La Crosse Boiling Water Reactor - Results of Root Cause ... · "Since we no longer leave either of...

LA CROSSE BOILING WATER.'REACTOR (LACBWR)

DAIRYLAND POWERCOOPERATIVE

December 15, 2011

In reply, please refer to LAC-14205

DOCKET NO. 50-409

Document Control DeskU.S. Nuclear Regulatory CommissionWashington, DC 20555-0001

Dear Sir or Madam:

SUBJECT:

REFERENCE:

Dairyland Power Cooperative (DPC)La Crosse Boiling Water Reactor (LACBWR)Possession-Only License No. DPR-45Results of Root Cause Analysis Performed for Non-Compliance with ODCMRequirement

(1) LACBWR Offsite Dose Calculation Manual, Rev. 11, December 2008 andreviewed with no changes December 2010

(2) Letter LAC-14191, DPC to NRC, "Non-Compliance with Offsite DoseCalculation Manual (ODCM) Requirement," October 7, 2011

(3) Root Cause Analysis Report--CAR 2011-137, December 14, 2011

On September 9, 2011, DPC determined that the plant's ventilation configuration was not in compliancewith LACBWR ODCM Section 3.3.1 which requires particulate filtration of Reactor Building exhaust air.DPC reported the condition to the NRC in accordance with the same ODCM requirement by letter ofReference 2.

DPC directed that a root cause analysis be prepared independently by Sargent & Lundy, LLC. Thisanalysis is contained in the report of Reference 3 and is included as an attachment to this letter.

Please contact Michael Brasel of my staff at 608-689-2331, if you have any questions or comments.

Sincerely,

Charles Sans Crainte, Vice President, Generation

CVS:MAB:jkl

A Touchstone Energy* Cooperative

La Crosse Boiling Water Reactor (LACBWR) * S4601 State Highway 35 * Genoa, WI 54632-8846 * 608-689-2331 e 608-689-4200 fax

Document Control Desk- LAC-14205

December 14, 2011

cc w/Attachment: John HickmanProject ManagerU.S. Nuclear Regulatory Commission

Mark Satorius .Regional Administrator, Region IIIU.S. Nuclear Regulatory Commission

Paul SchmidtManager, Radiation Protection SectionState:of.Wisconsin

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Dairyland Power CooperativeLACBWR Reactor Building Ventilation RCA

December 14,2011Page I of 13

!t~~o~ Ca.~se A~aI~sls ftenot - CAR Np1 2011-137

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At the direcion of the Dairyland Power Cooperative (DPC) LACBWR Plant Manager, aformal root cause analysis (RCA) was initiated to detepmine the actions and events thatresulted in Reactor Building (RB) exhaust air not being filtered prior to discharge.

This independent internal investigation was conducted by qualified root cause analysisspecialist, Donald Felz, with Technical Support provided by John Rich and Jeff McRill.This report details the results of the analysis, including a description of the issue,4•elneates #0 event timein, addresses relevant r%41 tqr4nd program information,reportson review of past CARs, identifies the extent obfkondktoi6, identifies root causes,and provides reommndations to preclude repetition of this error. The results of thisanalysis have been discussed with the appropriate management peemonnel.

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On September 9, 2011, an error was identified that the air in the RB was not beingfiltered ipdor to discharge to reduce the amount of radioactive particulates being releasedto the environment, as reuired by Section 3.3.1 of the Offeite Dose Calculation Manual.

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An Event Timefine for this ircident is as follows:

1. Operator Log Vol. 87 indicated that the mainf rokx doors 11/30/95were unlocked and opened.

2. -1995 Shift Supervisor Log indicated that the main aidock 11/30/95door interlocks were overridden and both doors were open.

3. Ucense Amendment No. 69 relocated TechnicalSpecification (TS) 4/5.2.4, Ventilation System Exhaust, 4/11/97without change, to the Ofsfte Dose Calculation Manual byfollowing the guidance of Generic Letter 89-01.. __-. ....

4. LACBWR Operating Manual Change No. 1498 stated,"Since we no longer leave either of the RB airlock doorsshut, we should ensure a positive airflow through the RB tothe stack if the RB isolates'.

5. LACBWR Operating Manual ChangeNo. 1502 was initiatedto remove reference to RB integrity, test of RB integrity and 9/18/97requirements of RB integrity.

6. LACBWR Operating Manual Change No. 1498 was 1212/97__approved. //9

7. LACBWR Operating Manual Change No. 1502 was 12/30/97approved.

8. D-Plan was revised to describe the current condition that the 12.06M03__ RB ventilation exhaust fan was not continuously in

RCA - CAR No. 2011-137.doc

Dairyland Power Cooperative December 14,2011LACBWR Reactor Building Ventilation RCA Page 2 of 13

operation. If main aidock doors were open whilethe .exhaust fan was not in operation, unfiltered RB air would bedrawn through the open main airlock doors by action of thestack blowers and discharged from the stack. (Ref. LetterLAC-13823, dtated 12116103) 9CAR No. 2011-137 was initiated to !dn tl the ODOM

__ requirement for filtered RB exhaust was not being followyed.' _/9/1

Th6, foIllowingdocuments were rviWeod:

License No. OPR-45, Appendix A, Technical Specifications-Li.cense.o.PR-45,......-Decommslsioni• Plan . , ,.,Opergling Manual

R- Ventilation Operating Procod.eOperat Manual Change : ..

- Offite Dose CalcuWlon Manual (ODCM). Operator Logs- Shift Supervisor Logs

Corective Action Reports (CAlb)Si-acility Cho" -(FCs) for major RI openings'- Maintenance Re.uens (MR) -

-Operations Review ComMitteb (ORC) Meeting Minutes

- Annual Effluent Repofts- Generic Letter 89-01

4.1. L Mense No. DPR-45. AM&endix A.6Techical Speifications (TSb

A review of the current License Amendment No.,71 TS revealed that there are norequirements noted relative to RB ventilation system exhaust. The technicalrequirements for RA ventilatbon system exhaust were relocated from the TS to theODCM via Lcense Amendment No. 89.

Prior to License Amendment No. 69, TS Section 4.2.4, "RB Ventilation System Exhaust,"required that whenever the RB Ventilation outlet dampers are open, the RB exhaustshall be through particulate filters.

4.2. L No-,

Interview with the LAC1WR Ucensing epresentative and review of relative DPR-46Ucense Amendment records revealed the following:



License Amendment No. 6§ d&ted July 31. 1991

This amendment for issuing LACBWR's decommissioning order and approving theDecommissioning Plan, did not provide a mechanism to make changes to the facility,such as dismantlement of unused systems, without prior NRC approval. For this reason,DPC requested a revision to the decommissioning order. The NRC issued"Confirmatory Order Modifying NRC Order Authorizing Decommissioning of Facility,"dated September 15, 1994, permitting DPC to make changes to the facility as describedIn the Decommissioning Plan If the changes did not involve an unreviewed safetyquestion meeting three criteria that were later ontained4n the ACP-06.3 Form 2.

Under the ConfirmAory Order, dismantlement of LACOWR system accelerated. Duringthis period the practice of opening RB main airlock doors to facilitaftdismantlementactivities and the removal of large equipment began., This time frame Is verfied with theShift Supervisor and Operatqr Log entries of November 30, 1995, referenced in Sections4.8 and 4.9 of this report.

The final rule, =Decommissloning of Nuclear Power Reactors,0 was published in theFederal Register July 1998 (61 FR 39278, July 29, 1996). In the rule, the NRCestablished that licensees would be allowed to perform decommissioning activiltis thatmeet the criteria of 10 CFRP 50.59, as amended, to ensure that concerns specific todecommissioning were considered by the licensee.

LWentse Amedm~en t- fig0 aroEM Andlif 1997R

This amendment revle license condition 2- to establish 50.59 as applica toLACBWR. Importantly, this amendment also removed cpntainment integrityrequirements. In the Safety Evaluation Report (SER) discussing the deletion of TSdealing with leak testing and maintenance of containment integrity, the NRC stated:

'The worst fuel pool accident that could occur is the loss of all gap activity fromthe 333 spent fuel assemblies stored in the pool. As noted in the evaluation ofthe old Subsections 4/5.1 FUEL STORAGE AND HANDUNG. above, theconsequences of this accident were previously found acceptable by the staff. Inthat analysis it was assumed that the containment was not functional; therefore,the continued maintenance of the integrity of the containment to resist LOCAforces or the loss of all spent fuel gap activity is not required."

As documented in the Safety Analysis for Operating Manual Change No. 1502, initiatedSeptember 18, 1997, LACBWR staff interpreted the deletion of containment Integrityrequirements as meaning the function of the RB to mitigate the consequences of anycredible accident at LACBWR was no longer necessary. Since there was no longer arequired containment function and airborne particulate levels were insignificant to thepublic health and safety even under worst case accident conditions, the direction shiftedto maintaining monitoring capability of the exhaust from the facility at the stack releasepoint. This direction is evident in evaluations of changes from this time forward where itis repeatedly documented that changes did not adversely affect the monitoring pathwayor that the monitored path was maintained. This monitoring focus was in keeping with10 CFR 50, Appendix A, Criterion 64 which states:


Dalryland Power Cooperative December 14,2011LACBWR Reactor Suilding Ventilation RCA Page 4 of 13

"Monitorin radioactLvfty rlases. Means shall be provided for monitoring the

reactor containment atmosphere, spaces containing components for recirculationof loss-o-coolant accident fluids, effluent discharge paths, and the plant environsfor radioactviy that may be released from normal operations, includinganticipated operational occurrences, and from postulated accidents."

The NRC approved License Amendment No. 69 to relocate the requirements for RBVentilation System exhaust from the TS, without change, to the ODCM by following theguidance of NRC Generic Letter 89-01. The basis of the NRC approval was that theODCM is referenced in the Defueled Technical Specifications (DTS) Subsection 8.4.2.2,which requires the licensee to maintain the ODCM and provides the mechanism forchanges to the ODCM. TS Sectiof 4.2.4 that was moved to the ODCM stated thatwhenever the RB Ventilatioh outlet dampers am open, theiRB Ventilation Systemexhaust shall be through particulate filters. It should be noted that the ODCM hadalready been revised to incorporate TS Section 4.2.4 in ODCMRevision 4, dated March1998. ..

4.3. F!77-71717771 "T'

Section 5.2.29 of the D~Plan that was in place (Revision - October 1998) at the timeLicense Amwendmnt No. 69 was approved stated:

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'fThe:ReatorBuilding ventilation system utilizes'two 30-,on, 12,000Wdfm airconditioning units for drawing fresh air into the building and for circulating the'air.throughout the building. The air enters the Reactor Building through two 20-inchIsolation dampers in series, and is exhausted from the building by a centrifugalexhaust fan which has a capacity of 6000 cfm at 4 inches of water staticpressure. The exhaust fan discharges through two 20-inch isolation dampers in

-%seriestothetunnel. .... . r".. ,

A 20nch damper is also provided for recirculation of the exhaust fan dischargeair. The exhaust system is provided with conventional and high-efficiency filtersand with a gaseous and particulate radiation monitor system.

Under the above configurton the air could not be exhausted through the stack

unfiltered.

Section 52.29 of the current "-Plan (Revision - November 2010) states:

"The Reactor Building ventilation system utilizes two 30-ton, 12,000-cfm airconditioning units for drawing fresh air into the buiding and for circulating the airthroughout the building. Each air-conditioning unit air inlet is provided with a filterbox assembly, face and bypass dampers, and one 337,500-Btwuhr capacitysteam coil that are used when heating is required Air enters the building throughtwo series 20-inch dampers and is exhausted from the building by action of thestack blowers Additional exhaust flow is available using a centrifugal exhaustfan that has a capacity of 6000 cfn at 4 inches of water static pressure. Theexhaust fan and building exhaust air discharge through two series 20-inchdampers to the Reactor Building ventilation outlet plenum connected to thetunnel.



A 20-inch damper is also provided for recirculation of the exhaust fan dischargeair. The exhaust system is provided with conventional and high-efficiency filtersand with a gaseous and particulate radiation monitor system."

Under this configuration the air could be exhausted through the HEPA filters in the RB tothe stack or unfiltered through open main airlock doors through the turbine building tothe stack f the exhaust fan was not running. The above change was made to the D-Plan as part of the annual D-Plan update to the NRC (Letter LAC-1 3823, dated12/16/03) that, as stated in the submittal, was made to bet describe current conditions(i.e., exhaust fan not in continuous operation) but did not include discussion of the openmain airlock doors configuration. The 50.59 screen for the 2003 D-Plan Annual Revisiondid indicate review of ODCM Sections 3.3.4 and 3.5, but did not indicate review ofODCM Section 3.3.1, which required filtration from the RB prior to discharge.Additionally, the 50.59 procedure that was in effect when the review was pedormed(ACP-06.4, Issue 1, dated 4/21/03) did not specifically require the ODCM to bereviewed. It should be noted that the requirement to review the ODCM was added toACP-06.4 in lssue 4 (dated6112/08). •. -

1. The 50.59 screen for the 2003 D-Plan Annual.Revisiondid, not review oDCM Section3.3.1, which required ftration from theRa prior to dischlrge. The 50.59 procedure.that was in effect when the review was perfrmed (ACP-C6.4, Issue 1, dated 4/21/03)did not specifically require the ODCM to be reviewed.

2. The current revised 0-lan does not describe the main airock doors openconfiguration and the effects that configuration has on air efflnt from the RB beingfiltered prior to discharge out the stack.&. - .

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4.4.

LACBWR Operating Manual, Volume-V, Service System (Revision - February 2011),Section 10, "Heating, Ventilation, and-Air Conditioning Systems," does not address thecurrent main airlock doors open configuration.

Issu~es):

1. The LAC8WR Operating Manual, Volume V, Section 10 was not revised to

reflect the current conditions (i.e., RB main airlock doors might be open).

4.5. RB Ventilation OoeQRtlina Procedure

Procedure OP-87-02, "Operation of RB Bi-Parting Doos," was reviewed. The purposeof this procedure Is to provide instructions for operation of the RB bi-parting doors. Theprocedure addresses the need to establish conditions for adequate airflow into the RBfrom outside to prevent unmonitored release of air effluent- It does not address therequirements for filtration of air. Steps 3.1.1 through 3.1.8 establish the actions requiredto establish a path for airflow from the RB to the stack. Specifically, step 3.1.6 states



that both main airlock doors are to be open. The procedure does not identify the stepsfor returning the RB back to its normal condition.

A review of the 50.69 screen performed for Procedure OP-87-02 revealed that it did notaddress the need for the air to be filtered prior to discharge to the stack.

1. The 50.69 screen for Procedure OP-87-02 failed to recognize that the aireffluent from the RB was required to be filtered prior to discharge out thestack.

2. Procedute OP-87-02 does not identify the steps for returning the RBventilation back to its normal condition.

4.6. Operating ManuaI Chanes,

On July. 15, 1997, LACBWR Operating Manual Change No. 1498 was initiated. Thischange stated that since LACBWR does not leave either of the RB airlock doors shut,there isa need to ensure a posltive aklow through the RB to the stack if the RB isolates.The "Reason for Changes! section of the ACP-06.3 Form 2 acknowledges that the RBairlock door are no longer kept shut. This change was processed in accordance withACP-06.3, LACBWR Operating Manual Review (Rev. 16, dated 8/16/95), which requiredthat a Safety Analysis in Accordance with Decommissioning Plan and TechnicalSpecfications (ACP-06.3 Form 2) be performed. This change was approved onDecember 2, 1997 and incorporated into the LACBWR Operating Manual, Volume I,Integrated Plant Operations, Alarm C81, "Reactor Building Dampers Closed."

On September 18, 1997, LACBWR Operating Manual Change No. 1502 was initiated.This change *as Initiated to remove reference to RB integrity, test of RB integrity andrequirements of RB integrity. The stated need for the. change was that the ContainmentBuildingr Integrity was removed from the TS under License Amendment No. 69. Includedin the change was acknowledgement that the airlock doors mechanical interlock isnormally disabled to allow both doors to remain open. This change was processed Inaccordance with ACP-06.3, LACBWR Operating Manual Review (Rev. 16, dated8/16/95), which required that a Safety Analysis in Accordance with DecommissioningPlan and Technical Specifications (ACP-06.3 Form 2) be performed. This change wasapproved on December 30, 1997, and Incorporated into the LACBWR OperatingManual, Volume XI, Reactor Containment Building. "

As previously noted In Section 4.2 of this report, the NRC approved License AmendmentNo. 69 on April 11, 1997, to relocate the requirements for RB ventilation system exhaustfrom the TS, without change, to the ODCM. Therefore, the Safety Analyses that wereperformed for Operating Manual Changes No. 1498 and 1502 would not have noted therequirement for RB exhaust to be filtered prior to discharge out the stack. Additionally,ACP-06.3 did not specifically require that the ODCM be reviewed, and the SafetyAnalyses failed to recognize that the D-Plan required RB exhaust being filtered priordischarge out the stack.



1.. The Safety Analysis in Accordance with Decommissioning Plan andTechnical Specifications (ACP-06.3 Form 2) performed for LACBWROperating Manual Changes No. 1498 and 1502 did not recognize th thatthe ODCM required the RB exhaust air to be fiotered prior discharge out thestack.

4.7. Osite Dt uai (0M

The OCM (Rev. 11, dated December 2010), Section 3.3.1, "Gaseous Effluents -Reactor Building Isolation," states:

"Normal air discharge from LACBWR is made as an elevated stack release. Airis swept through the Turbine Building and RB and then Osharged up, the stack.Wenever the RB Venttn Oaompe am oen, the air frm R4 l• shallbedischarged through a set ofHEPA patkcate fler to.reluce Ue amountof.,

,,.ad/active pafticee being released to *4e0e4v'onrent:.This f. •.nof theRB Ventilation Sydst&- exhaut lmp4 mntts,b erquhernents of 10 CFR Part50.36a, General.DesIn. C9tarlo,.0 of Appendix A to 10CPR Part 50,; nd the,design objectives in $acton l.D 9of.Appenxifbto 10 CFR Part 50.. * ,,

With RB Ventilation System: exhaust being dischrged without filtation, prepareand submit to the Commissiqn.within.30 days a.,Special Report which dWspusthe circumstances and **at action Will be taken to prevent recuqunce.

During normal SAFSTOR operations, radioactive airborne particulate cn centrations inthe RB range from IOE-11 to IOE-12 pc/cma and are insignificant. Postulated accidentconditions do not create radioactive airborne particulate having any significance to thepublic health and safety. Despite these fat., the ODCM Section 3.3.1 requirement forfiltration of air from the RO to reduce the amount of radioactive particutates being,released to the environment hos no been changed.

I. LACBWR did not recognize that they were not in compliance with this ODCMrequirement to discharge air through the HEPA filters when the RB ventilationdampers were open while the exhaust fan was not running with main airockdoors open.

4.8. Omma Lows

Operator logs were reviewed to determine when the RB main airlock doom were openedfor extended periods, over and above normal opening for equipment removal, etc. Thisreview noted the following:



- Operator Log Vol. 87 indicated that the main airlock doors were unlocked andopened on 11/30/95.

- Operator Log Vol. 89 indicated that the main ailock doors were closed on10/13197.

- Operator Log Vol. 89 Indicated that the RB door is shut and then opened on3/15/98.

4.9. Shift Suesor LoMs

Shift Supervisor Logs were reviewed to determine when the RB main airlock doors wereopened for extended periods, over and above normal opening for equipment removal,etc. 1995 Shift Supervisor Logs documented that the main aidock door interlocks wereoverridden and both doors were opened n t1130/95.

4.10. Corective Action Reports (CARs) . .

A database search for CARs related to RB ventilation was performed. CAR No. 2009-17, initiated on 3/4/09, noted that as a result of the access door (bi-parting doors) beinginstalled, the RB was no longer airtight and that procedures for Hi-Red Alarms were notchanged to ensure negative pressure would be maintained in the RB and that therewould be no chance for an unmonitored discharge from the building. Operating Manualchanges weiproposed and an immediate temporary charnge Was initiated. The causalanalysis performed indicated that the there was no analysis performed of what the affectof the b-parting door installation (Ref. Facility Change FC-37-06-34) may have on theoverall RB ventilation system. It stated that the initial analysis (for FC-37-06-34) of thissituation was not sufficient, but was being addressed, and that a review of the ODCMindicated that even though and monitored air effluents are required, a loss ofeither filtration or monitoring can be dealt with In a planned recovery evolution.

1. Although the causal analysis recognized that the ODCM required air effluentsto be filtered, it did not result in any actions to bring the RB Into compliancewith the ODCM filtration requirement, or recommend that the ODCM bechanged to reflect actual operating conditions.

4.111. EFaclty M (F-C-*1for mHiofRBog incw

The following 50.59 Evaluations were reviewed for the Installation of the Reactor

Building Bi-Parting Doors:

FG-37-06-3. Reactor Buildina Modification. dated 10123/06

RB air inflow was addressed to maintain a monitored gaseous effluent path to thestack by employing a combination of strategies available. Among the optionsnoted were; operating the 6,000-cfm RB exhaust fan, and operating the two35,000-cfm stack blowers. Filtration requirements from the ODCM were notaddressed.



FC-37-06-34. Reactor =uidina Restoration Activities, dated 11/5/06

RB air inflow was addressed to maintain a monitored gaseous effluent path to thestack by employing a combination of strategies available. Among the optionsnoted were; operating the 6,000-cfm RB exhaust fan, and operating the two35,000-cfm stack blowers. Filtration requirements from the ODCM were not

* addressed.

MOSu~ ): •. .:, ::

1. When the 50.69 evaluations for the above FCs were performed,: the D-Plan had notbeen revised to allow for unfiltered exhaust discharge out-the stack, the filtrationrequirements were already moved from the TS to the OXCM, andthe 50.59evaluation process did not specifically requirfthat tIhe ODCM be rev*#md.Consequently, thereiere no pocbse baftiers that would have alentified therequirement for RB airfiltration td#rto discharge.

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4.12. 1247,1717 =LM-7. 0-777,77-Tilt]

Ameview of MRs associated with RB door maintenance did not reveal any activitiespertinent to the timeline for when the main airlock doors were opened and dosed forextended periods.

4.13. ORC f Min

The following ORC meeting minutes were reviewed:

Jnuy 211997- Discussed a memo from the Mechanical Maintenance7." 0pettiO#ftt permission to defer the 3-year preventive maintenance

(PM) on the Personnel Aidock inner door. The airlock was stated to be in afailed" mods and the ba vave Is not ued.

Failed mode would imply that the mecharnc interlocks between the Inner andouter doors were dafeatediremoved to allow independent door operation, or bothdoom open.

1. I 1 Discussed f the Reactor Bin Isolates'automatically, thenOperations will atmtn to restore Reactor Building air flow. If it is not possible,on- airlock door will need to be closed to ensure positive air flow from the ReactorBuilding thrugh the stack

This would Imply that the air lock doors were normally in the open position.

4.14. Annua Efflent Reno..s

The Annual Radioactive Effluent Reports for 1990-2010 were reviewed. Although theannual doses to the public were well below 10 CFR 20 and 40 CFR 190 limits during theperiod from 1990 through 2010, the gaseous effluent release data for this period was



reviewed to determine if bypassing the filtration units had a measurable effect on dlosesto the public. The release data indicate that the effect of operating without filtration isinsignificant. In part, this is because the dose rates from 1995 through 2010 are lessthan the liowest dose rate between 1990 and 1995, which also means that bypassing thefiltration units did not increase the annual dose above that which is already well belowregulatory limits.

The maximum annual organ doses for the perod from 1990 through 2010 are plotted inAttachment A to this report. The doses during the perod from 1995 through 2010(bypassed filtration) are less than a few percent of the doses from 1990 to 1995 (withfiltration). For the purposes of estimating the maximum dose reduction that could beachieved by filtration, it is assunedthat the fle are 99% efficient (which'isconservative for estimating the maximum effect the filters could have on doses). Withthis assumption, the largest possible dose reduction would be 99% of the maximumdose during the period from 1995 through 2010, which is 1.58E-04 mRem. Thus themaximum dose that could be eliminated by the fiftersie less than 1.58E-4 mRem. Thisis an insignificant fraction of the dose limits of 10 CFRz20(100 mRemr TEDE), 40 CFR190 (25mReom organ dose) or 10 CFR 50 Appendix 1(15 mRem organ dose). Thereforeit is concluded that operating without filtration had an insignificant effect on complianceWith btaU dob .imits to the public.

4.15. Generic2Letr89-01 -..

Generic Letter 89-01 addresses the "Implementation of Programmatic Controls forRadiological Effluent Technical Specifications (RETS) in the Administrative ControlsSection~of the-Technical Specifications andthe Relocation-of Procedural Details ofRETS to the OffIite Dose Calculation Manual or to the Process Control Program. It wasverified that the guidance of this GL was followed when TS Section 4.2.4 wasincorporated into the ODCM under UWendeAmendment No: 69.

The extent of this condition with regards to moving TS requirements to other controlledmechanisms, such as the-OCOM Is negligible. There have been no subsequent licenseamendments that resulted in moving TS requirements to lower tier implementingdocuments.

The extent of condition with regards to the adequacy of 50.59 reviews is indeterminate.The 50.59 screens and evaluations reviewed were specific to activities surrounding RBventilation, and it was determined that they were not performed adequately. However,an extended review should be performed on other non-RB ventilation related SafetyAnalyses and 50.59 reviews conducted during the period in question to determineoverall adequacy of the Safety Analysis/50.59 review process.

6&0 R&OT UiME CONQLU81ON

The annual doses to the public were well below 10 CFR 20 and 40 CFR 190 limitsduring the period from 1990 through 2010. The gaseous effluent release data for thisperiod revealed that bypassing the filtration units did not have a measurable effect on

RCA - CAR No. 2011-137,doc

Dairyland Power Cooperative December 14, 2011LACBWR Reactor Building Ventilation RCA Page 11 of 13

doses to the public. The release data indicates that the effect of operating withoutfiltration was insignificant.

A human error and organizational/programmatic diagnostic flow chart were utilized todetermine the organizational/programmatic and human error root causes that exist. Theprimary purpose for utilizing this technique is to identify the apparent causes and toassure that the investigative technique was thorough and complete to aspure that theresultant recommendations are consistentwM. regards to adequay addressing theissues.

Thehuman error rto u was Inadequate 50.59 Training (i.e. nWtrlning for theneeded skills or'" n not compete or dtoiled enough). Posslblcontributing factorsinclude inadequate managerial methods.

The Organizational/progammAMOotcause was Insufficient DetaiL (Le. vagueness inprocedures).' Possible 66ftiritiflgtdt W de inadequate proram design andinadequate work planning process. It should be noted that the requirement to review theODCM was added to ACP-06.4 in Issue 4 (dated 6112/08).

7.0 REgg.QFND~ADtfiAfter reviewing the pertinent information and considering the identified root causes, the

.- f.olkwrng ecommendations are provided:

1. Revise the ODCM and OfW, as needed, to provide relief from the.filtrationrequirement and to reflect the appropriate operating configuration.

2. Evaluate Safety Analyses and/or 50.59 reviews conducted on other Important-to-Safety (ITS) and Quality Level I Non-RB Ventilation systems conducted sinceLicense Amendment No. 69 was issued to assess the adequacy and effectiveness ofthe 50.59 reviews.

3. Conduct training for personnel qualified to perform 50.59 reviews to reinforce therequirements and expectations of ACP-06.4 for the 10 CFR 50.59 review process.

4. Revise LACBWR Operating Manual, Volume V, Section 10, "Heating, Ventilation,and Air Conditioning Systems," as required, to reflect the current operationalconfiguration of main airlock doors open.

5. Revise procedure OP-87-02 to Identify the steps for returning the RB back to itsnormal operating condition.


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