Source: https://kanterella.com/wiki/Special:Ask/-5B-5BCategory:Finding-5D-5D-20-5B-5BSite::Millstone-5D-5D/-3FStart-20date/-3FSite/-3FIdentified-20by/-3FTitle/-3FDescription/mainlabel%3D/order%3Ddescending/sort%3DStart-20date/offset%3D0/format%3Dtable/searchlabel%3D-5BMillstone-20findings-5D
Timestamp: 2020-07-13 12:32:44
Document Index: 497534347

Matched Legal Cases: ['art 50', 'art 50', 'art 50', 'art 50', 'art 50', 'art 21', 'art 50', 'art 21', 'art 50', 'art 21', 'art 21', 'art 21', 'art 21', 'art 21', 'art 21', 'art 21', 'art 50', 'art 50', 'art 50', 'art 50', 'art 50', 'art 50', 'art 50', 'art 50', 'art 50', 'art 50', 'art 50', 'art 50', 'art-20', 'art-20']

[[Category:Finding]] [[Site::Millstone]]
{{#ask: [[Category:Finding]] [[Site::Millstone]]
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05000336/FIN-2018003-01 30 September 2018 23:59:59 Millstone NRC identified Failure to Assure that Safety-Related Service Water Piping Conformed to the Procurement Documents The inspectors identified a Green finding and associated non-cited violation (NCV) of Title 10 of the Code of Federal Regulations (10 CFR) Part 50, Appendix B, Criterion VII, Control of Purchased Material, Equipment, and Services, when the licensee failed to identify that a replacement service water pipe spool (JGD-1-25) was not in conformance with the American National Standards Institute (ANSI) B31.1 code, a condition of the purchase order, and was installed in the plant.
05000336/FIN-2018011-01 30 September 2018 23:59:59 Millstone NRC identified Reviews of Incoming Industry Operation Experience Not Completed The inspectors identified that Millstone could not demonstrate that incoming industry operational experience reports (ICES) since 2015 had been properly reviewed for applicability to Millstone and for those items that were applicable, were evaluated and corrective actions developed as necessary as required by program guidance. A population of over 1600 ICES reports were identified where it could not be determined if required reviews were complete. Because there are parallel processes which may have reviewed these items, additional review is necessary to determine whether this issue represents a performance deficiency that is of more than minor significance. Therefore, this item is characterized as an unresolved item (URI). The purpose of the operational experience program is to identify conditions adverse to quality (CAQs) found at other plants, evaluate whether the concern is applicable to either Millstone unit, and evaluate and develop corrective actions for those CAQs when necessary. The inspectors noted that a performance improvement report (PIR) is automatically created for the Dominion fleet whenever an OPEX report is received (regardless of its source). Once the corporate PIR is generated, each site is required to check a box that it was received and also disposition it. The PIR remains opened until each site has completed this action. Prior to 2015, the corporate Operating Experience Coordinator would perform an applicability review and assign the remaining items to the site for further evaluation. When the corporate organization was reorganized, the headquarters review of OPEX became mostly administrative and the individual sites were expected to fully disposition the report. Since 2015, more than 1600 OPEX records were discovered that required disposition for Millstone. These records were still open and no records exist to show whether reviews were completed. Therefore it is uncertain if all applicable ICES reports were reviewed. Planned Closure Actions: The NRC will conduct a problem identification and resolution annual sample using NRC IP 71152 once Dominion has notified the NRC that they have completed their review of the 1600 ICES reports. Licensee Actions: Dominion wrote Condition Report (CR) 1105042 to capture the issue, conducted an investigation, and developed a plan to review the 1600 ICES reports which have no documented reviews. Dominion anticipates this review will be completed by the end of the first quarter of 2019.Corrective Action Reference: CR 1105042NRC Tracking Number: 05000336 & 05000423/2018-011-01
05000336/FIN-2018403-01 30 September 2018 23:59:59 Millstone NRC identified Security
05000336/FIN-2018010-01 30 June 2018 23:59:59 Millstone NRC identified Over-Duty Breakers on Safety-Related Buses on Unit 2 The team identified a finding of very low safety significance (Green) and an associated non-cited violation (NCV) of Title 10 of the Code of Federal Regulations (10 CFR) Part 50, Appendix B, Criterion III, Design Control. Specifically, Dominion incorrectly concluded that the 480V safety-related breakers were conforming to the plants licensing basis following their identification that the calculated short circuit fault current exceeded the breaker rating. Dominions evaluation failed to take into consideration that non-class 1E loads fed from safety-related buses must be isolated from the class 1E system by fully qualified safety-related isolation devices (breakers). Dominions design basis requires that a circuit fault on the non-class 1E side of the isolation device shall not cause the loss of the associated safety-related system
05000423/FIN-2018010-02 30 June 2018 23:59:59 Millstone NRC identified Over-Duty Breakers on Safety-Related Bus 34C on Unit 3 The team identified a finding of very low safety significance (Green) and an associated NCV of 10 CFR Part 50, Appendix B, Criterion III, Design Control. Specifically, Dominion did not adequately evaluate the results of the Unit 3 short circuit calculations for the 4.16 kV breakers. Dominions evaluation of the short circuit calculation results did not identify that the breakers were non-conforming to the licensing basis. The teams review of the calculation results found that the momentary and interrupting duty ratings of the 4kV safety-related breakers associated with Bus 34C were not within their short-circuit ratings when evaluated under design fault condition and, therefore, not in accordance with the licensing basis of the plant.
05000336/FIN-2018010-04 30 June 2018 23:59:59 Millstone NRC identified Flood Seals Not Installed in Unit 2 A EDG and Auxiliary Building Penetrations The team identified a finding of very low safety significance (Green) and associated NCV of 10 CFR Part 50, Appendix B, Criterion XIV, Corrective Actions. Dominion identified a condition adverse to quality but did not correct the condition. Specifically, Dominion performed evaluations and walk downs in 2012 and 2016 to validate that all necessary flood seals for design basis and beyond design basis flood events had been properly installed. Dominion determined that they could not verify 50 wall penetrations had seals installed and entered the deficiency into the corrective action program. The team noted that an electrical conduit that passed through a Unit 2 A emergency diesel generator (EDG) building exterior wall, located below the design basis flood height, was one of the penetrations in question. During the inspection, following NRC questions, Dominion removed the electrical conduit cover plate and confirmed that a seal was not installed.
05000423/FIN-2018010-05 30 June 2018 23:59:59 Millstone NRC identified Inadequate Test Control of ECCS Valve Interlocks The team identified a finding of very low safety significance (Green) involving an NCV of 10 CFR Part 50, Appendix B, Criterion XI, Test Control. Specifically, Dominion did not ensure that all testing required to demonstrate that emergency core cooling system (ECCS) valve interlock circuits would perform satisfactorily was being performed. The team determined that certain interlocks associated with ECCS valve 3SIL*MV8804A control circuit were not properly tested to demonstrate that the valve would not open if interlocks had not been met or would open, when required, with minimum interlock requirements met during design basis accidents.
05000336/FIN-2018010-03 30 June 2018 23:59:59 Millstone NRC identified Failure to Correct Part 21 Power Supply Defects The team identified a finding of very low safety significance (Green) and associated NCV of 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings. Specifically, Dominion did not accomplish repairs to safety-related power supplies in accordance with instructions and procedures. The team identified that actions taken by Dominion to address Part 21 Report #48863, Foxboro Power Supply Potential Failures due to Defective Tie Wraps and Holder, were performed without procedure or engineering evaluations and the work activities performed were not documented. Specifically, instrumentation and control technicians altered the safety-related power supplies without approved design documents, plant procedures, or work orders, and records of the completed activities were not available
05000336/FIN-2018410-01 30 June 2018 23:59:59 Millstone NRC identified Security
05000423/FIN-2017004-01 31 December 2017 23:59:59 Millstone Self-revealing Failure to Maintain RCS Pressure during Solid Plant Cooldown A self-revealed NCV of very low safety significance (Green) of Title 10 of the Code of Federal Regulations (10 CFR) Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, was identified wherein, on October 13, 2017, Dominion failed to accomplish an activity affecting quality, Plant Cooldown, in accordance with approved procedures. Specifically, during solid plant cooldown, over the course of 18 seconds, reactor coolant system (RCS) pressure increased from 350 psia to 472 psia, which exceeded the limit of 435 psia established by Attachment 1, RCS Cooldown Curves, of operating procedure OP 3208, Plant Cooldown, Revision 028. Dominion operations staff took prompt actions to restore RCS pressure within limits and completed a required engineering evaluation to determine the effect of the out of limit condition on the structural integrity of the RCS. Dominion entered this issue into the corrective action program (CAP) as condition report (CR) 1080842 and completed a root cause evaluation of the event. This finding was determined to be more than minor because it adversely affected the configuration control attribute of the Barrier Integrity cornerstone objective to provide reasonable assurance that physical design barriers (RCS) protect the public from radionuclide releases caused by accidents or events. The inspectors evaluated the finding using IMC 0609, Appendix G, Attachment 1, Shutdown Operations Significance Determination Process Phase 1 Initial Screening and Characterization of Findings, and determined the finding to be of very low safety significance (Green). The finding had a cross-cutting aspect in the area of Human Performance related to Work Management because the licensee did not implement an adequate process of planning, controlling, and executing work activities such that nuclear safety was the overriding priority. Specifically, Dominion failed to recognize the increased risk of isolating instrument air during solid plant operations. (H.5)
05000336/FIN-2017003-01 30 September 2017 23:59:59 Millstone Self-revealing Inadequate Procedure Results in Inadvertent Lowering of Spent Fuel Pool Level A self-revealing NCV of very low safe ty significance (Green) of Technical Specification (TS) 6.8, Procedures, was identified because Dominion did not adequately establish Operating Procedure (OP) 2305, Spent Fuel Pool Cooling and Purification System. Specifically, from initial issuance until June 20, 2017, the procedure did not direct operators to verify the primary demineralizer bypass valve was closed while lining up to fill the spent fuel pool from the coolant waste receiver tanks, resulting in an unexpected loss of spent fuel pool inventory. Dominion has documented this condition within their corrective action program (CAP) as condition report (CR) 1064323, revised procedure OP 2305, and performed an apparent cause evaluation. The inspectors determined that the finding was more than minor because it was associated with the procedure quality attribute of the Barrier Integrity cornerstone and adversely affected its objective to provide reasonable assurance that physical design barriers, such as fuel cladding, protect the public from radionuclide releases caused by accidents or events. Specifically, spent fuel pool level was inadvertently lowered when operators aligned the system in accordance with OP 2305, which resulted in a reduced net positive suction head for the spent fuel pool cooling pumps as indicated by control room alarm. The finding screened to be of very low safety significance (Green) because it did not result in a loss of spent fuel pool water inventory below the minimum analyzed level limit and did not cause the spent fuel pool temperature to exceed the maximum analyzed temperature limit. This finding has a cross-cutting aspect in the Human Performance cross-cutting area, Avoid Complacency because Dominion did not recognize and plan for the possibility of a latent deficiency in procedure OP 2305 when used while the primary demineralizers were bypassed. (H.12)
05000336/FIN-2017007-01 30 September 2017 23:59:59 Millstone NRC identified Failure to Replace Auxiliary Feedwater Solenoid Valves within the Required Frequency The inspection team identified a Green non-cited violation of Technical Specification 6.8.1.a, Procedures, because Dominion did not implement procedures as required by Regulatory Guide 1.33, Revision 2, Appendix A.9, Procedures for Performing Maintenance, to properly maintain the environmental qualification of safety-related auxiliary feedwater solenoid valves 2-FW-43AS and 2-FW-43BS. Specifically, Dominion failed to implement the recurring work event task and associated work order to ensure that these auxiliary feedwater solenoid valves were replaced prior to exceeding the qualified life of the solenoid coil and elastomer components. Dominion entered this issue into their corrective action program as condition report 1076005, planned replacement of the solenoid valves, and calculated an alternate ambient temperature for use in determining the qualified life of the solenoid valves. Dominion re-performed the qualified life calculation using this revised ambient temperature and extended the qualified life to support operability. The inspection team determined that this issue was more than minor because it adversely impacted the equipment performance attribute of the Mitigating Systems cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. This issue is also similar to more- than-minor examples 3.j and 3.k presented in IMC 0612, Appendix E, Examples of Minor Issues. Specifically, this performance deficiency resulted in a condition where there was reasonable doubt as to the operability and reliability of the solenoid valves for both auxiliary feedwater regulating valves, and thus, both trains of auxiliary feedwater. As such, Dominion needed to conduct additional engineering evaluation to extend the service life of the solenoid valves, thus justifying that the valves would continue to perform their safety function. The inspection team determined the finding to be of very low safety significance (Green) because the finding was a deficiency affecting the reliability of a mitigating structure, system, or component, and the structure, system, or component maintained its operability or functionality. The inspection team determined that no cross-cutting aspect was applicable because the finding was not indicative of current performance.
05000336/FIN-2017002-01 30 June 2017 23:59:59 Millstone NRC identified Potential Untimely Corrective Action for Anchor Darling Double Disc Gate Valves The inspectors identified that Dominion has not implemented corrective actions to address potential substantial safety hazards associated with several safety significant valves at Millstone Unit 2 that was reported in a 10 CFR Part 21 notification letter dated February 25, 2013. Specifically, after establishing a corrective action plan, to date Dominion has not implemented actions to either evaluate or inspect susceptible valves. However, inspectors need to compare actions taken to Dominions CAP requirements and review industry recommendations to address the Part 21 letter to determine if this represents a performance deficiency or violation of NRC requirements. As a result, the NRC has opened an unresolved item (URI) related to this issue of concern. Description. In 2012, Browns Ferry Nuclear Plant Unit 1 experienced a failure of an isolation valve due to a failure of the valve stem to wedge anti-rotation wedge pin as noted in a 10 CFR Part 21 Notification Letter dated January 4, 2013. Subsequent analysis by Flowserve, owner of Anchor/Darling, determined the cause was a manufacturing defect, wherein the wedge pin installation torque was insufficient to meet the design needs of the valve. Flowserve further concluded that other valves of this type, Anchor Darling double disc gate valves in motor operated valve (MOV) applications with Limitorque or Rotork actuators, could be susceptible to similar failures. As documented in the associated 10 CFR Part 21 Notification Letter from Flowserve dated February 25, 2013, Millstone was susceptible to a potential substantial safety hazard due to this potential failure mechanism. Dominion captured this condition in CR504097 and determined that the following Millstone Unit 2 valves were susceptible: CS-4.1A, Containment Spray Header Isolation CS-4.1B, Containment Spray Header Isolation CS-13.1A, RWST Outlet Isolation CS-13.1B, RWST Outlet Isolation CS-16.1A, Containment Sump Outlet Header Isolation CS-16.1B, Containment Sump Outlet Header Isolation The Dominion fleet MOV Program owner accepted the action (CA284339) to establish a corrective action plan on November 21, 2014, approximately 21 months after 10 CFR Part 21 notification by Flowserve. The corrective action plan for the susceptible valves included valve performance monitoring consistent with current MOV program requirements as well as stem position monitoring during travel every cycle which would indicate potential degradation of the wedge pin. Ultimate resolution for each location incorporates valve disassembly, intrusive inspection, and re-torque of the stem/wedge connection to mitigate the notified potential substantial safety hazard. To date, Dominion has not performed stem position monitoring, contrary to their corrective action plan, thereby limiting their capacity to identify wedge pin degradation without assessment of the change. Furthermore, due to the invasive nature of the ultimate resolution as well as the safety functions of the susceptible locations, final corrective actions for each valve must be performed with the unit offline. Dominion initially established ultimate resolution at each location in spring of either 2016 or 2017 without alignment to an outage schedule or cycle plan. On February 16, 2016, because the 2016 valves would be worked during a refueling outage, the facilities safety review committee met, extending due dates until June 1, 2017. Immediately preceding the spring 2017 refueling outage, Dominion realigned ultimate resolution for the susceptible valves to the fall 2018 and spring 2020 refuel outages due to failure to receive parts required to complete contingency maintenance. Ultimately, from February 25, 2013, through the present, the inspectors identified that Dominion delayed implementation of corrective actions for multiple potential substantial safety hazards that was communicated in a 10 CFR Part 21 notification letter. However, inspectors need to compare actions taken to Dominions CAP requirements and review industry recommendations to address the Part 21 letter to determine if this represents a performance deficiency or violation of NRC requirements. (URI 05000336/2017002-01, Potential Untimely Corrective Action for Anchor Darling Double Disc Gate Valves)
05000336/FIN-2017405-01 30 June 2017 23:59:59 Millstone NRC identified Security
05000336/FIN-2017403-03 31 March 2017 23:59:59 Millstone NRC identified Security
05000336/FIN-2017403-04 31 March 2017 23:59:59 Millstone NRC identified Security
05000336/FIN-2017403-05 31 March 2017 23:59:59 Millstone NRC identified Security
05000336/FIN-2017403-01 31 March 2017 23:59:59 Millstone NRC identified Security
05000336/FIN-2017001-03 31 March 2017 23:59:59 Millstone Licensee-identified Licensee-Identified Violation As discussed in Section 4OA2.2 of this report, the inspectors concluded that the ECCS minimum flow recirculation check valves should have been characterized as Category A valves, and should have been leak rate tested as per the IST Program. The associated LER is discussed in Section 4OA3.1. Title 10 CFR 50.55a, Codes and Standards, Section (f)(4), required in part, that throughout the service life of a pressurized water-cooled nuclear power facility, valves that are classified as Class 1, 2, or 3 must meet the IST requirements set forth in the ASME OM Code. Dominions Code of Record, ASME OM Code - 2001 Edition, Subsection ISTC-1300, Valve Categories, required that valves within the scope of Subsection ISTC-1300 shall be placed in one or more of the following categories, which included Category A (those valves for which seat leakage is limited 28 to a specific maximum amount in the closed position for fulfillment of their required function). The inspectors concluded that minimum flow recirculation check valve 2- CS-6A should have been a Category A valve, and leak rate tested, to assure fulfillment of its safety function (to mitigate the dose consequences of a postulated accident). Contrary to the above, since 1975, when the check valve 2-CS-6A was initially categorized, Dominion failed to appropriately categorize the subject valve and therefore did not meet the ASME OM Code requirements and 10 CFR 50.55a requirements. Specifically, failure to categorize the check valve as a Category A resulted in the valve not being subject to leak rate testing. This issue is more than minor because it was associated with the equipment performance attribute of the Mitigating Systems cornerstone and adversely affected the cornerstone objective of ensuring the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. The inspectors determined that the finding was of very low safety significance because it did not result in the loss of operability or functionality of a system or train, and the actual leakage through the check valve would not have resulted in a radiological dose in excess of regulatory requirements. Dominion entered the issue into the CAP as CR 582112 and CA 3013009. Because Dominion identified this issue of very low safety significance and it has been entered into their CAP, this finding is being treated as a licensee-identified NCV, consistent with Section 2.3.2.a of the NRC Enforcement Policy. This item was considered licensee-identified because it was identified by Dominion as a result of deliberate observation by licensee personnel, and was entered into their CAP.
05000336/FIN-2017001-01 31 March 2017 23:59:59 Millstone NRC identified Failure to Maintain CST Temperature in Accordance with Procedural Requirements Green. The inspectors identified a Green NCV of Title 10 of the Code of Federal Regulations (10 CFR) Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, for the failure to adequately implement Operating Procedure (OP) 2319B, Condensate Storage and Surge System. Specifically, Dominion failed to maintain the Millstone Unit 2 condensate storage tank (CST) temperature above procedural requirements. Dominion has documented this condition within their corrective action program (CAP) as condition report (CR) 1066291. The inspectors determined this finding was more than minor as it adversely affected the protection from external factors attribute of the Mitigating Systems cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. The reliability of the mitigating systems heat removal function was challenged based upon the reasonable doubt of lost operability of the CST to provide a sufficient supply of water to the auxiliary feedwater (AFW) system. There was reasonable doubt of lost operability due to indications of CST water temperature below OP 2319B prescribed limitations, winter temperatures falling, and an inability to restore CST recirculation system in a timely manner. The finding was determined to be of very low safety significance (Green), when all screening questions were answered No as the conditions discussed in the Dominion engineering evaluation, approved on January 7, 2017, were capable of showing that no safety systems or functions were lost. This finding has a crosscutting aspect in the Problem Identification and Resolution, Resolution, in that Dominion did not take effective corrective actions or corrective maintenance to address CST recirculation pump degradation in a timely manner, prior to the onset of winter, commensurate with their safety significance such that operations could maintain CST water temperature above procedurally defined limitations. (P.3)
05000336/FIN-2017403-02 31 March 2017 23:59:59 Millstone NRC identified Security
05000423/FIN-2017001-02 31 March 2017 23:59:59 Millstone NRC identified Change of C Charging Pump Testing Requirements Contrary to ASME OM Green. The inspectors identified a Green NCV of 10 CFR 50.55a(f) because Dominion did not perform all required inservice testing (IST) of the Unit 3 C charging pump, 3CHS*P3C, in accordance with the American Society of Mechanical Engineers (ASME) Operation and Maintenance (OM) Code. Specifically, from April 15, 2016, to the end of the inspection period, Dominion stopped the required Group A quarterly surveillances which could result in a condition where degradation of the charging pump would remain undetected by IST testing. Dominion entered this issue into their CAP as CR 1064337. 4 This finding was more than minor in accordance with IMC 0612, Power Reactor Inspection Reports, Appendix B, Issue Screening, dated September 7, 2012, as it adversely affected the Equipment Performance attribute of the Mitigating Systems cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. Eliminating quarterly IST surveillance tests could challenge the reliability of the C charging pump and allow degradation of the equipment remaining undetected. In accordance with IMC 0609, Significance Determination Process, Attachment 4, Initial Characterization of Findings, and IMC 0609, Appendix A, Exhibit 2, Mitigating Systems Screening Questions, Section A, Mitigating Systems, Structures or Components and Functionality, the finding screened to be of very low safety significance (Green), when the deficiency affecting the design or qualification whereupon the component maintains operability or functionality question was answered yes. The C charging pump has not yet experienced any failures. This finding has a cross-cutting aspect in Human Performance, Change Management, in accordance with IMC 0310, Aspects within the Cross-Cutting Areas, where leaders use a systematic process for evaluating and implementing change so that nuclear safety remains the overriding priority. Specifically, Dominion evaluated this change to the IST program without requesting relief from the ASME Code requirements. (H.3)
05000336/FIN-2016004-04 31 December 2016 23:59:59 Millstone Licensee-identified Licensee-Identified Violation 10 CFR 50, Appendix B, Criterion XVI, Corrective Action, states in part that measures shall be established to assure that conditions adverse to quality are promptly identified and corrected. Contrary to this, Dominion failed to identify 3SWP*MOV115A, the circulating water pump lube water valve, was part of a population of valves subject to dealloying and did not take appropriate corrective actions prior to valve failure. Dominion discovered this issue during a planned system walkdown and entered it into the CAP as CR1052697. The inspectors evaluated this finding using IMC 0609.04, Initial Characterization of Findings, and IMC 0609, Appendix A, Exhibit 2, Mitigating Systems Screening Questions, and determined that the finding was of very low safety significance (Green) because the finding did not represent a loss of system or function, or an actual loss of a train for greater than its TS allowed outage time, or an actual loss of function of one or more non-TS trains of equipment designated as high safety-significant in accordance with the licensees maintenance rule program for greater than 24 hours.
05000336/FIN-2016004-01 31 December 2016 23:59:59 Millstone NRC identified Routine Failure to Perform Engineering Evaluation of Long Term Scaffolding The inspectors identified a Green NCV of Title 10 of the Code of FederalRegulations (10 CFR) Part 50, Appendix B, Criterion V, Instructions, Procedures, andDrawings, for the failure to adequately implement procedure MA-AA-105, Scaffolding,Revision 17. Specifically, Dominion routinely failed to perform engineering evaluations oflong term scaffolding installed in the plant for greater than 90 days. Dominion hasdocumented this condition within their corrective action program (CAP) as condition reportCR1049493.The inspectors determined that this finding was more than minor as it represents the routine failure to perform 10 CFR 50.59 engineering evaluations consistent with the requirements of procedures MA-AA-105 and CM-AA-400 which if left uncorrected, would have the potential to lead to a more significant safety concern as informed by IMC 0612, Appendix E,Examples of Minor Issues, example 4.a. The finding screened to be of very low safety significance (Green), when all screening questions were answered No as the conditions identified did not challenge safety system functions. This finding has a cross-cutting aspect in the Problem Identification and Resolution, cross-cutting area associated with Resolution,in that under CR1049057, Dominion did not take effective corrective action to resolve and correct the identified gaps in the tracking and assessment of scaffolding installed for greater than 90 days as directed by MA-AA-105 and CM-AA-400, resulting in three further failures to evaluate long term scaffolding identified by the inspectors in the Unit 2 A Safeguards Room. (P.3)
05000336/FIN-2016004-02 31 December 2016 23:59:59 Millstone NRC identified Failure to Maintain Licensed Operator Examination Integrity The inspectors identified an NCV of 10 CFR 55.49, Integrity of Examinations and Tests, for the failure of the licensee to ensure that the integrity of an operating test administered to licensed operators was maintained. During the annual operating exam, 19of the Unit 2 licensed operators received more than two of five job performance measures(JPMs) (>50 percent) for their operating tests that had been administered to other licensed operators in previous weeks of the same exam cycle. This failure resulted in a compromise of examination integrity because it exceeded the Dominion Nuclear Fleet Procedure TR-AA-730, "Licensed Operator Biennial and Annual Operating Requalification Exam Process,4 Revision 9, requirement to repeat less than or equal to 50 percent of the JPMs during the exam cycle. However, this compromise did not lead to an actual effect on the equitable and consistent administration of the examination. This issue was entered into Dominions CAP as CR1056308.The failure of Dominions training staff to maintain the integrity of examinations administered to licensed operations personnel was a performance deficiency. The performance deficiency was more than minor, and therefore a finding, because if left uncorrected, the performance deficiency could have become more significant in that allowing licensed operators to return to the control room without valid demonstration of appropriate knowledge on the biennial examinations could be a precursor to a more significant event. Using IMC 0609, Significance Determination Process, and the corresponding Appendix I, Licensed Operator Requalification Significance Determination Process, the finding was determined to have very low safety significance (Green) because although the finding resulted in a compromise of the integrity of operating test JPMs and compensatory actions were not immediately taken when the compromise should have been discovered in 2016, the equitable and consistent administration of the test was not actually impacted by this compromise. This finding has a cross-cutting aspect in the area of Human Performance associated with Field Presence, because the licensee failed to ensure that deviations from standards and expectations are corrected promptly such that the 50 percent maximum limit on repeated JPMs was not exceeded. Specifically, Dominion supervisory review and approval of the original examination plan and subsequent changes to that plan could have discovered the deviation from standards and expectations. (H.2)
05000423/FIN-2016004-03 31 December 2016 23:59:59 Millstone NRC identified Untimely Corrective Action for Vital Inverters The inspectors identified a Green NCV of 10 CFR 50, Appendix B, Criterion XVI,Corrective Action, for Dominions failure to take timely corrective actions to replacedegraded diodes in Unit 3 vital inverters INV-1 and INV-2 upon receipt of information that called their reliability into question. Specifically, following two inverter failures, Dominion had not taken any corrective actions to replace degraded diodes in the Unit 3 vital inverters from the receipt of the Exelon Power Labs report on September 20 until the susceptible diodes were inspected and replaced on November 17 and 22. Dominion entered this issue into their CAP as CR1041301. The inspectors found that Dominions failure to take timely corrective action to replace degraded vital inverter diodes was a performance deficiency within Dominions ability to foresee and correct. This performance deficiency was considered to be more than minor because it would affect the Mitigating Systems cornerstone equipment performance attribute objective to ensure the availability and reliability of vital 120V power. Specifically,manufacturing defects in the diodes caused these subcomponents to fail when they were expected to last the life of the inverter. The finding was evaluated in accordance with IMC 0609, Appendix A, The Significance Determination Process for Findings At-Power, and determined to be of very low safety significance (Green) because although the failure challenged the reliability of the inverters, it did not result in a loss of operability or functionality. This finding has a cross-cutting aspect in the Human Performance crosscutting area associated with Work Management, in that Dominion focused on managing the risk associated with voluntarily entering a 24 hour technical specifications (TS) limiting condition for operation (LCO) to replace the degraded diodes instead of the potential risk of another inverter failure. (H.5)
05000336/FIN-2016008-02 30 September 2016 23:59:59 Millstone Licensee-identified Licensee-Identified Violation LER 05000336/2013-003-00 (Unit 2) describes an unanalyzed condition in which Dominion identified their DC ammeter circuits were unfused. Specifically, Dominion did not provide overcurrent protection for wiring associated with DC ammeter indication in the control room to prevent wires from overheating due to fire induced faults and excessive currents flowing through the cable. With enough current flowing through the cable, the potential existed that the overloaded ammeter wiring could damage system wiring or adjacent safety-related circuits in the cable raceways needed for post-fire safe shutdown. This condition could result in a loss of the associated safe shutdown components or a secondary fire in another fire area. The failure to protect safe shutdown cables from the effects of postulated fires was a performance deficiency. This performance deficiency was a violation of Millstone Power Station, Unit 2, Renewed Facility Operating License Condition 2.C.(3), which requires in part, post-fire safe shutdown cables remain free of the effects of fire-induced cable faults during postulated fires. Contrary to the above, Dominion identified they failed to meet this requirement and the condition existed since initial construction of Unit 2. The issue was more than minor because it was associated with the protection against external events (fire) attribute of the mitigating systems cornerstone and it adversely affected the cornerstone objective of ensuring the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. The team determined that the finding was of very low safety significance (Green), based IMC 0609, Appendix F, Fire Protection Significance Determination Process (SDP), Phase 2 screening criteria. The finding screened to Green based upon, task number 2.3.5, because the affected cables were routed in alternate shutdown fire areas that are continually manned or protected by detection and automatic suppression systems. Remaining fire areas are protected by detection systems, automatic suppression systems or rely on manual fire-fighting activities. Additionally, the cable construction is Institute of Electrical and Electronics Engineers (IEEE) 383 (thermoset) which decreases the likelihood of inter-cable and intra-cable interactions. Based on a team walkdown, the team determined that the ammeter cable routing was not routed near a credible fire ignition source in the affected fire areas. Because this finding is of very low safety significance and had been entered into Dominions corrective action program (CR530987), this violation is being treated as a Green, licensee-identified NCV consistent with the NRCs Enforcement Policy.
05000336/FIN-2016403-03 30 September 2016 23:59:59 Millstone NRC identified Security
05000336/FIN-2016008-03 30 September 2016 23:59:59 Millstone Licensee-identified Licensee-Identified Violation LER 05000336/2014-002-00 (Unit 2) describes an unanalyzed condition in which Dominion identified DC motor control circuits were unfused. Specifically, Dominion did not provide overcurrent protection for wiring associated with 125 V DC control circuits for a non-safety related main turbine emergency lube oil pump to prevent wires from overheating due to fire induced faults and excessive currents flowing through the cable. With enough current flowing through the cable, the potential existed that the overloaded motor control wiring could damage adjacent control circuit wiring for components which are needed to achieve and maintain post-fire safe shutdown for a fire in several fire areas (turbine battery room, cable vault, plant equipment operator meeting area, control room). This condition could result in a loss of the associated safe shutdown components or a secondary fire in another fire area. The failure to protect safe shutdown cables from the effect of postulated fires was a performance deficiency. This performance deficiency was a violation of Millstone Power Station, Unit 2, Renewed Facility Operating License Condition 2.C.(3), which requires, in part, post-fire safe shutdown cables remain free of the effects of fire induced cable faults during postulated fires. Contrary to the above, Dominion identified they failed to meet this requirement and the condition existed since initial construction. The issue was more than minor because it was associated with the protection against external events (fire) attribute of the mitigating systems cornerstone and it adversely affected the cornerstone objective of ensuring the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. The team determined that the finding was of very low safety significance (Green), based on IMC 0609, Appendix F, Fire Protection Significance Determination Process, Phase 2 screening criteria. The finding screened to Green based upon, task number 2.3.5, because the affected cables were routed in alternate shutdown fire areas that are continually manned or protected by detection and automatic suppression systems. Remaining fire areas are protected by detection systems, automatic suppression systems or rely on manual firefighting activities. Additionally, the cable construction is IEEE 383 (thermoset) which decreases the likelihood of inter-cable and intra-cable interactions. Based on a team walkdown, the team determined that the main turbine emergency lube oil pump cable routing was not routed near a credible fire ignition source in the affected fire areas. Because this finding is of very low safety significance and had been entered into Dominions corrective action program (CR541980), this violation is being treated as a Green, licensee-identified NCV consistent with the NRCs Enforcement Policy.
05000336/FIN-2016403-05 30 September 2016 23:59:59 Millstone Licensee-identified Licensee-Identified Violation
05000336/FIN-2016403-04 30 September 2016 23:59:59 Millstone NRC identified Security
05000423/FIN-2016008-04 30 September 2016 23:59:59 Millstone Licensee-identified Licensee-Identified Violation LER 05000423/2014-002-00 (Unit 3) describes an unanalyzed condition in which Dominion identified DC motor control circuits were unfused. Specifically, Dominion did not provide overcurrent protection for wiring associated with 125 V DC control circuits for non-safety related main turbine emergency lube oil and main generator emergency seal oil pumps to prevent wires from overheating due to fire induced faults and excessive currents flowing through the cable. With enough current flowing through the cable, the potential existed that the overloaded motor control wiring could damage adjacent control circuit wiring for components which are needed to achieve and maintain post-fire safe shutdown for a fire in several fire areas (turbine battery switchgear area, cable spreading room, instrument rack room, control room). This condition could result in a loss of the associated safe shutdown components or a secondary fire in another fire area. The failure to protect safe shutdown cables from the effect of postulated fires was a performance deficiency. This performance deficiency was a violation of Millstone Power Station, Unit 3, Renewed Facility Operating License Condition 2.H, which requires, in part, post-fire safe shutdown cables remain free of the effects of fire induced cable faults during postulated fires. Contrary to the above, Dominion identified they failed to meet this requirement and the condition existed since initial construction. The issue was more than minor because it was associated with the protection against external events (fire) attribute of the mitigating systems cornerstone and it adversely affected the cornerstone objective of ensuring the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. The team determined that the finding was of very low safety significance (Green), based on IMC 0609, Appendix F, Fire Protection Significance Determination Process, Phase 2 screening criteria. The finding screened to Green based upon, task number 2.3.5, because the affected cables were routed in alternate shutdown fire areas that are continually manned or protected by detection and automatic suppression systems. Remaining fire areas are protected by detection systems, automatic suppression systems or rely on manual firefighting activities. Additionally, the cable construction is IEEE 383 (thermoset) which decreases the likelihood of inter-cable and intra-cable interactions. Based on a team walkdown, the team determined that the main turbine emergency lube oil and main generator emergency seal oil pump cable routing was not routed near a credible fire ignition source in the affected fire areas. Because this finding is of very low safety significance and had been entered into Dominions corrective action program (CR541983), this violation is being treated as a Green, licensee-identified NCV consistent with the NRCs Enforcement Policy.
05000336/FIN-2016003-01 30 September 2016 23:59:59 Millstone NRC identified Failure to Review Standing Orders The inspectors identified a Green NCV of Technical Specification (TS) 6.8.1.a, for Dominions failure to implement procedures as required by Regulatory Guide 1.33, Revision 2, Appendix A.1, Administrative Procedures, during the performance of watch turnover. This resulted in multiple operators across multiple crews in both Unit 2 and 3 standing watch without performing a review of the applicable standing orders for up to 4 months from March to July 2016. Dominion entered the condition in their corrective action program (CAP) as condition report (CR)1042287. The inspectors determined that the finding was more than minor because if left uncorrected the performance deficiency could lead to a more significant event. Specifically, the operators did not review TS amendments, emergency action level classifications, emergency operating procedures, and plant computer issues impacting the plant prior to taking watch. Without reviewing the standing orders to understand the information contained within, operators could potentially take improper actions to control the plant during evolutions and abnormal conditions. The finding was determined to be of very low safety significance (Green) because it did not affect design or qualification of a mitigating structure, system, and component (SSC), did not represent a loss of system function, and did not involve external event mitigation systems. The inspectors determined that the finding has a cross-cutting aspect in the Human Performance cross-cutting area associated with Field Presence, where leaders are commonly seen in the work areas of the plant observing, coaching, and reinforcing standards and expectations. Specifically, Dominion leadership observations in the control room or management review of monthly standing order audits could have discovered the deviation from standards and expectations. (H.2)
05000336/FIN-2016404-01 30 September 2016 23:59:59 Millstone NRC identified Security
05000336/FIN-2016403-01 30 September 2016 23:59:59 Millstone NRC identified Security
05000423/FIN-2016003-02 30 September 2016 23:59:59 Millstone NRC identified Failure to Scope Safety Related Acoustic Valve Monitoring System into the Maintenance Rule The inspectors identified a Green NCV of Title 10 of the Code of Federal Regulations (10 CFR) 50.65(b)(1), for Dominions failure to include the safety-related Unit 2 Pressurizer Safety Valve, Acoustic Valve Monitoring System (AVMS) SSC within the scope of the maintenance rule program. Specifically, Dominion removed the Millstone Unit 2 AVMS, which is required to remain functional during and following a design bases event to provide indication to operators in the control room of significant abnormal degradation of the reactor coolant pressure boundary and monitor for loss of coolant due to an open safety relief valve, from the scope of the maintenance rule monitoring program. Dominion has documented this condition in their CAP as CR1049493. The inspectors determined that the finding was more than minor because it was associated with the equipment performance attribute of the Initiating Events cornerstone and adversely affected the objective to limit the likelihood of events that upset plant stability and challenge critical safety functions during shutdown as well as power operations. Specifically, Dominions removal of AVMS from maintenance rule performance and condition monitoring and the failures observed have resulted in the complete loss of availability and reliability of each channel of AVMS such that they cannot perform their intended function. The finding was determined to be of very low safety significance (Green) because the conditions associated with the most applicable design basis event are bound by the small break loss of coolant accident (LOCA) analysis and did not affect other systems used to mitigate a LOCA. This finding has a crosscutting aspect in the Human Performance cross-cutting area associated with Procedure Adherence, in that Millstone Maintenance Rule Expert Panel (MREP) members did not follow the Dominion maintenance rule program implementing procedure, ER-AA-MRL-100, which provides guidance for scoping systems into the maintenance rule. (H.8)
05000336/FIN-2016008-01 30 September 2016 23:59:59 Millstone NRC identified Unapproved OMA in Lieu of Meeting III.G.2 Fire Protection Requirements for Fire Area R-14, Lower 4kV Switchgear Room and Cable Vault The team identified a finding of very low safety significance (Green) involving a noncited violation of Millstone Power Station, Unit 2, Renewed Facility Operating License Condition 2.C.(3) to implement and maintain in effect all provisions of the approved fire protection program as described in the Final Safety Analysis Report (FSAR). Specifically, Dominion failed to maintain the #2 steam generator (SG) atmospheric dump valve (ADV) free from fire damage, which may have affected the availability to maintain hot shutdown conditions from the main control room for a fire in Fire Area R-14, Lower 4.16kV Switchgear Room and Cable Vault. Dominion promptly entered this safe shutdown issue into their corrective action program as condition report (CR) 1043458. Immediate corrective actions included implementing compensatory measures in the form of fire watches for fire area R-14 that are being tracked by Reasonable Assurance of Safety (RAS) determination 3037040. Longer term corrective actions included submitting an exemption request to the NRC for use of a local operator manual action (OMA) to operate the #2 SG ADV in lieu of meeting fire protection requirements for fire area R-14. The team considered Dominions immediate and longer term corrective actions appropriate. The performance deficiency was more than minor because it affected the Mitigating Systems cornerstone objective to ensure the availability, reliability, and capability of systems that respond to an external event to prevent undesirable consequences in the event of a fire. Specifically, the use of an OMA during post-fire safe shutdown is not as reliable as normal systems operation which could be utilized had the requirements of 10 CFR Part 50, Appendix R, Section III.G.2 been met and, therefore, prevented fire damage to credited components and/or cables, specifically the #2 SG ADV. The inspectors used IMC 0609, Appendix F, Fire Protection Significance Determination Process, Phase 1 and determined the reactor is able to reach and maintain a hot safe shutdown condition because the SG ADVs are used for transition to cold shutdown, therefore this finding was of very low safety significance (Green). This finding does not have a cross cutting aspect because the performance deficiency occurred greater than three years ago when the June 30, 2011 exemption request letter to the NRC was supplemented by letter on February 29, 2012, and is not indicative of current licensee performance.
05000336/FIN-2016403-02 30 September 2016 23:59:59 Millstone NRC identified Security
05000336/FIN-2016002-01 30 June 2016 23:59:59 Millstone NRC identified Secondary Containment Inoperability Due to Inadequate Procedures The inspectors documented a self-revealing Green NCV of Title 10 of the Code of Federal Regulations (10 CFR) Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, because Dominion did not develop a Unit 3 supplementary leak collection and release system (SLCRS) damper procedure that was adequate to prevent the inoperability of the system. Specifically, deficiencies in procedure SP 3614I.3A, Supplementary Leak Collection and Release System Boundary Isolation Damper Test, as well as the SLCRS damper monitoring program and preventative maintenance strategy, led to both trains of the Unit 3 SLCRS failing their respective surveillance tests resulting in the inoperability of secondary containment. After the issue was identified, Dominion entered the condition into their corrective action program (CAP) as condition report (CR)1033408, declared the secondary containment inoperable until the plant entered a mode of technical specifications non-applicability, and conducted walkdowns and repairs to the system to restore it to compliance. This performance deficiency was considered to be more than minor because it adversely affected the system, structure, and component (SSC) and barrier performance attribute of the Barrier Integrity cornerstone objective to provide reasonable assurance that physical design barriers protect the public from radionuclide releases caused by accidents or events. Specifically, inadequate maintenance of the SLCRS system led to a system differential pressure during operation that was not adequate to meet its design basis surveillance requirement and thus rendered the system inoperable. Additionally, the performance deficiency was similar to IMC 0612, Appendix E, minor example 2.a. The finding was evaluated in accordance with IMC 0609, Appendix A, The Significance Determination Process for Findings At-Power, and determined to be of very low safety significance (Green) since it only represented a degradation of the radiological barrier function provided for the auxiliary building. The finding is related to the cross-cutting aspect of Human Performance, Design Margins, because Dominion did not operate and maintain equipment within design margins. Specifically, Dominion did not appropriately monitor and maintain the SLCRS system in such a way that declining damper performance trends were identified and prevented prior to the inoperability of the system.
05000336/FIN-2016001-02 31 March 2016 23:59:59 Millstone Self-revealing Failure of Feedwater Isolation Valve to Close Due to Electrical Jumper Being Installed The inspectors identified a self-revealing Green NCV of TS 3.3.2 for Dominions failure to meet the operability requirements for the C feedwater isolation valve (FWIV) testing and valve limit testing work associated with Design Change MP3-09-01030, an electrical jumper was left installed in the C FWIV (3FWS*CTV41C) control circuit. This prevented both channels of the engineered safety features actuation system (ESFAS) signal from closing the C FWIV when called upon during an actual feedwater isolation actuation associated with the reactor trip on January 25, 2016. The installed jumper rendered the C FWIV inoperable for over one year. Dominions immediate corrective actions included restoring the channels for 3FWS*CTV41C to operable status by removing the electrical jumper, inspecting the other FWIV control circuits for electrical jumpers, and retesting all of the FWIVs for proper operation. The performance deficiency was determined to be more than minor because it adversely affected the configuration control attribute of the Mitigating Systems cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. Specifically, the failure to remove an electrical jumper on the C FWIV during the implementation of a design change led to the failure of the valve to perform its closure safety function when called upon. The finding was evaluated in accordance with IMC 0609, Appendix A, The Significance Determination Process for Findings At-Power, and determined to be of very low safety significance (Green) since it did not represent an actual loss of safety function of the system as there was a redundant means of feedwater isolation. The finding has a cross-cutting aspect in Human Performance, Work Management, because Dominion did not implement a process of planning, controlling, and executing work activities such that nuclear safety is the overriding priority. Specifically, maintenance and operations personnel did not follow the work management procedure for generating a new work order when the additional electrical jumper was installed (H.5).
05000423/FIN-2016001-03 31 March 2016 23:59:59 Millstone Licensee-identified Licensee-Identified Violation Dominion identified a Severity Level (SL) IV NCV of 10 CFR 50.59(d)(1), Changes, Tests, and Experiments, for the failure to perform an evaluation of a change to the facility as described in the UFSAR which would have required prior approval. During a design basis review of Millstone Unit 3 SW system, Dominion discovered that multiple fittings installed in the system beginning in 1989 were manufactured with Nickel Copper Alloy (UNS N04400) per material specification SB366. Although a material with improved properties, this is not an ASME Boiler Pressure Vessel Code of record Section III (ASME III) permitted material fabrication specification without required additional documentation. The Millstone Unit 3 UFSAR Table 3.2-1, List of QA Category I and Seismic Category I Structures, Systems, and Components, Revision 24.3, requires the SW system to be compliant with ASME III Code Class 3. The inspectors determined that the failure of Dominion to perform written evaluations in accordance with 10 CFR 50.59(d)(1) when installing non-conforming material into Unit 3 beginning in 1989 was a performance deficiency which was within Dominions capability to foresee and prevent. The inspectors identified this condition as more than minor as installation of an ASME III non-conforming material into the Unit 3 SW system would have required prior approval. Because the performance deficiency impacted the ability of the NRC to perform its regulatory function, the inspectors evaluated the issue using the traditional enforcement process. In accordance with the NRC Enforcement Policy, Section 6.1.d.2, this condition screened as SL IV as it was assessed as having very low safety significance (Green) by IMC 0609, Significance Determination Process, when the screening questions were all answered No. 10 CFR 50.59(d)(1), Changes, Tests, and Experiments, states in part, The licensee shall maintain records of changes in the facility, of changes in procedures, and of tests and experiments made pursuant to paragraph (c) of this section. These records must include a written evaluation which provides the bases for the determination that the change, test, or experiment does not require a license amendment pursuant to paragraph (c)(2) of this section. Contrary to the above, from March 1993 through March 29, 2016, Dominion did not perform written evaluations to provide the bases for determining that a change, test, or experiment made pursuant to 10 CFR 50.59(c)(2) did not require a license amendment for installation of SB-366 components into the SW system. Because Dominion identified this issue of very low safety significance (Green) and it has been entered into their CAP (CR1031360), this finding is being treated as a SL IV, licensee-identified NCV consistent with the NRC Enforcement Policy Section 2.3.2. This item was considered licensee identified since Dominion identified this issue during a design basis review.
05000336/FIN-2016001-01 31 March 2016 23:59:59 Millstone NRC identified Repetitive Failures to Correct Unit 3 Turbine Driven Auxiliary Feedwater Pump Performance Issues The inspectors identified a Green NOV of Title 10 of the Code of Federal Regulations (10 CFR) 50, Appendix B, Criterion XVI, Corrective Action, for Dominions repetitive failure to take effective corrective actions for significant conditions adverse to quality involving the degradation of the Unit 3 turbine driven auxiliary feedwater (TDAFW) pump turbine control valve linkage. Specifically, Dominions corrective actions to correct the TDAFW control system have not fully considered all potential failure modes such that continued unreliable operation due to linkage and control systems problems resulted in an overspeed trip of the TDAFW system in February 2016. Inspectors have previously documented this condition under two separate violations of 10 CFR 50, Appendix B, Criterion XVI. The performance deficiency was determined to be more than minor since it was associated with the equipment performance attribute of the Mitigating Systems cornerstone and adversely affected its objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. In accordance with IMC 0609, Appendix A, Exhibit 2, Mitigating Systems Screening Questions, the inspectors determined this issue required a detailed risk evaluation based on the finding representing an actual loss of function of a single train for greater than its technical specification (TS) allowed outage time. A Region I Senior Reactor Analyst (SRA) completed a detailed risk evaluation and concluded the risk significance of this issue was in the high E-8 range, or very low safety significance (Green). In accordance with IMC 0310, Aspects within the Cross-Cutting Areas, dated December 4, 2014, this finding has a cross-cutting aspect in Human Performance, Design Margins, in that the organization failed to operate and maintain equipment within design margins. The Unit 3 TDAFW has little margin to inoperability. Dominion did not pursue a thorough review of the potential interactions of different failure modes after correcting the obvious causes from past failures, which contributed to the February 22, 2016, overspeed event (H.6).
05000336/FIN-2015012-02 31 December 2015 23:59:59 Millstone NRC identified Failure of the STA to Support the Crew During a Plant Cooldown The NRC identified a Green NCV of Millstone Power Station Unit No. 2 TS 6.8.1, Procedures involving the shift technical advisors (STAs) failure to follow position-specific procedural guidance, to support all phases of plant operation. Specifically, the STA was not involved in providing independent, objective, and technical assessment of plant conditions when PZR level began to decrease when SDC was being place in service and during the subsequent cooldown. Later in the event, the STA did provide support to the crew to confirm the existence of a leak. After the event, the STA was removed from watch standing duties pending remediation. Dominion entered this issue into their corrective action program as CR1012358. The finding was more than minor because it is associated with the human performance attribute of the Mitigating Systems cornerstone and adversely affected its objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences (i.e., core damage). Specifically, during the initiation and operation of the SDC system, the STA did not provide sufficient technical input to aid the crew in the determination of the existence of a reactor coolant system leak. The finding screened to very low safety significance (Green) using Manual Chapter 0609, Appendix G, Attachment 1, Shutdown Operations Significance Determination Process Phase 1 Screening and Characterization of Findings, Exhibit 3 - Mitigating Systems Screening Questions. Specifically, the finding did not represent a loss of system safety function. This finding had a cross-cutting aspect in the area of Human Performance, Teamwork, in that individuals and work groups communicate and coordinate their activities within and across organizational boundaries to ensure nuclear safety is maintained. Specifically, the STA did not fulfill his responsibilities to support the crew by assessing plant conditions during the initiation and operation of the SDC system during the plant cooldown.
05000336/FIN-2015004-03 31 December 2015 23:59:59 Millstone Licensee-identified Licensee-Identified Violation 10 CFR Part 50.54(q), states that power reactor licensees shall follow and maintain in effect emergency plans which meet the standards in 10 CFR Part 50.47(b) and Appendix E to Part 50. 10 CFR Part 50.47(b)(4) requires, in part, that the nuclear facility licensee have a standard emergency classification and action level scheme in use, and state and local response plans call for reliance on information provided by facility licensees for determinations of minimum initial off-site response measures. Appendix E, Section IV.C.2 states in part that, nuclear power reactor licensees shall establish and maintain the capability to assess, classify, and declare an emergency condition within 15 minutes after the availability of indications to plant operators that an emergency action level has been exceeded and shall promptly declare the emergency condition as soon as possible following identification of the appropriate emergency classification level. Contrary to the above, on November 4, Unit 3 control room operators received a fire alarm in the A EDG enclosure at 10:56 AM, but did not declare an Unusual Event for a fire in a safe shutdown area until 11:25 AM. The control room received a report from the EDG enclosure at approximately 10:55 AM that there were visible flames on the exhaust line of the A EDG and they entered Emergency Operating Procedure 3509, Fire Emergency, but the declaration was not made within the required 15 minutes. The control room operators received additional information that there was charring and scorching on the A EDG at 11:33 AM and appropriately upgraded the emergency declaration to an Alert (fire affecting a safe shutdown area and damage to the equipment indicated). The upgraded Alert declaration was made at 11:35 AM, within the required 15 minutes. The inspectors determined that the finding is of very low safety significance (Green) because it was related to the timeliness of an NOUE, in accordance with IMC 0609, Appendix B, "Emergency Preparedness Significance Determination Process, Attachment 1, "Failure to Implement (Actual Event) Significance Logic." Dominion entered the issue into the CAP as CR 1017078.
05000336/FIN-2015012-03 31 December 2015 23:59:59 Millstone Self-revealing Procedure Failed to Direct Adequate Venting of SDC System A self-revealing Green NCV of Millstone Power Station Unit No. 2 TS 6.8.1, Procedures, was identified because the procedure used by Dominion to place the SDC system in service did not verify that the SDC suction line to the LPSI pumps was filled and vented prior to placing the system in service which appears to be the likely cause for opening SDC suction Relief Valve (RV) 2-SI-468. To address this issue, Dominion revised the procedure to include venting at SI-075 as part of step 4.12.2 of OP 2207. Dominion entered this issue into their corrective action program as CR1011898. The finding was more than minor because it was associated with procedure quality attribute of the Initiating Events cornerstone and affected the cornerstone objective of limiting the likelihood of events that upset plant stability and challenge critical safety functions during shutdown operations. Specifically, the finding identifies an increase in the likelihood of a loss of SDC resulting from the unexpected opening of RV 2-SI-468. Using a bounding and conservative quantitative detailed risk analysis, coupled with deterministic risk-informed defense-in-depth considerations, the finding was determined to be of very low risk significance (Green). This finding had a cross-cutting aspect in the area of Human Performance, Resources, because Dominion did not ensure procedures were adequate to support nuclear safety. Specifically, the plant cooldown procedure did not ensure that the SDC suction line to the LPSI pumps was full of water prior to placing the system in service (H.1).
05000336/FIN-2015012-04 31 December 2015 23:59:59 Millstone Licensee-identified Licensee-Identified Violation 10 CFR Part 50.54(q), states that power reactor licensees shall follow and maintain in effect emergency plans which meet the standards in 10 CFR Part 50.47(b) and Appendix E to Part 50. 10 CFR Part 50.47(b)(4) requires, in part, that the nuclear facility licensee have a standard emergency classification and action level scheme in use, and state and local response plans call for reliance on information provided by facility licensees for determinations of minimum initial off-site response measures. Appendix E, Section IV.C.2 states in part that, nuclear power reactor licensees shall establish and maintain the capability to assess, classify, and declare an emergency condition within 15 minutes after the availability of indications to plant operators that an emergency action level has been exceeded and shall promptly declare the emergency condition as soon as possible following identification of the appropriate emergency classification level. Contrary to the above, when the crew entered AOP-2568A at 8:53 a.m., charging flow was about 80 gpm greater than letdown flow with PZR level lowering and the RCS cooldown was secured. The SM did not declare a UE (Identified Leakage greater than 25 gpm) until 9:32 a.m. Dominion determined that the event declaration was accurate because the SM ultimately determined that the leakage was Identified Leakage but untimely and entered the issue into the CAP (CR1011949). Because of the UE condition, the inspectors determined that the finding is of very low safety Significance (Green) using IMC 0609, Appendix B, "Emergency Preparedness Significance Determination Process, Attachment 1, "Failure to Implement (Actual Event) Significance Logic."
05000336/FIN-2015004-01 31 December 2015 23:59:59 Millstone NRC identified Charging Packing Lubrication Pump Inadequate Operating Procedure Acceptance Criteria The inspectors identified a Green NCV of Title 10 of the Code of Federal Regulations (10 CFR) 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, associated with Dominions failure to include in the Unit 2 charging pump operating procedure appropriate acceptance criteria for determining operability of the Unit 2 charging pumps upon the loss of the associated charging flushing/lubrication pump. Specifically, Dominion implemented a procedure change which stated that the condition of the charging flushing/lubrication pumps does not affect charging pump operability or mission time without supporting technical information and contrary to guidance provided in the charging pump vendor technical manual, impacting an operability determination on December 13, 2015. Dominion has entered the concern associated with the charging pump operability acceptance criteria into their corrective action program (CAP) under condition report (CR)1021512. This finding was determined to be more than minor in accordance with IMC 0612, Power Reactor Inspection Reports, Appendix B, Issue Screening, dated September 7, 2012, because it was associated with the equipment performance attribute of the Mitigating Systems cornerstone and adversely affected its objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. Further, this finding was found to be consistent with more than minor examples 3.j and 3.k of IMC 0612, Appendix E, Examples of Minor Issues, dated August 11, 2009. This finding was evaluated in accordance with IMC 0609, Significance Determination Process, Attachment 4, Initial Characterization of Findings, and IMC 0609, Appendix A, Exhibit 2, Mitigating Systems Screening Questions, Section A, Mitigating Systems, Structures or Components and Functionality, and screened as very low safety significance (Green) since it was not a qualification or design deficiency, did not represent a loss of system or function, and did not exceed its technical specification (TS) allowed outage time. Inspectors identified a cross-cutting aspect in Human Performance, Documentation, in that Dominion lacked technical documentation to support the operability assertion in the charging pump operating procedure to address contrary guidance provided in the charging pump vendor manual.
05000336/FIN-2015012-01 31 December 2015 23:59:59 Millstone NRC identified Failure to Implement Procedural Guidance During a Loss of RCS Inventory The NRC identified a Green NCV of Millstone Power Station Unit No. 2 Technical Specifications (TS) 6.8.1, Procedures involving Dominions failure to implement procedural steps when prompted by plant conditions to mitigate the event. Specifically, when pressurizer (PZR) level began to decrease while placing the shutdown cooling (SDC) system in service, the crew did not implement procedural guidance in OP-2207, Plant Cooldown, nor enter AOP 2568A, RCS Leak, Mode 4, 5, 6, and Defueled, as these procedures would have directed operators to locate the source of the leak. Later in the event, once the procedural guidance was implemented, action was taken to identify the location of the leak and it was isolated. After the event, selected crew members were removed from watch standing duties pending remediation. Dominion entered this issue into their corrective action program as CR1012358. The finding was more than minor because it is associated with the human performance attribute of the Mitigating Systems cornerstone and adversely affected its objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences (i.e., core damage). Specifically, when entry conditions were met, operators did not implement procedural guidance that would have directed them to locate the source of the leak. The finding screened to very low safety significance (Green) using Manual Chapter 0609, Appendix G, Attachment 1, Shutdown Operations Significance Determination Process Phase 1 Screening and Characterization of Findings, Exhibit 3 - Mitigating Systems Screening Questions. Specifically, the finding did not represent a loss of system safety function. This finding had a cross-cutting aspect in the area of Human Performance, Procedure Adherence, in that licensed operators are expected to implement processes, procedures, and work instructions. Specifically, Dominion operators did not implement procedural guidance when prompted by plant conditions immediately after starting the A Low Pressure Safety Injection Pump (LPSI).
05000336/FIN-2015004-02 31 December 2015 23:59:59 Millstone NRC identified Turbine Driven Auxiliary Feedwater Pump Corrective Actions to Prevent Recurrence The inspectors identified a Green NCV of 10 CFR 50, Appendix B, Criterion XVI, Corrective Action, for Dominions failure to take corrective action to prevent repetition for a significant condition adverse to quality according to the definition in PI-AA-200, Corrective Action. Specifically, PI-AA-200 lists unplanned entry into a TS action that results in taking a unit off-line as an example of a significant condition adverse to quality. On July 26, 2014, Dominion performed a TS required shutdown of Unit 2 due to the inoperability of the turbine driven auxiliary feedwater (TDAFW) pump. Dominion cancelled the root cause evaluation (RCE) assigned to investigate the cause of the plant shutdown, stating that the direct cause of the shutdown was foreign material in the flow orifice in a recirculation line for the TDAFW pump. No corrective actions to prevent recurrence (CAPRs) were assigned after the direct cause was determined. Dominion entered this issue into their CAP as CR1019514. This performance deficiency was determined to be more than minor in accordance with IMC 0612, Power Reactor Inspection Reports, Appendix B, Issue Screening, dated September 7, 2012, because it was associated with the equipment performance attribute of the Mitigating Systems cornerstone and adversely affected its objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. Specifically, taking CAPRs will help to ensure the availability and reliability of the TDAFW pump. This finding was evaluated in accordance with IMC 0609, Significance Determination Process, Attachment 4, Initial Characterization of Findings, and IMC 0609, Appendix A, Exhibit 2, and screened as very low safety significance (Green) since it was not a qualification or design deficiency, did not represent a loss of system or function, and did not exceed its TS allowed outage time. The inspectors determined this issue had a cross cutting aspect in Human Performance, Consistent Process, where individuals use a consistent, systematic approach to make decisions. Specifically, Dominion inappropriately used the corrective action procedure to change the causal evaluation category without properly balancing the risk of the decision, and therefore did not develop CAPRs for a significant condition adverse to quality.
05000336/FIN-2015003-03 30 September 2015 23:59:59 Millstone Licensee-identified Licensee-Identified Violation 10 CFR 50, Appendix B, Criterion VII, Control of Purchased Material, Equipment, and Services, requires, in part, that measures shall be established to assure that purchased services conform to the procurement documents. Contrary to Criterion VII, Design Change MP3-09-01030, Replacement of Actuators on 3FWS*CTV41 A/D (FWIVs), was supplied by Dominions vendor (Flowserve) and accepted by Dominion with an inadequate valve weak link analysis (valve backseat determined to be the weak link versus the steam coupling bolts). This was identified by Dominion during installation of MP3-09-01030 which required significant changes to the modification design prior to returning the FWIVs to service. This issue is more than minor because, if left uncorrected, the issue would have the potential to lead to a more significant safety concern. Specifically, not correcting the valve weak link analysis had the potential to lead to damage and/or failure of the FWIV stem coupling bolts rendering the valve inoperable. The inspectors evaluated this finding using IMC 0609.04, Initial Characterization of Findings, and IMC 0609, Appendix A, Exhibit 3, Barrier Integrity Screening Questions. The inspectors determined that the finding was of very low safety significance (Green) because the finding did not represent an actual open pathway in the physical integrity of reactor containment. Dominion documented the issue in CRs 564977 and 564801.
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