05000293/FIN-2016011-01

Finding

Title

Failure to Identify All Root Causes of a Significant Condition Adverse to Quality

Description

The NRC team identified a Green non-cited violation of Title 10 of the Code of Federal Regulations (10 CFR) Part 50, Appendix B, Criterion XVI, Corrective Action, because Entergy did not adequately determine all root causes associated with a significant condition adverse to quality related to the failure to identify, evaluate, and correct the A SRVs failure to open upon manual actuation during a plant cooldown on February 9, 2013. Specifically, Entergy did not establish adequate measures to assure that the cause of a significant condition adverse to quality, inadequate shift manager operability determination rigor and its associated causes, were adequately determined and corrective action taken to preclude repetition. Entergys immediate corrective actions included planning to conduct operations management face-to-face conversations with shift manager qualified individuals to reinforce the shift managers responsibility for operability and functionality determination accuracy and rigor. Entergy entered this issue into the corrective action program as CRPNP-2017-00363 and CR-PNP-2017-00828. The performance deficiency was more than minor because it is associated with the equipment performance attribute of the Mitigating Systems cornerstone and if left uncorrected, the performance deficiency would have the potential to lead to a more significant safety concern. Specifically, if left uncorrected, the performance deficiency could have the potential to result in repetition of a failure to identify, evaluate, and correct an SRVs failure to open or a similar significant condition adverse to quality. The NRC team evaluated the finding using Exhibit 2, Mitigating Systems Screening Questions, of IMC 0609, Appendix A, Significance Determination Process for Findings At-Power, and determined this finding did not affect the design or qualification of a mitigating structure, system, or component; represent a loss of system and/or function; involve an actual loss of function of at least a single train or two separate safety systems for greater than its technical specification-allowed outage time; or represent an actual loss of function of one or more non-technical specification trains of equipment designated as high safety-significant. Therefore, the NRC team determined the finding was of very low safety significance (Green). The NRC team determined that the finding had a cross-cutting aspect in the area of Human Performance, Avoid Complacency, because individuals did not recognize and plan for the possibility of mistakes, latent issues, and inherent risk, even while expecting successful outcomes. Specifically, Entergy incorrectly assumed that CR-PNP-2013-00825 contained inadequate information to determine that the A SRV had not opened, and this assumption ultimately impacted the root cause results documented in CR-PNP-2016-01621 [H.12].

01
Site:	Pilgrim
Report	IR 05000293/2016011 Section 4OA4
Date counted	Mar 31, 2017 (2017Q1)
Type:	NCV: Green
cornerstone	Mitigating Systems
Identified by:	NRC identified
Inspection Procedure:	IP 95003
Inspectors (proximate)	A Nguyen A Sanchez C Bickett C Norton D Dodson D Jackson D Silk E Duncan F Arner G Eatmon G Pick J Brand J Bream J Josey J Schoppy K Miller L Micewski M Keefe N Staples R Clagg R Lorson R Ruiz S Elkhiamy D Sieracki
Violation of:	10 CFR 50 Appendix B 10 CFR 50 Appendix B Criterion XVI Technical Specification
CCA	H.12, Avoid Complacency
INPO aspect	QA.4
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v • d • e

Finding - Pilgrim - IR 05000293/2016011

1(4)2(8)3(0)4(0)5(0)6(0)7(2)8(0)9(0)10(0)201(0)301(0)403(4)404(0)405(2)14(3)

IR 05000293/2016011: 1 2 3 4 5 6 7 8 9 10 11 12 13

Finding List (Pilgrim) @ 2017Q1

CCA Matrix: 2017Q1

	Q	CCA	Title
05000293/FIN-2016003-04	2016Q3	H.8	Failure to Adequately Evaluate the Effect of Degraded Normally Energized Agastat relays on PCIVs Operability
05000293/FIN-2016003-03	2016Q3		Failure to Properly Implement Agastat Control Relays Preventive Maintenance Procedure in Accordance with TS 5.4.1
05000293/FIN-2016003-02	2016Q3	P.5	Inadequate Operability Assessment on EDG B
05000293/FIN-2016003-01	2016Q3	P.2	Process Radiation Monitor Subsystems 10 CFR 50.65(a)(2) Not Met
05000293/FIN-2016403-02	2016Q4	H.1	Security
05000293/FIN-2016403-10	2016Q4		Security
05000293/FIN-2016004-05	2016Q4	H.5	Feedwater Regulating Valve Failure Results in Reactor Scram
05000293/FIN-2016004-04	2016Q4	H.14	Failure to Correct a Condition Adverse to Quality Associated with Main Steam Isolation Valve
05000293/FIN-2016004-02	2016Q4	H.6	Ineffective Corrective Actions to Correct High Pressure Coolant Injection System Vibrations
05000293/FIN-2016403-01	2016Q4	H.12	Security
05000293/FIN-2016403-03	2016Q4	H.11	Security
05000293/FIN-2016403-04	2016Q4	H.14	Security
05000293/FIN-2016403-06	2016Q4		Security
05000293/FIN-2016004-03	2016Q4	H.12	Failure to Properly Assess and Manage Risk Associated with Shutdown Transformer Protective Relay Testing
05000293/FIN-2016403-05	2016Q4	H.7	Security
05000293/FIN-2016004-01	2016Q4	H.14	Failure to Promptly Perform an Operability Evaluation for a Recirculation Flow Converter
05000293/FIN-2016011-10	2017Q1	H.14	Failure to Promptly Correct a Condition Adverse to Quality for the Residual Heat Removal System
05000293/FIN-2017001-01	2017Q1		Concern Regarding Ability to Declare EALs during Loss of Control Room Air Conditioning
05000293/FIN-2017406-01	2017Q1		Security
05000293/FIN-2017001-04	2017Q1		Failure to Submit a Required 50.72 Notification
05000293/FIN-2016011-07	2017Q1		Failure to Report Condition Prohibited by Technical Specifications and a Safety System Functional Failure
05000293/FIN-2017001-03	2017Q1	P.2	Untimely Corrective Actions associated with Boraflex degradation in the Spent Fuel Pool
05000293/FIN-2017001-02	2017Q1	H.8	Failure to Follow Procedures for Controlled Shutdown
05000293/FIN-2016011-11	2017Q1	H.3	Failure to Adequately Develop and Implement Targeted Performance Improvement Plans
05000293/FIN-2016011-09	2017Q1	P.2	Ineffective Corrective Actions to Address Conditions Adverse to Quality Regarding Components in Contact with or Close Proximity to the Drywell Liner
05000293/FIN-2016011-08	2017Q1	P.2	Failure to Adequately Monitor the Performance of Maintenance Rule Scoped Components
05000293/FIN-2016011-05	2017Q1	H.1	Failure to Establish Corrective Actions to Address Scope of Procedure Quality Issues
05000293/FIN-2016011-04	2017Q1	H.4	Programmatic Issue with Implementation of the Operability Determination Process
05000293/FIN-2016011-03	2017Q1	H.8	Failure to Issue Appropriate Corrective Actions to Preclude Repetition for the Causes of the September 2016 Scram
05000293/FIN-2016011-02	2017Q1	H.8	Failure to Establish Corrective Actions to Preclude Repetition of a Significant Condition Adverse to Quality
05000293/FIN-2016011-01	2017Q1	H.12	Failure to Identify All Root Causes of a Significant Condition Adverse to Quality
05000293/FIN-2016011-06	2017Q1		Design Change Not Appropriately Reviewed by Entergy

Self-Identified List (Pilgrim)

	Q	Title
05000293/FIN-2016403-07	2016Q4	Licensee-Identified Violation
05000293/FIN-2016403-08	2016Q4	Licensee-Identified Violation
05000293/FIN-2016403-09	2016Q4	Licensee-Identified Violation
05000293/FIN-2016004-06	2016Q4	Licensee-Identified Violation
05000293/FIN-2016011-12	2017Q1	Licensee-Identified Violation
05000293/FIN-2016011-13	2017Q1	Licensee-Identified Violation

[Pilgrim Findings full list]

05000293/FIN-2016011-01

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