05000293/FIN-2014008-02
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Finding | |
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| Title | Failure to Complete Several Corrective Actions as Required by Program Requirements |
| Description | In 2013, four reactor scrams occurred at Pilgrim which resulted in two PIs in the Initiating Events cornerstone crossing the Green to White threshold. To address these risk significant performance issues, both individually and collectively, Entergy performed four RCEs for the individual scram events which occurred on January 10, February 8, August 22, and October 14. Additionally, Entergy performed a RCE to assess the commonalities between the four scram events and CCA to assess if any safety culture aspects caused or significantly contributed to the events. EN-LI-102, Corrective Action Program, Revision 23, provides instructions for the administration of Entergy corrective action process, including the identification, reporting, evaluation, and correction of a broad range of problems, areas for improvements, and standards performance deficiencies. Issues addressed in the corrective action process must include Adverse Conditions and Conditions Adverse to Quality, and can include minor problems that may be precursors to more significant events, areas for improvement and standards performance deficiencies identified during assessments and other activities. To that end, EN-LI-102 contains instructions for review and approval of corrective action development, response and documentation, and due date extensions. Section 5.6[4] of EN-LI-102 states that corrective action response must address the intent of the action and must not indicate correction or implementation based on future action. In review of the corrective action plans and status of completed or scheduled corrective actions to address the risk-significant performance issues, inspectors identified multiple deficiencies in implementing the CAP procedure. As documented in section 4OA4.02.03.a.1, a.2, a.4, and d.2 of this report, inspectors identified that some of the corrective actions specified in the RCEs were not completed in accordance with CAP requirements. Specifically, inspectors identified: Several of the human performance related corrective actions from the RCE of a scram on January 10, 2013, during surveillance testing had been cancelled or closed. To determine whether the closure of the corrective actions was appropriate, inspectors reviewed a sampling of recently performed surveillances and observed performance of maintenance in the field. During this review, inspectors noted that several procedures did not have critical steps annotated as such, one procedure directed work to be performed following system restoration, and identified examples of technicians proceeding with testing when challenged with test equipment challenges or unexpected system response. Ultimately, inspectors determined that observations of maintenance execution did not support closure or cancellation of corrective actions identified in the RCE and determined that the numerous procedure deficiencies and human performance issues identified by inspectors represented conditions adverse to quality that were reasonably within Entergys ability to identify and correct by execution of corrective actions identified in the RCE; Despite corrective actions to upgrade severe weather procedures to address deficiencies revealed during a winter storm on February 8, 2013, inspectors identified that the procedure changes did not fully meet the intent of the corrective actions because there were no substantive changes to the procedures for pre-storm actions. Additionally, inspectors determined that the inadequate guidance for pre-storm actions represented a condition adverse to quality that was reasonably within Entergys ability to identify and correct by execution of corrective actions identified in the RCE; An action to send a transformer insulator that faulted offsite for vendor analysis was not completed as required by CAP requirements. Despite being selfidentified by Entergy in preparation for the inspection, this deficiency still existed at the time of the inspection; and One of two effectiveness reviews for a RCE was not completed as required by CAP requirements. Entergy entered the issues into the CAP as CR-PNP-2014-5909, CR-PNP-2014-5976, CR-PNP-2014-5977, CR-PNP-2014-5682, CR-PNP-2014-5625, CR-PNP-2014-5826, CR-PNP-2014-5735, and CR-PNP-2014-06067 and took action to address the identified deficiencies. In particular, for the first example, Entergy revised the RCE to include additional corrective actions for procedural reviews prior to performance of work and enhanced oversight of maintenance activities. For the second example, Entergy made numerous additional changes to severe weather procedures. As discussed in section 4OA4.02.05.b.1, Entergys site safety culture review adequately identified the components of nuclear safety culture that caused or significantly contributed to the four scram events. In particular, inspectors noted Entergy identified that implementation of the stations CAP has not been effective in ensuring adequate corrective actions are taken to address issues in a timely manner, and Entergy identified corrective actions to improve performance in this area. As discussed in section 4OA4.02.05.a.5, inspectors identified examples of approved corrective actions intended to address challenges in CAP implementation not being completed as prescribed. For these corrective actions, inspectors discussion with Entergy personnel revealed that the performance improvement department determined that the actions were not producing the desired results, and decided to implement CAP training instead. However, Entergy did not present these change to the CARB for approval of the revision as required by EN-LI-102. This was entered into the CAP as CR-PNP-2014-06040. Ultimately, inspectors determined that the specific deficiencies in execution of corrective actions identified by inspectors were symptomatic of the identified challenges in CAP implementation, and correspondingly determined that corrective actions specified in the common cause and safety culture evaluations were not effective at ensuring that performance issues identified by the numerous RCEs were corrected. |
| Site: | Pilgrim |
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| Report | IR 05000293/2014008 Section 4OA4 |
| Date counted | Dec 31, 2014 (2014Q4) |
| Type: | NCV: Green |
| cornerstone | Initiating Events |
| Identified by: | NRC identified |
| Inspection Procedure: | IP 95002 |
| Inspectors (proximate) | B Smith C Bickett J Grieves J Patel M Keefe R Mckinley S Morrow S Rich A Keim |
| Violation of: | 10 CFR 50 Appendix B Criterion XVI |
| CCA | P.3, Resolution |
| INPO aspect | PI.3 |
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Finding - Pilgrim - IR 05000293/2014008 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Finding List (Pilgrim) @ 2014Q4
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