision 13

IT-10B, Test of Electric-Driven Auxiliary Feed Pumps and Valves With Flow to Unit 2 Steam

Generators (Quarterly), Revision 12

Internal Correspondence NMC Assist Visit for PBNP Preparation for USNRC Red Finding

Follow-up Inspection, September 9, 2002

Internal NRC Memorandum from R. L. Hague, Point Beach Senior Resident Inspector, to J. F.

Streeter, Reactor Projects Branch #2, Regarding Point Beach Auxiliary Feed System Automatic

Initiation/Operability, March 10, 1983

Internal Wisconsin Electric Correspondence Between C. W. Krause and G. A. Reed Regarding

NRC Auxiliary Feedwater System Questions, November 19, 1980

Isometric Drawing MAFL18300110, Auxiliary Feedwater Pump Suction From Condensate

Storage Tanks, August 15, 1997

Isometric Drawing MAFK18300106, Auxiliary Feedwater Pump Suction From Condensate

Storage Tanks 1-T24A and B, December 20, 1996

Just In Time Training (JITT), Control of AFW JITT, November 2002

Letter from C. W. Fay, Wisconsin Electric Corp. to H. R. Denton, USNRC, Regarding

Requirements for Auxiliary Feedwater Systems, Point Beach Nuclear Plants, Units1 and 2,

October 29, 1979

Letter from D. G. Eisenhut, USNRC, to S. Burstein, Wisconsin Electric Company, Regarding

NRC Requirements for Auxiliary Feedwater Systems at Point Beach Plant, Units 1 and 2,

September 21, 1979

Letter from S. Burstein, Wisconsin Electric Company, to H. R. Denton, USNRC, Regarding

Implementation of NUREG-0578 for Point Beach Nuclear Plant, Units 1 and 2, December 17,

1979
41

Letter from C. W. Fay, Wisconsin Electric Company, to H. R. Denton, USNRC, Regarding

Additional Information Auxiliary Feedwater System, Point Beach Nuclear Plant, Units 1 and 2,

February 4, 1980

Letter from C. W. Fay, Wisconsin Electric Company, to H. R. Denton, USNRC, Regarding

Additional Information Auxiliary Feedwater System, Point Beach Nuclear Plant, Units 1 and 2,

July 8, 1980

Letter from R. A. Clark, USNRC, to S. Burstein, Wisconsin Electric Company, Regarding

Auxiliary Feedwater System Safety Evaluation Report, January 27, 1981

Letter from C. W. Fay, Wisconsin Electric Company, to H. R. Denton, USNRC, Regarding

Requirements for Auxiliary Feedwater System, Point Beach Nuclear Plant, Units 1 and 2,

April 9, 1981

Letter from R. A. Clark, NRC, to S. Burstein, Wisconsin Electric Company, Regarding Auxiliary

Feedwater System Request for Additional Information, July 28, 1981

Letter from C. W. Fay, Wisconsin Electric Company, to H. R. Denton, NRC, Regarding

Additional Information, Auxiliary Feedwater System, Point Beach Nuclear Plant, Units 1 and 2,

September 16, 1981

Letter from R. A. Clark, NRC, to C. W. Fay, Wisconsin Electric Company, Regarding

NUREG-0737 Item E.1.1., Auxiliary Feedwater System Evaluation for Point Beach Nuclear

Plant, Units 1 and 2, April 21, 1982

Letter from R. A. Clark, NRC, to C. W. Fay, Wisconsin Electric Company, Regarding

NUREG-0737 Item II.E.1.2, Auxiliary Feedwater System Automatic Initiation and Flow

Indication, May 3, 1982

Letter from T. G. Colburn, NRC, to C. W. Fay, Wisconsin Electric Company, Regarding

Amendments Modifying the Limiting Conditions for Operation of the Technical Specifications

With Respect to Auxiliary Feedwater Pump Operation, July 27, 1982

Letter from C. W. Fay, Wisconsin Electric Company, to H. R. Denton, NRC, Regarding Auxiliary

Feedwater System Modifications, Point Beach Nuclear Plant, Units 1 and 2, February 11, 1983

Letter from C. W. Fay, Wisconsin Electric Company, to H. R. Denton, NRC, Regarding Auxiliary

Feedwater System Operability, Point Beach Nuclear Plant, Units 1 and 2, March 24, 1983

Letter from S. Burstein, Wisconsin Electric Company, to H. R. Denton, NRC, Regarding

Auxiliary Feedwater System Operability, Point Beach Nuclear Plant, Units 1 and 2, May 4, 1983

Letter from C. W. Fay, Wisconsin Electric Company, to H. R. Denton, NRC, Regarding Auxiliary

Feedwater System Operability, Point Beach Nuclear Plant, Units 1 and 2, June 20, 1983

Letter from J. R. Miller, NRC, to C. W. Fay, Wisconsin Electric Company, Regarding

Modifications to the Motor Driven Auxiliary Feedwater Pump Isolation Valves, September 15,

1983
42

Letter from C. W. Fay, Wisconsin Electric Company, to H. R. Denton, NRC, Regarding Auxiliary

Feedwater System Operability, Point Beach Nuclear Plant, November 11, 1983

Letter from C. W. Fay, Wisconsin Electric Company, to H. R. Denton, NRC, Regarding Auxiliary

Feedwater System Operability, Point Beach Nuclear Plant, Units 1 and 2, July 6, 1984

Letter from Flowserve Corporation Pump Division to Point Beach Nuclear Station, Aux. Feed

Water Pump Minimum Flow Analysis, March 2, 2001

Licensee Event Report (LER) 05000266/1997-014; 05000301/1997-014, Auxiliary Feedwater

System Inoperability Due to Loss of Instrument Air, April 18, 1997

LER 05000266/2001-005-00, PRA Assessment of Auxiliary Feedwater System Reveals

Procedural Vulnerability Related to Loss of Instrument Air, January 28, 2002 

Modification Package MR 88-099, Increase the Minimum Recirculation Flow Rate of the AFW

Pumps, July 5, 1988

Modification Package MR 88-099*B, Increased Aux Feed Pump Mini-Recirculation Line Flow

Capacity [P-38A and P-38B], December 18, 1991

Modification Package MR 88-099*A, Increased Aux Feed Pump Mini-Recirculation Line Flow

Capacity [1P29], February 14, 1992

Modification Package MR 88-099*C, Increased Aux Feed Pump Mini-Recirculation Line Flow

Capacity [2P29], February 14, 1992

Modification Package MR 88-099*D, Replace Existing Aux Feedwater Pump Conduit Supports

(P38A and B) as Shown on Dwg. SK-ELEC-012, Sheet 1-16, July 1, 1992

Modification Package 99-029*A, Aux Feed Water Pump 38A Minimum Flow Recirculation

Orifice, December 22, 2000

Modification Package 99-029*B, Aux Feed Water Pump 38B Minimum Flow Recircline Orifice,

December 22, 2000

Modification Package 99-029*D, Aux Feed Water Pump 2P-29 Minimum Flow Recirc Line

Orifice, October 11, 2002

Modification Package 99-029*C, Aux Feed Water Pump 1P-29 Minimum Flow Recirc Line

Orifice, October 23, 2002

Modification Package 02-029, Aux Feed Mini Recirc Safety Upgrade/Remove AF-117 Internals,

September 12, 2002

NP 5.3.1, Action Request Process, December 20, 2001

NP 7.2.1, Plant Modifications, July 21, 1999 (Revision 6), December 8, 1999 (Revision 7), and

June 12, 2002 (Revision 10)
43

NP 7.2.2, Design Control, September 30, 1998

NP 7.2.3, Engineering Change Requests, March 31, 1999 (Revision 4) and March 6, 2002

(Revision 6)

NP 7.2.6, Engineering Change Process, March 31, 1999 (Revision 1) and October 2, 2001

(Revision 2)

NP 7.7.10, Safety-Related and QA-Scope Classification, October 14, 1998

NMC Root Cause Evaluation Manual, Revision 0, June 14, 2002

NPM 2002-0583, Potential AFW Common Mode Failure Event Resolution, October 31, 2002

NPM 2002-0594, Oversight of Plant Modifications, November 8, 2002

NPM 2002-0598, Managing Risk for On-Line Work, November 8, 2002

NPM 2002-0599, AFW Recirculation Line Orifice Evaluation, November 8, 2002

NRC Special Inspection Team Entrance Meeting Handout, Potential Common Mode Failure

Auxiliary Feedwater, October 31, 2002; and Preliminary Event Timeline

NRC Summary of Meeting Held on May 11, 1979 to Discuss the Auxiliary Feedwater System at

Point Beach Nuclear Plant; Signed by Charles M. Trammel, May 15, 1979

Nuclear Plant Business Unit Procedure (NP) 1.2.3, Temporary Procedure Change,

November 12, 2002

Operating Instruction OI-62A, Motor-Driven Auxiliary Feedwater System (P-38A & P-38B),

Unit 0, Revision 21

OI-62B, Turbine-Driven Auxiliary Feedwater System (P-29), Unit 0, Revision 9

OI-150, Heating the Condensate Storage Tanks, October 21, 2002

Operations Manual (OM) 4.3.1, AOP and EOP Writer’s Guide, Revision 5

OM 4.3.2, EOP/AOP Verification/Validation Process, Revision 3

Operability Determination OPR 000031, Potential for Simultaneous Failure of All AFW Pumps

Due to Insufficient Minimum Pump Flow, Revisions 0 and 1

Operability Determination OPR 000040, Potential for AFW Pump Stalling Due to SW Debris,

Revision 0, January 30, 2003

Operability Determination OPR 000041, Nitrogen Backup System for AFW AOVs

AF4007/4012/4014/4019, Revision 0, January 30, 2003
44

Operability Determination OPR 000042, Service Water to Auxiliary Feedwater Pump Suction

Power Supply Issues, Revision 0, January 31, 2003

Operability Determination OPR 000044, MSSV Setpoint Tolerance Not Included in AFW ISI

[Inservice Inspection] Acceptance Criteria Calculation, Revision 0, February 6, 2003 

Operability Determination OD CR 01-3595, Potential for Simultaneous Failure of All AFW

Pumps Due to Loss of Air & Directed Operator Action, Revision 2

Operability Determination OD CR 01-3648, Potential to Damage P-038A/B During Appendix R

Fire with LOOP & IA (Loss-of-Offsite Power and Instrument Air) Loss, Revision 0

Operations Training Standard 12, Revision 0, September 16, 2002

Operating Experience Guide 001, Root Cause Evaluation, Revision 6, June 20, 2001

Performance Improvement International Letter to Point Beach, Preliminary Analysis of Auxiliary

Feed Water Reduced Flow and Scope of Final Analysis, November 7, 2002

Performance Improvement International, PII Report #02-1719, Degraded Auxiliary Feedwater

Recirculation Flow at the Point Beach Nuclear Station for the Nuclear Management Company

(NMC), December 20, 2002

Piping and Instrumentation, Auxiliary Feedwater System,

MAFK000004, September 24, 1999; September 1, 2002

MAFK000005, September 1, 2002

MAFK00000173, September 13, 2002

MAFK00000318, August 31, 2002

Piping and Instrumentation Diagram, Service Water System, 

MWSK00001022, April 28, 2001

MWSK00000362, November 10, 2001

Point Beach Form-1584, Design Input Checklist, August 12, 2002

Point Beach Letter, NRC 2002-0068, Reply to a Notice of Violation (EA-02-031), NRC Special

Inspection Report No. 50-266/01-17(DRS); 50-301/01-17(DRS), August 12, 2002

Point Beach Letter, NRC 2002-0086, Clarification of Reply to a Notice of Violation (EA-02-031),

NRC Special Inspection Report No. 50-266/01-17(DRS); 50-301/01-17(DRS), September 26,

2002 

Point Beach Memorandum NPM 2002-0293, Risk Ranking of Human Actions from the PBNP

PRA, June 4, 2002

Point Beach Nuclear Plant Event Notification Worksheet, EN# 39330, At 10:27AM CST, the

Auxiliary Feed Water System (AFWS) for the Point Beach Nuclear Plant, Units 1 and 2, Was

Declared Inoperable Due to the Potential for Fouling of the Minimum Recirculation Orifices for

Each of the Four AFW Pumps, October 29, 2002
45

PRA Update Project Work Plan, Revision 1, August 28, 2002

PRA Update Project - Phase 2 Project Work Plan, Revision 0, July 22, 2002

PRA Update Project Phase 2, Status Update, September 24, 2002

QF-1010-01a, Needs Analysis Worksheet for TWR #02-297, Revision 1

RCE 00-034, Evaluate the Aux Feed Pump Recirc Line Weld-Cracking Events by CR 98-2550,

CR 99-1163, and CR 99-1363 by Conducting RCE 99-081, May 27, 1999

RCE 01-069, Increased CDF in AFW PRA Model Due to Procedural Inadequacies Related to

Loss of Instrument Air; Revision 1, May 14, 2002

RCE000191, Possible Common Mode Failure of Aux Feed Recirculation Lines,

December 12, 2002 (draft)

Rockwell Manufacturing Company Drawing C-464529, Edward F. Stainless Steel Univalve

Check Valve, August 3, 1967 (Point Beach Drawing PB31M05902401605, December 13, 1984)

Safety Evaluation SE 97-201, Setpoint Change to Auxiliary Feedwater Bypass Control Valves

Time Delay Relay Septpoints (1⁄2-NC005, 62-P38A, and 62P38B), December 4, 1997

Safety Monitor Calculations, Unit 1, November 1 and 4, 2002

Safety Monitor Calculations, Unit 2, November 1 and 4, 2002

SCR 2002-0458, AFW Minimum Flow Requirement Change to AOP, EOP, CSP, ECA, SEP,

OI-1 A/B Procedures, October 29, 2002

SEN 174, Loss of Non-Vital Bus Causes Dual Unit Scram and Degraded Auxiliary Feedwater

System, November 10, 1997

Shutdown Emergency Procedure 1.1, Alternate Core Cooling, Revision 5, April 11, 2002

Southwest Research Institute letter to Nuclear Management Company—PBNP, Contamination

Testing of Pressure Breakdown Orifice, March 5, 2003

Table of Power Supplies and Failure Modes for Auxiliary Feedwater System Electrical

Components, November 25, 2002

Technical Specification Basis 3.7.5, Auxiliary Feedwater (AFW) System, Unit 1 - Amendment

No. 201, Unit 2 - Amendment No. 206

Technical Specification Basis Change Request 2002-0358, TS Basis B 3.7.5, September 10,

2002

Training Handbook 11.4, Auxiliary Feedwater System, April 8, 2002
46

TWR #02-297, AFW Mini-Recirc Issue OPS Training Needs Analysis Summary, November 1,

2002

Work Order 0213473 and Associated Work Plan, Inspect T-24B North Condensate Storage

Tank, November 7, 2002