UNITED STATES

NUCLEAR REGULATORY COMMISSION

REGION I
2100 RENAISSANCE BLVD., SUITE 100
KING OF PRUSSIA, PA 19406-2713

January 20, 2015

Mr. Bryan Hanson

Senior Vice President, Exelon Generation Company, LLC
President and Chief Nuclear Officer, Exelon Nuclear
4300 Winfield Road
Warrenville, IL 60555
SUBJECT: OYSTER CREEK NUCLEAR GENERATING STATION - NRC SUPPLEMENTAL
INSPECTION REPORT 05000219/2014010
Dear Mr. Hanson:
On December 11, 2014, the U. S. Nuclear Regulatory Commission (NRC) completed a
supplemental inspection pursuant to Inspection Procedure 95001, "Supplemental Inspection for
One or Two White Inputs in a Strategic Performance Area," at your Oyster Creek Nuclear
Generating Station. The enclosed inspection report documents the inspection results, which
were discussed on December 11, 2014, with Mr. J. Dostal, Plant Manager, and other members
of your staff.
As required by the NRCs Reactor Oversight Process Action Matrix, this supplemental
inspection was performed because the Unplanned Scrams per 7000 Critical Hours
performance indicator (PI) crossed the green-to-white threshold following an unplanned scram
on July 11, 2014. On October 21, 2014, your staff reported the Unplanned Scrams per 7000
Critical Hours PI that crossed the threshold from green-to-white. Based on your report, the
NRC assigned a white PI Action Matrix input to the Initiating Events cornerstone in the third
quarter of 2014, due to unplanned scrams on October 3, October 6, and December 14, 2013,
and July 11, 2014.
In response to this Action Matrix input, the NRC informed you in our mid-cycle assessment letter
dated September 2, 2014, that a supplemental inspection under Inspection Procedure 95001
would be required. The NRC was informed on November 5, 2014, of your staffs readiness for
this inspection.
The NRC performed this supplemental inspection to determine if (1) the root causes and the
contributing causes for the risk-significant issues were understood; (2) the extent of condition
and extent of cause of the issues were identified; and (3) corrective actions were or will be
sufficient to address and preclude repetition of the root and contributing causes. The inspection
consisted of examination of activities conducted under your license as they related to safety,
compliance with the Commissions rules and regulations, and the conditions of your operating
license.
Based on the results of this inspection, the NRC concluded that, overall, the supplemental
inspection objectives were met and no significant weaknesses were identified. The NRC
determined that your staffs evaluation identified a collective root cause of the four reactor
scrams which was decision makers do not always understand the likelihood or consequence

B. Hanson

of the malfunction of degraded equipment to cause a transient. To correct this root cause,
Exelon developed a single risk process to help decision makers better understand the risk
and consequences of malfunctions which cause plant transients.
The NRC has determined that completed or planned corrective actions were sufficient to
address the causes of the events that led to the white PI. In accordance with Inspection Manual
Chapter 0305, Operating Reactor Assessment Program, the Unplanned Scrams per 7000
Critical Hours performance indicator will continue to be considered as a White Action Matrix
input until the performance indicator has returned to the Green performance band. Any future
changes in Action Matrix column designation will be communicated via separate
correspondence.
One self-revealing finding of very low safety significance (Green) was identified. This finding did
not involve a violation of NRC requirements. If you disagree with the cross-cutting aspect or the
finding not associated with a regulatory requirement in this report, you should provide a
response within 30 days of the date of this inspection report, with the basis for your
disagreement, to the Regional Administrator, Region I; and the NRC Resident Inspector at
Oyster Creek.
In accordance with Title 10 Code of Federal Regulations 2.390 of the NRCs Rules of Practice,
a copy of this letter, its enclosure, and your response (if any) will be available electronically for
public inspection in the NRC Public Document Room or from the Publicly Available Records
(PARS) component of the NRCs Agencywide Documents Access Management System
(ADAMS). ADAMS is accessible from the NRC website at http://www.nrc.gov/reading
rm/adams.html (the Public Electronic Reading Room).
Sincerely,
/RA/

Silas R. Kennedy, Chief

Reactor Projects Branch 6
Division of Reactor Projects
Docket Nos.
License Nos.

50-219
DPR-16

Enclosure: Inspection Report 05000219/2014010

w/Attachment: Supplementary Information
cc w/encl: Distribution via ListServ

B. Hanson

of the malfunction of degraded equipment to cause a transient. To correct this root cause,
Exelon developed a single risk process to help decision makers better understand the risk
and consequences of malfunctions which cause plant transients.
The NRC has determined that completed or planned corrective actions were sufficient to
address the causes of the events that led to the white PI. In accordance with Inspection Manual
Chapter 0305, Operating Reactor Assessment Program, the Unplanned Scrams per 7000
Critical Hours performance indicator will continue to be considered as a White Action Matrix
input until the performance indicator has returned to the Green performance band. Any future
changes in Action Matrix column designation will be communicated via separate
correspondence.
One self-revealing finding of very low safety significance (Green) was identified. This finding did
not involve a violation of NRC requirements. If you disagree with the cross-cutting aspect or the
finding not associated with a regulatory requirement in this report, you should provide a
response within 30 days of the date of this inspection report, with the basis for your
disagreement, to the Regional Administrator, Region I; and the NRC Resident Inspector at
Oyster Creek.
In accordance with Title 10 Code of Federal Regulations 2.390 of the NRCs Rules of Practice,
a copy of this letter, its enclosure, and your response (if any) will be available electronically for
public inspection in the NRC Public Document Room or from the Publicly Available Records
(PARS) component of the NRCs Agencywide Documents Access Management System
(ADAMS). ADAMS is accessible from the NRC website at http://www.nrc.gov/reading
rm/adams.html (the Public Electronic Reading Room).
Sincerely,
/RA/
Silas R. Kennedy, Chief
Reactor Projects Branch 6
Division of Reactor Projects
Docket Nos.
License Nos.

50-219
DPR-16

Enclosure: Inspection Report 05000219/2014010

w/Attachment: Supplementary Information
cc w/encl: Distribution via ListServ
Distribution w/encl: (via email)
D. Dorman, RA
D. Lew, DRA
H. Nieh, DRP
M. Scott, DRP
R. Lorsen, DRS
J. Trapp, DRS
S. Kennedy, DRP
R. Powell, DRP

K. MorganButler, RI OEDO
C. Bickett, DRP
S. Haney, DRP, RI
A. Dugandzic, DRP
C. Roettgen, DRP
B. Bollinger, DRP
J. Kulp, DRP, SRI
A. Patel, DRP, RI
J. DeVries, DRP, OA

T. Setzer, DRP
RidsNrrPMOysterCreek Resource
RidsNrrDorlLpl1-2 Resource
ROPReports Resource
N. McNamara, SLO
D. Tifft, SLO
D. Screnci, PAO
N. Sheehan, PAO

DOCUMENT NAME: G:\DRP\BRANCH6\+++Oyster Creek\OC 95001 Unplanned Scrams 2014\OC 95001 2014010 final.docx

ADAMS Accession No.

ML15020A632

SUNSI Review

OFFICE
NAME
DATE

RI/DRP
TSetzer/ TCS
01/08/15

Non-Sensitive
Sensitive

RI/DRP
RI/DRP
CBickett/ CAB
SKennedy/ SRK
01/08/15
01/20/15
OFFICIAL RECORD COPY

Publicly Available
Non-Publicly Available

1
U.S. NUCLEAR REGULATORY COMMISSION
REGION I

Docket No:

50-219

License No:

DPR-16

Report No:

05000219/2014010

Licensee:

Exelon Generation Company, LLC

Facility:

Oyster Creek Nuclear Generating Station

Location:

Forked River, NJ

Dates:

December 8 through 11, 2014

Inspectors:

Thomas Setzer, Senior Project Engineer, Team Leader

Sherlyn Haney, Hope Creek Resident Inspector

Approved by:

Silas R. Kennedy, Chief

Reactor Projects Branch 6
Division of Reactor Projects

Enclosure

2
SUMMARY
IR 05000219/2014010; 12/8/2014 12/11/2014; Oyster Creek Nuclear Generating Station;
Supplemental Inspection Inspection Procedure (IP) 95001
A regional Senior Project Engineer and a Resident Inspector from the Division of Reactor
Projects, Region I, performed this inspection. No significant weaknesses were identified in
this report. One self-revealing finding of very low safety significance (Green) was identified.
The significance of most findings is indicated by their color (i.e., greater than Green, or Green,
White, Yellow, Red) and determined using Inspection Manual Chapter (IMC) 0609, Significance
Determination Process (SDP), dated June 2, 2011. Cross-cutting aspects are determined
using IMC 0310, Aspects Within the Cross-Cutting Areas, dated December 4, 2014. The
NRCs program for overseeing the safe operation of commercial nuclear power reactors is
described in NUREG-1649, Reactor Oversight Process, Revision 5.
Inspection Procedure 95001, "Supplemental Inspection for One or Two White Inputs in a
Strategic Performance Area.
The NRC performed this supplemental inspection in accordance with NRC inspection procedure
95001, Supplemental Inspection for One of Two White Inputs in a Strategic Performance Area,
to assess Exelons evaluation associated with the Initiating Events performance indicator (PI) for
Unplanned Scrams per 7000 Critical Hours. This PI crossed the green-to-white threshold
(value > 3.0) on July 11, 2014, when Oyster Creek experienced its fourth reactor scram in the
previous ten months of operation.
Based on the results of the inspection, the inspectors concluded that Exelon had adequately
performed a root cause evaluation (RCE) or apparent cause evaluation (ACE) for each event,
and a RCE collectively for the four events. The NRC has determined that completed or planned
corrective actions were sufficient to address the causes of the events that led to the white PI.
Cornerstone: Initiating Events

Green. A self-revealing finding (FIN) of very low safety significance was identified for
Exelons failure to implement the temporary configuration change program when a
temporary repair was performed on condenser bellows expansion joint Y-1-26. The
temporary repair impacted the design function of Y-1-26 and led to failure of the
downstream side of the bellows, causing a loss of condenser vacuum and manual
reactor scram on July 11, 2014. Exelon replaced both the expansion joint Y-1-26 and
the 2nd stage reheater steam supply relief valve V-1-132 on July 11, 2014, during forced
outage 1F35. Exelon entered this issue into the corrective action program (IR 2422831).
This finding was more than minor because it was associated with the Design Control
attribute of the Initiating Events cornerstone, and adversely affected the cornerstone
objective to limit the likelihood of events that upset plant stability and challenge critical
safety functions during shutdown as well as power operations. The inspectors
determined that this finding was of very low safety significance (Green) using Exhibit 1 of
NRC IMC 0609, Appendix A, The Significance Determination Process (SDP) for
Findings At-Power, dated June 19, 2012, because the finding did not cause both a
reactor trip and the loss of mitigation equipment relied upon to transition the plant from
the onset of the trip to a stable shutdown condition (e.g. loss of condenser, loss of feed
water). The inspectors determined that this finding had a cross-cutting aspect in the

Enclosure

3
area of Problem Identification and Resolution, Operating Experience, because Exelon
did not systematically and effectively evaluate relevant internal operating experience
related to a similar condenser bellows expansion joint failure in 1986. [P.5] (Section
4OA3)

Enclosure

4
REPORT DETAILS

4.

OTHER ACTIVITIES

4OA3 Follow-Up of Events and Notices of Enforcement Discretion (71153 2 samples)

.1

(Closed) Licensee Event Report (LER) 05000219/2013-004-00: Manual Scram due to

Rise in Reactor Pressure during Turbine Valve Testing
On December 14, 2013, operators initiated a manual reactor scram due to reactor
pressure control abnormalities during quarterly turbine valve testing with reactor power
at 95 percent of rated thermal power. Turbine control valves 2 and 3 failed closed when
the servo motor feedback support bracket bolts loosened, then detached, from their
supports. Also, a vertical connection to transmit the required turbine bypass valve relay
position from the turbine front standard to the bypass valve assembly had become
detached. This condition is reportable under Title 10 of the Code of Federal Regulations
(10 CFR) 50.73(a)(2)(iv)(A) as an event that resulted in a manual actuation of the reactor
protection system.
A RCE was performed to evaluate the equipment failures and determined the root
cause was the original equipment manufacturer during manufacture did not follow their
assembly drawings and installed inappropriate locking mechanisms (split washers)
instead of the assembly drawing required parts (lock plates). The corrective action
restored the turbine control valve servo motor feedback support brackets to original
assembly design by installing lock plate securing mechanisms.
The inspectors performed an in-depth review of this LER and Exelons RCE, supporting
documentation, station procedures, and interviewed members of station staff and
management regarding the event. No issues were identified during this review. This
LER is closed.

.2

(Closed) LER 05000219/2014-001-00: Manual Scram due to Lowering Vacuum

a.

Inspection Scope
On July 11, 2014, during planned reactor power ascension with reactor power at
approximately 56 percent of rated thermal power, operators initiated a manual reactor
scram upon receiving indications of degrading main condenser vacuum. The apparent
cause of the event was determined to be failure of the downstream bellows of the 'B'
Condenser Steam Inlet Expansion Joint due to fatigue loading. On October 6, 2013, the
upstream bellows was repaired due to a circumferential fracture. The upstream fracture
in the bellows was repaired with standard fiberglass wraps, high temperature carbon
fiber wraps, and the application of Belzona. Repeated wrapping of the upstream side of
the bellows most likely restricted the allowable movements of that bellows, requiring the
downstream bellows to account for the additional movement. Additionally, in July 2014,
a reheater relief valve (V-1-132) upstream of the bellows was confirmed to be leaking
past its seat. The combination of the leak-by of the relief valve with the restricted
movement of the bellows created increased fatigue stresses on the downstream bellows.

Enclosure

5
This condition is reportable under 10 CFR 50.73(a)(2)(iv)(A) as an event that resulted in
a manual actuation of the reactor protection system. The inspectors reviewed Exelons
apparent cause analysis, supporting documentation, station procedures, and interviewed
members of station staff and management regarding the event. A self-revealing finding
of very low safety significance (Green) was identified and is discussed below. This LER
is closed.
b. Findings
Introduction. A self-revealing finding of very low safety significance (Green) was
identified for Exelons failure to implement the temporary configuration change program
when a temporary repair was performed on condenser bellows expansion joint Y-1-26.
The temporary repair impacted the design function of Y-1-26 and led to failure of the
downstream side of the bellows, causing a loss of condenser vacuum and manual
reactor scram on July 11, 2014.
Description. On October 6, 2013, Oyster Creek operators entered abnormal operating
procedure (ABN)-14 due to degrading condenser vacuum. A manual scram was later
performed when condenser vacuum degraded below 23 Hg. Following the scram,
operations and maintenance personnel identified an approximate 1 hole on the
upstream side of Y-1-26, B Condenser Steam Inlet Bellows Expansion Joint. The
function of Y-1-26 is to provide a flexible pressure retaining connection to absorb motion
in a system caused by thermal expansion and low levels of vibration. Y-1-26 is a
universal type expansion joint which contains two bellows in series separated by a pipe
spool and tie rods designed to contain the pressure thrust force.
Evaluation of the 1 hole in the upstream side bellows indicated that the failure was most
likely due to fatigue cracking. An indentation at the fracture site also suggested an
impact had occurred, possibly during a past maintenance outage. A condenser
waterbox preventive maintenance inspection task was completed in October 2012 during
refueling outage 1R24, during which an accidental impact from a tool or scaffold pole
may have occurred.
Rather than replace the bellows, Exelon decided on October 7, 2013, to perform a
temporary repair by wrapping the bellows circumferentially with fiberglass and then
applying Belzona, a type of industrial coating. After the temporary repair was completed,
the plant was restarted. Between October 7, 2013, and July 9, 2014, the bellows repair
was rewrapped a total of five times. The repeated wrapping of the bellows stiffened and
restricted the normal design movement of the bellows, and as a result, transferred
higher fatigue loading and stresses to the downstream bellows.
On November 17, 2013, operators identified leak-by of 2nd stage reheater steam supply
relief valve V-1-132. Steam from V-1-132 ports directly to the B main condenser and
passes through the Y-1-26 condenser bellows expansion joint. Recognizing the
challenge to the integrity of the temporary leak repair caused by this leak-by, system
engineers scheduled the replacement of V-1-132 in the next forced outage. On July 11,
2014, the combination of the V-1-132 leak-by and higher stresses caused by the
temporary leak repair wrapping led to a failure of the downstream bellows, a loss of
condenser vacuum, and subsequent manual reactor scram. Exelon replaced both the
expansion joint Y-1-26 and the 2nd stage reheater steam supply relief valve V-1-132 on

Enclosure

6
July 11, 2014, during forced outage 1F35. Exelon entered this issue into the corrective
action program (IR 2422831).
Exelon procedure CC-AA-112, Temporary Configuration Changes, describes a
configuration change as a change to the form, fit, or function of any structure, system
or component (SSC). If a temporary installation or alteration of an SSC is performed
to allow for continued operation, then a temporary configuration change package is
required. By wrapping the bellows with fiberglass and Belzona, Exelon performed a
modification to the expansion joint. Specifically, the function of the expansion joint was
modified when the temporary leak repair was applied, which restricted the normal design
movement of the expansion joint and contributed to its failure on July 11, 2014.
In December 1986, Oyster Creek experienced a similar event (LER 86-034-01) when
a manual scram occurred due to the lifting of V-1-132, which resulted in a failure of the
Y-1-26 bellows expansion joint. Operating experience from this event should have
prompted the station to consider taking immediate corrective actions on V-1-132 and/or
Y-1-26 before a bellows failure, but this operating experience was not fully considered in
the sites decision making.
Analysis. The inspectors determined that Exelons failure to evaluate the temporary
repair in accordance with station procedure CC-AA-112, Temporary Configuration
Changes, was a performance deficiency that was within Exelons ability to foresee and
correct, and should have been prevented. This finding was more than minor because it
was associated with the Design Control attribute of the Initiating Events cornerstone, and
adversely affected the cornerstone objective to limit the likelihood of events that upset
plant stability and challenge critical safety functions during shutdown as well as power
operations. Specifically, the higher stresses caused by the temporary leak repair caused
a failure of the bellows and led to a manual reactor scram. The inspectors determined
that this finding was of very low safety significance (Green) using Exhibit 1 of NRC IMC
0609, Appendix A, The Significance Determination Process (SDP) for Findings AtPower, dated June 19, 2012, because the finding did not cause both a reactor trip and
the loss of mitigation equipment relied upon to transition the plant from the onset of the
trip to a stable shutdown condition (e.g. loss of condenser, loss of feed water). The
inspectors determined that this finding had a cross-cutting aspect in the area of Problem
Identification and Resolution, Operating Experience, because Exelon did not
systematically and effectively evaluate relevant internal operating experience related to
a similar condenser bellows expansion joint failure in 1986. [P.5]
Enforcement. This finding does not involve enforcement action because no violation of a
regulatory requirement was identified. Because this finding does not involve a violation
and is of very low safety significance (Green), it is identified as a FIN. (FIN
05000219/2014010-01, Failure to Evaluate a Temporary Configuration Change)
4OA4 Supplemental Inspection (IP 95001)
.1

Inspection Scope
The NRC conducted this supplemental inspection in accordance with IP 95001,
Supplemental Inspection for One or Two White Inputs in a Strategic Performance Area,
to assess Exelons evaluations associated with a white Initiating Events cornerstone PI
reported in the third quarter of 2014. The objectives of this supplemental inspection
were to:

Enclosure

Provide assurance that the root and contributing causes of risk-significant issues
were understood;
Provide assurance that the extent of condition and extent of cause of risk-significant
issues were identified; and
Provide assurance that corrective actions for risk-significant issues were sufficient to
address the root and contributing causes and to preclude repetition.

The following four reactor scrams contributed to the white PI:

On October 3, 2013, at 0643 hours, an automatic reactor scram occurred during a

plant startup from maintenance outage 1M30. The scram was caused by both
Reactor Protection Systems channels receiving simultaneous intermediate range
monitor (IRM) Hi-Hi signals on IRM channels 12, 13, 14, 17, and 18. All IRMs began
behaving erratically at the same time, cycling between Hi-Hi and downscale, due to
noise susceptibility of the IRM channels (Issue Report (IR) 1567196).

On October 6, 2013, during reactor startup from maintenance outage 1M30, main
condenser vacuum began to significantly degrade and resulted in a manual
reactor scram. The source of the condenser vacuum degradation was a hole of
approximately one inch in diameter on the B condenser steam inlet expansion
joint (Y-1-26) on the south side of B condenser. Inadequate protection of the
bellows led to fracture by fatigue cracking or stress corrosion cracking (IR 1568503).

On December 14, 2013, Oyster Creek initiated a manual reactor scram due to an
uncontrolled reactor pressure rise. Troubleshooting identified that turbine control
valve 2 and 3 servo motor feedback lever brackets had become loose, then
detached, from their supports. A vertical connection to transmit the required turbine
bypass valve position from the turbine front standard to the bypass valve assembly
had also detached. The original equipment manufacturer did not follow their
assembly drawings during manufacturing and installed inappropriate locking
mechanisms (split washers) instead of the assembly drawing required parts (lock
plates) (IR 1597041).

On July 11, 2014, during reactor start up from forced outage 1F34, Abnormal
Procedure (ABN) ABN-14, Loss of Condenser Vacuum, was entered due to rapidly
degrading condenser vacuum. Reactor power was lowered in an attempt to stabilize
plant conditions. ABN-1, Reactor Scram, was subsequently entered and a manual
reactor scram was performed when condenser vacuum degraded to 23.5" Hg. The
Y-1-26 expansion joint downstream bellows had failed due to fatigue cracking
caused by high stress on the downstream bellows from rigidity of the repeated
temporary leak repairs on the upstream bellows and steam leak-by from V-1-132
(IR 1680755).

Enclosure

8
The Unplanned Scrams per 7000 Critical Hours PI is based on the number of unplanned
scrams that are experienced by a unit within the previous 7000 critical hours of reactor
operation as measured on a 12-month periodicity. During a time-frame spanning
approximately ten months, from October to July 2014, Oyster Creek experienced four
reactor scrams. This resulted in plant performance crossing the green-to-white PI
threshold value of greater than three unplanned scrams per 7000 critical hours. As a
result, Exelon entered the Regulatory Response Column of the NRCs Action Matrix in
the third quarter of 2014.
Exelon informed the NRC staff on November 5, 2014, that they were ready for the
supplemental inspection. The inspectors reviewed Exelons collective RCE for the four
scrams (IR 1687264), the causal evaluations conducted for each reactor scram (IRs
listed above), and a focused self-assessment completed by Exelon as a readiness
review for the NRC supplemental inspection. The inspectors reviewed corrective actions
that were taken and planned to address the identified causes. The inspectors also held
discussions with Exelon personnel to ensure that the root and contributing causes and
the contribution of safety culture components were understood and corrective actions
taken or planned were appropriate to address the causes and preclude repetition.
.2
2.01

Evaluation of the Inspection Requirements

Problem Identification
a. As directed by IP 95001, determine that the evaluation documented who identified the
issue (i.e., licensee-identified, self-revealing, or NRC-identified) and under what
conditions the issue was identified.
Between October 3, 2013 and July 11, 2014, the Oyster Creek reactor scrammed four
times. This resulted in Oyster Creek crossing the green-to-white PI threshold value of
greater than three unplanned scrams per 7000 critical hours during the third quarter of
2014. This was properly reported by Exelon to the NRC during the third quarter 2014
NRC PI submittal, which indicated the Unplanned Scrams per 7000 Critical Hours PI
as white. Since the PI was characterized and reported properly via the licensees PI
reporting process, the white PI is considered licensee-identified.
Overall, the inspectors determined that Exelons evaluation of the issue adequately
documents the identification of the issue and the conditions under which the issue was
identified. A timely RCE or ACE was conducted for each individual reactor scram event.
Additionally, a collective RCE for the four scrams to identify common causes among the
four events was performed.
b. As directed by IP 95001, determine that the evaluation documented how long the issue
existed and prior opportunities for identification.
The Oyster Creek PI for Unplanned Scrams per 7000 Critical Hours crossed the greento-white threshold value following the July 11, 2014, manual scram, and was properly
reported to the NRC via the third quarter 2014 PI submittal. The inspectors determined
that Exelons evaluation of the issue adequately documented how long the issue existed
(since the first scram in October 3, 2013) and prior opportunities for identification.

Enclosure

9
c. As directed by IP 95001, determine that the licensees evaluation documents the plant
specific risk consequences, as applicable, and compliance concerns associated with the
issue(s).
In their collective root cause report (IR 1680755), the inspectors noted that Exelon
assessed the risk consequences from four scrams over one year and concluded that the
increase in core damage frequency to be approximately 1.3E-6. The December 14,
2013 scram was determined to be complicated due to the failure of the bypass system
and required operators to maintain reactor pressure control using the isolation
condensers in accordance with emergency operating procedures. Since the PI program
is a voluntarily industry initiative to provide a quantitative measure of a plants
performance to be considered in the Reactor Oversight Process vice a regulatory
requirement, there are no compliance concerns for the white PI. For the individual
scrams, performance deficiencies were identified and a finding of very low safety
significance (Green) was documented for the October 3, 2013 reactor scram in NRC
Inspection Report 05000219/2014002 and for the July 11, 2014 reactor scram in Section
4OA3 of this report. As documented in the respective inspection reports, corrective
actions were planned or completed to restore compliance. The team reviewed these
corrective actions as discussed in Section 2.03.
Overall, the inspectors determined that Exelons evaluation of the issue adequately
documented the plant specific risk consequences, as applicable, and compliance
concerns associated with the issue.
d. Findings
No findings were identified.
2.02

Root Cause, Extent of Condition, and Extent of Cause Evaluation

a. As directed by IP 95001, determine that the licensee evaluated the issue using a
systematic methodology to identify the root and contributing causes.
The inspectors verified that Exelon staff implemented PI-AA-125-1001, Root Cause
Analysis Manual, in the conduct of the stations cause analysis to identify the root and
contributing causes. The station utilized a variety of causal analysis methods listed in
PI-AA-125-1006, Investigation Techniques Manual, to analyze the four scrams; which
included Event and Causal Factor Charts, Failure Analysis, Taproot Analysis and Barrier
Analysis. The inspectors noted these techniques were supported by data gathering via
interviews and document reviews.
The root and apparent causes for the five cause evaluations performed by Exelon are
summarized below.
IRM Erratic Behavior Causes Automatic Reactor Scram (IR 1567196)
The root cause of the event was determined to be susceptibility of the IRM channels to
electrical noise due to low shield to ground resistance. Contributing to the event was an
internal fault on the 22 SRM which caused significant noise coupling to occur on the
SRM. Exelon determined moisture intrusion into the cabling contributed to the
degradation of the IRM ground resistance.

Enclosure

10
Condenser Expansion Bellows (Y-1-26) Hole and Fracture (IR 1568503)
The apparent cause of the bellows failure was impact damage due to inadequate
protection of the bellows led to fracture by fatigue cracking or stress corrosion cracking.
Contributing to the problem is that the expansion bellows inspection preventive
maintenance does not provide guidance for visual inspection of surface defects and
corrosion.
Turbine Control System to Control Reactor Pressure (IR 1597041)
The root cause determined the original equipment manufacturer (circa 1965) did not
follow their assembly drawings during manufacture and installed inappropriate locking
mechanisms (split washers) instead of the assembly drawing required parts (lock
plates).
Condenser Expansion Bellows (Y-1-26) Failure (IR1680755)
The apparent cause of the event was determined to be failure of the downstream side of
condenser bellows Y-1-26 due to fatigue loading. A previous temporary leak repair on
the upstream side caused the expansion joint to be restricted and unable to account for
loading during plant operation. This failure was accelerated by ongoing leak-by of the
steam supply relief valve for the 2nd stage reheater V-1-132.
White NRC PI for Unplanned Scrams per 7000 Critical Hours (IR 1687264)
The root cause was determined to be decision makers do not always understand the
likelihood or consequence of the malfunction of degraded equipment to cause a
transient. Contributing to the problem is that internal operating experience is not utilized
to determine the likelihood and/or consequence of the malfunction of degraded
equipment to cause a transient.
b. As directed by IP 95001, determine that the licensees root cause evaluation was
conducted to a level of detail commensurate with the significance of the issue.
The inspectors concluded that Exelons root cause and apparent cause teams
appropriately implemented their procedures and processes to determine the
appropriate causal factors in each of the four reactor scram events. Overall, the
inspectors determined that Exelons root cause and apparent cause evaluations were
conducted to a level of detail commensurate with the significance of the issues.
c. As directed by IP 95001, determine that the licensees root cause evaluation included a
consideration of prior occurrences of the issue and knowledge of operating experience
(OE).
As required by Exelon procedures, Exelons root cause and apparent cause teams
reviewed OE from multiple sources including the Exelon fleet corrective action program
and the Oyster Creek corrective action process. Additionally, relevant NRC generic
communications were incorporated. In each of the four reactor scram events, Exelons
root and apparent cause teams identified several internal and external OE items that
were relevant to the stations experience. Exelon used that information to inform the root
cause and apparent cause process and corrective actions.

Enclosure

11
The inspectors determined that, in general, Exelons root cause team appropriately
considered relevant OE to inform their investigations and causal determination process.
However, in one instance, the inspectors identified that Exelon did not incorporate
lessons learned from a 1986 Oyster Creek event when condenser bellows Y-1-26 had
failed after V-1-132 began to leak by. Recommendations from the 1986 event to protect
the bellows from the introduction or intrusion of seawater during maintenance activities
were never incorporated into the site preventive maintenance program. The failure to
incorporate the OE was determined not to be a violation of NRC requirements. Exelon
entered this issue into their corrective action program (IR 2422831).
d. As directed by IP 95001, determine that the licensees root cause evaluation addresses
the extent of condition and extent of cause of the issue.
Exelon completed individual cause evaluations for each of the four reactor scrams.
Additionally, Exelon performed a common root cause evaluation that considered the
collective impact of the four reactor scrams that occurred from October 2013 to
November 2014.
The team concluded that adequate extent of cause and extent of condition reviews
were conducted for each individual reactor scram event as part of their root cause and
apparent cause evaluations. Additionally, Exelon also conducted a programmatic and
organizational factors review to identify latent organization weaknesses in each of the
four reactor scram events. Overall, the inspectors determined that Exelons root cause
and apparent cause evaluations addressed the extent of condition and extent of cause
of the issue.
e. As directed by IP 95001, determine that the licensees root cause, extent of condition,
and extent of cause evaluations appropriately considered the safety culture components
as described in IMC 0305.
Exelons root cause manual requires a safety culture review for root cause evaluations.
Exelon conducted the safety culture reviews in accordance with PI-AA-125-1006,
Investigation Techniques Manual, Attachment 17. Apparent cause evaluations are not
required to have a safety culture review.
Exelon safety culture reviews evaluated the 13 safety culture components in NRC
Regulatory Issues Summary 2006-13 and as described in IMC 0310, Components
Within the Cross-Cutting Areas. The root cause teams appropriately identified station
performance gaps with respect to aspects of human performance, decision-making, and
corrective action program prior opportunities for identification during its review. Exelon
developed corrective actions commensurate to the identified performance gaps to
prevent recurrence.
Overall, the inspectors determined that Exelons root cause report included a proper
consideration of whether the root cause, extent of condition, and extent of cause
evaluations appropriately considered the safety culture components.
f.

Findings
No findings were identified.

Enclosure

12
2.03

Corrective Actions

a. As directed by IP 95001, determine that (1) the licensee specified appropriate corrective
actions for each root and/or contributing cause, or (2) an evaluation that states no
actions are necessary is adequate.
The root cause, apparent cause, and collective root cause reports identified appropriate
corrective actions to address the root, contributing, and common causes for the
individual reactor scrams and collective performance issues. The inspectors determined
that corrective actions for the reactor scrams and common cause evaluation were
reasonable, with specific actions to address the personnel, procedural, and equipment
issues associated with the white PI and its associated individual reactor scram inputs.
b. As directed by IP 95001, determine that the licensee prioritized corrective actions with
consideration of risk significance and regulatory compliance.
The inspectors noted that immediate corrective actions for each of the reactor scrams
were performed in a timely manner to support plant restart. Longer term actions were
scheduled in an appropriate time frame. Overall the inspectors determined that the
corrective actions were prioritized commensurate with their significance.
c. As directed by IP 95001, determine that the licensee established a schedule for
implementing and completing the corrective actions.
Corrective actions to prevent recurrence, as well as a significant number of lower-tier
corrective and preventive actions, identified in the root cause and apparent cause
evaluations had been completed at the time of this inspection.
A change management plan for implementing a site wide risk process (Exelon procedure
AD-AA-3000) was still open at the time of this inspection. This change management
plan was nearly complete with only a few remaining procedures to be revised. The
inspectors met with the responsible manager of the change management plan and
determined that the remaining procedure revisions would be complete by the end of
2014. The inspectors determined that the due dates for the open actions were
reasonable.
d. As directed by IP 95001, determine that the licensee developed quantitative and/or
qualitative measures of success for determining the effectiveness of the corrective
actions to preclude repetition.
Effectiveness reviews for the root and apparent cause evaluations were assigned but
not completed at the time of the inspection. The inspectors verified that the due dates
for these effectiveness reviews were reasonable. However, the inspectors identified one
instance in which an effectiveness review was not assigned or completed. Exelon did
not assign an effectiveness review for the apparent cause evaluation associated with the
July 11, 2014 reactor scram. Exelon procedure PI-AA-125-1003, Apparent Cause
Evaluation Manual, requires an effectiveness review be completed for all significance
level 1 and 2 apparent cause evaluations; however, one was not completed for the
July 11, 2014 event. The inspectors determined that this was a performance deficiency
but screened it as minor since the corrective actions taken to date to correct the
condenser bellows and second stage reheater valve have proven to be effective and

Enclosure

13
have not resulted in any further plant transients. Exelon entered this issue into the
corrective action program (IR 2423191).
e. As directed by IP 95001, determine that the licensees planned or taken corrective
actions adequately address the Notice of Violation (NOV) that was the basis for the
supplemental inspection, if applicable.
The NRC staff did not issue an NOV to the licensee; therefore, this inspection
requirement was not applicable.
f.

Findings
No findings were identified.

2.04

Evaluation of IMC 0305 Criteria for Treatment of Old Design Issues

The inspectors determined this issue did not meet the IMC 0305 criteria for treatment as
an old design issue.

4OA6

Exit Meeting
On December 11, 2014, the inspectors presented the inspection results to Mr. J. Dostal,
Plant Manager, and other members of his staff. The inspectors asked Exelon if any of
the material examined during the inspection should be considered proprietary. Exelon
did not identify any proprietary information.
Regulatory Performance Meeting
Following the December 11, 2014 exit meeting, the NRC discussed with Exelon its
performance at Oyster Creek in accordance with IMC 0305, Section 10.01.a. The
meeting was attended by the Region I Division of Reactor Projects, Projects Branch 6,
Branch Chief, NRC inspectors, the Oyster Creek Plant Manager, and other Exelon staff.
During this meeting, the NRC and Exelon discussed the issues related to the white PI
for unplanned scrams that resulted in Oyster Creek being placed in the Regulatory
Response Column of the Action Matrix. This discussion included the causes, corrective
actions, extent of condition and extent of cause for the issues identified as a result of the
white PI.

ATTACHMENT: SUPPLEMENTARY INFORMATION

Enclosure

A-1
SUPPLEMENTARY INFORMATION
KEY POINTS OF CONTACT
Licensee Personnel
G. Stathes, Site Vice President
J. Dostal, Plant Manager
M. Arnao, Operations Services Manager
A. Bready, Site Risk Analyst
J. Clark, Engineering Programs Manager
F. Jordan, Risk Classification Manager
M. McKenna, Licensing Manager
W. Saraceno, ERT Branch Manager
R. Smith, NSSS Branch Manager
LIST OF ITEMS OPENED, CLOSED, DISCUSSED, AND UPDATED
Opened/Closed
05000219/2014010-01

FIN

Failure to Evaluate a Temporary Configuration

Change (Section 4OA3)

Closed
05000219/2013-004-00

LER

Manual Scram due to Rise in Reactor Pressure

during Turbine Valve Testing (Section 4OA3)

05000219/2014-001-00

LER

Manual Scram due to Lowering Vacuum (Section

4OA3)

LIST OF DOCUMENTS REVIEWED

Condition Reports
1567196
1568503
1597041
1597572
1605893
1680755
1681201
1687264
2385412
2390842
2400821
2400831
2422831*
2423121*
2423191*
*Issued as a result of NRC inspection.

Attachment

A-2
Procedures
2400-GMM-3900.52, Inspection and Torquing of Bolted Connection, Revision 7
2400-SMM-3411.26, Turbine Control Valve Hydraulic Enclosure, Revision 9
AD-AA-3000, Nuclear Risk Management Process, Revision 0
CC-AA-102, Design Input and Configuration Change Impact Screening, Revision 28
CC-AA-103, Configuration Change Control for Permanent Physical Plant Changes, Revision 25
CC-AA-103-1003, Owner's Acceptance Review of External Technical Products, Revision 11
CC-AA-106-1001, Configuration Change Walkdowns, Revision 5
CC-AA-103-1001, Configuration Change Control Guidance, Revision 5
CC-AA-107-1001, Post Modification Acceptance Testing, Revision 5
CC-MA-102-1001, Design Inputs and Impact Screening - Implementation, Revision 11
CC-AA-112, Temporary Configuration Changes, Revision 20
CC-AA-404, Maintenance Specification: Application Selection, Evaluation and Control of
Temporary Leak Repairs, Revision 8
ER-AA-200, Preventive Maintenance Program, Revision 0
ER-AA-600-1015, FPIE PRA Model Update, Revision 17
LS-AA-125-1001, Root Cause Analysis Manual, Revision 10
LS-AA-125-1003, Apparent Cause Evaluation Manual, Revision 10
PI-AA-125-1006, Investigation Techniques Manual, Revision 0
PI-AA-125-1003, Apparent Cause Evaluation Manual, Revision 1
PI-AA-125-1001, Root Cause Analysis Manual, Revision 0
PI-AA-120, Issue Identification and Screening Process, Revision 1
PI-AA-125, Corrective Action Program Procedure, Revision 0
PI-AA-125-1001, Root Cause Analysis Manual, Revision 0
PI-AA-125-1003, Apparent Cause Evaluation Manual, Revision 1
PI-AA-125-1004, Effectiveness Review Manual, Revision 0
Work Orders
A2319608
A2339472
A2369271
C2031016
Miscellaneous
Exelon PowerLabs Failure Analysis of Condenser 1-B Steam Inlet Expansion Joint, dated
September 15, 2014, project number OYS-32061
OC-MD83-03, Management Directive 8.3 Event Analysis for the Oyster Creek Manual Scram,
dated December 17, 2013
OC-MD83-03, Management Directive 8.3 Event Analysis for the Oyster Creek Loss of
Condenser Vacuum Scram, dated July 11 2014
LER 86-034-01, event date 12/29/86
LER 2013-004-00: Manual Scram due to Rise in Reactor Pressure during Turbine Valve Testing
LER 2014-001-00: Manual Scram due to Lowering Vacuum
Focused Area Self-Assessment (2385412) Pre-NRC Supplemental Inspection 95001
SCRF 1R24-758
Supply Order 057730
Supply Order 055045

Attachment

A-3
LIST OF ACRONYMS USED
ACE
ADAMS
CFR
DRP
IMC
IP
IR
IRM
LER
NOV
NRC
OC
OE
PARS
PI
RCE
RI
SDP
SSC

Apparent Cause Evaluation

Agencywide Document Access Management System
Code of Federal Regulations
Division of Reactor Projects
Inspection Manual Chapter
Inspection Procedure
Issue Report
Intermediate Range Monitor
Licensee Event Report
Notice of Violation
Nuclear Regulatory Commission
Oyster Creek
Operating Experience
Publicly Available Records System
Performance Indicator
Root Cause Evaluation
Resident Inspector
Significance Determination Process
Structure, System, or Component

Attachment