IR 05000245/2011010

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August 8, 2011

EA-11-047Mr. David A. HeacockPresident and Chief Nuclear OfficerDominion Nuclear Connecticut, Inc.lnnsbrook Technical Center5000 Dominion Blvd.Glen Allen, VA 23060

SUBJECT: FINAL SIcNIFICANCE DETERMINATION FOR A WHITE FINDING, WITHASSESSMENT FOLLOW-UP; NOTICE OF VIOLATION; AND RESULTS OFREGULATORY CONFERENCE INRC SPECIAL TNSPECTION REPORT NO.05000336/20110101- MILLSTONE POWER STATION UNlr 2

Dear Mr. Heacock:

This letter provides you the final significance determination for the preliminary White findingdiscussed in the U.S. Nuclear Regulatory Commission (NRC) letter dated May 27 , 2011, as wellas our assessment of the current performance of the Dominion Nuclear Connecticut, Inc.(Dominion) Millstone Power Station (Millstone) Unit 2. This updated assessment of MillstoneUnit 2 supplements, but does not supersede, our annual assessment letter issued onMarch 4, 2011 (ML1 1062017 4)' .As described in the May 27,201 1 letter, the finding was identified during an NRC specialinspection initiated on February 22,2011. The finding involved the failure of Millstone Unit 2personnel (including licensed Reactor Operators and Senior Reactor Operators)to carry outtheir assigned roles and responsibilities and to effectively manage reactivity during main turbinecontrol valve testing on February 12,2011, as well as the failure to have appropriate guidancein procedures to address multiple reactivity additions. This finding contributed to an unintendedeight percent power increase during the test. The finding was presented at an exit meeting heldat the conclusion of the special inspection on April 14,2011, and is described in detail in thesubject inspection report (NRC Inspection Report 05000336/2011008; M1111 470484).The May 27,2011 letter also included an offer for Dominion to attend a regulatory conference(RC) or reply in writing to provide its position on the facts and assumptions the NRC used toarrive at the finding and its safety significance. At Dominions request, a RC was held on July19,2011, at the NRCs Region I office in King of Prussia, Pennsylvania. During the RC,Dominion presented their observations on what occurred during the February 12,201 1 event,the results of their root cause assessment, and corrective actions being taken to preventrecurrence. Dominion also presented its views on the NRCs articulation of the finding and thecriteria used to determine the significance of the finding (lnspection Manual Chapter (lMC)0609, Appendix M,'significance Determination Process Using Qualitative Criterid'), as1 Designation in parentheses refers to an Agency-wide Documents Access and Management System(ADAMS) accession number. Documents referenced in this letter are publicly-available using theaccession number in ADAMS. documented in the NRC special inspection report. Specifically, Dominion stated that it wasdifficult to ascertain which of the qualitative decision-making attributes, considered in IMC 0609Appendix M, factored most significantly into the NRCs preliminary determination that the findingwas of White significance. A copy of the Dominion presentation and a list of RC attendees areincluded in Enclosures 2 and 3 to this letter.The NRC used a qualitative assessment tool (lMC 0609, Appendix M)to assess the significanceof this finding due to the contribution of multiple human performance failures to this event, whichwere not easily modeled using quantitative risk assessment methods. The Appendix Massessment involved analysis of several factors including: review of six specific attributes of thefinding (such as the impact the issue had on defense-in-depth, whether there was a reduction insafety margin, and the extent of condition); and consideration of any additional applicablecircumstances. The relative weight of each of these inputs was determined by NRCmanagement review.For the Millstone Unit 2 issue, the NRC staff concluded that a number of factors led to theincreased significance of the finding, including: 1) multiple human performance errors werecommitted by plant operators who play a vital role in maintaining defense-in-depth; 2) theoperators actions resulted in multiple positive reactivity additions to the reactor and reducedsafety margin; 3) other Millstone Unit 2 operating crews also displayed some degradedperformance during the post-event assessment; 4) the performance issues with the involvedoperating crew and the procedural deficiencies existed for an extended period of time prior tothe event; and 5) Millstones immediate response to the event, including recognizing that itoccurred and entering it into the sites corrective action program, was delayed. The NRC alsoconcluded that other factors lessened the significance of the finding, including: 1) fissionproduct barriers were not compromised during the event; 2) although an automatic plant tripwas inappropriately prevented by operator actions, one was not actually required to prevent fueldamage; and, 3) Dominions root cause analysis was thorough and identified corrective actionsthat appear to address the underlying causal factors of the event.After considering the information developed during the inspection, the information Dominionprovided during the RC, and a qualitative assessment of the factors described above, the NRCdetermined that the inspection finding is of low to moderate safety significance, and is thereforeappropriately characterized as White. The most significant factors in making this determinationwere the multiple, operator-induced positive reactivity additions that contributed to theunplanned reactor power increase and the impact on defense-in-depth associated withdegraded human performance, and a lack of effective communication between operating crewmembers, which was exhibited during this event. You have 30 calendar days from the date ofthis letter to appeal the staffs determination of significance for the identified White finding. Suchappeals will be considered to have merit only if they meet the criteria given in the IMC 0609,Attachment 2,"Process for Appealing NRC Characterization of Inspection FindingsJ' An appealmust be sent in writing to the RegionalAdministrator, Region 1,475 Allendale Rd., King ofPrussia, PA 19406. You are not required to respond to this letter. However, if you choose torespond, you should follow the instructions specified in the enclosed Notice when preparingyour response. As a result of our review of Millstone Unit 2 performance, including this White finding in theInitiating Events Cornerstone, we have assessed Millstone Unit 2 to be in the RegulatoryResponse column of the NRC Action Matrix. Therefore, we plan to conduct a supplementalinspection using lnspection Procedure 95001 , "lnspection for One or Two White Inputs in aStrategic Performance Areaj'when Dominion staff notify us of their readiness for this inspection. 'This inspection is conducted to provide assurance that the root cause and contributing causesof risk significant performance issues are understood, the extent of condition is identified, andthe corrective actions are sufficient to prevent recurrence.The NRC has also determined that violations of NRC regulations occurred, as cited in theenclosed Notice of Violation (Notice). The violations involve failures by Millstone Unit 2 staff to:1) correctly implement written procedures regarding their authorities and responsibilities for safeoperation and shutdown; and, 2) develop written procedures related to the reactor protectionsystem and for power operation and transients involving multiple reactivity additions. Details ofthe violations are provided in the attached Notice. In accordance with the NRC EnforcementPolicy, the Notice is considered an escalated enforcement action because it is associated with aWhite finding.At the July 1 9,2011, RC, Dominion staff described the corrective actions Dominion has taken inresponse to the violations. These actions include: 1) initiation of a Prompt lssue ResponseTeam within 12 hours1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br /> of the event; 2) re-creation of the event on the Millstone Unit 2 simulator;3) establishment, within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> of the event, of senior station management oversight in theMillstone Unit 2 control room resulting in over 100 individual observations conducted in over1000 man-hours; 4) suspension of crew qualifications for remedial training and assessment;5) performance of a root cause evaluation by a team including three non-Dominion industrypersonnel; and, 6) implementation of a performance management program with ongoingevaluation of operator crew performance resulting in remediation, as warranted, andreinforcement of operator accountability.The NRC has concluded that the information regarding the reason for the violations, thecorrective actions taken and planned to correct the violations and prevent recurrence, and thedate when full compliance was achieved is already addressed adequately on the docket in NRClnspection Report 05000336/201 1008, the information you presented at the RC(ML1 12000150), and this letter. Therefore, you are not required to respond to this letter unlessthe description therein does not accurately reflect your corrective actions or your position.Notwithstanding our final assessment of the finding and related violations, the NRC staffappreciates Dominions feedback provided during the RC that the special inspection report,including the specific IMC 0609, Appendix M analysis table provided in Attachment 4 to thatreport, may not have succinctly communicated how the NRC preliminarily determined thefindingfs significance to be White. The NRC staff will consider Dominions feedback in futurecommunications on the bases for our significance determination of findings, particularly whenthey are evaluated using this qualitative assessment tool. The NRC staff recognizes thatDominion was identifying certain corrective actions in parallel with questions that were beingraised by the NRC, and that these actions (such as disqualifying some, but not all, of theoperating crew members) were implemented without NRC involvement. While this clarificationis noteworthy, as discussed during the RC, Millstone managemenfs response to the event (mostsignificantly, that of the Shift Manager and other Senior Reactor Operators involved) was not aprimary factor in the NRC preliminary significance determination. In accordance with 10 CFR 2.390 of the NRC's "Rules of Practice," a copy of this letter, itsenclosure, and your response, if you choose to provide one, will be made availableelectronically for public inspection in the NRC Public Document Room located at NRCHeadquarters in Rockville, MD, and from the NRC's Agency-wide Documents Access andManagement System (ADAMS), accessible from the NRC Web site athttp://www.nrc.gov/reading-rm/adams.html. To the extent possible, your response, if youchoose to provide one, should not include any personal privacy, proprietary, or safeguardsinformation so that it can be made available to the Public without redaction.

Sincerely,William M. DeanRegional AdministratorDocket No. 50-336License No. DPR-65

Enclosures:

1, Notice of Violation2. Regulatory Conference Agenda/List of Attendees (ML112000518)3. Dominion Regulatory Conference Presentation (ML112000536)cc w/encl: Distribution via ListServ In accordance with 10 CFR 2.390 of the NRC's "Rules of Practice," a copy of this letter, itsenclosure, and your response, if you choose to provide one, will be made availableelectronically for public inspection in the NRC Public Document Room located at NRCHeadquarters in Rockville, MD, and from the NRC's Agency-wide Documents Access andManagement System (ADAMS), accessible from the NRC Web site athttp://www.nrc.gov/reading-rm/adams.html. To the extent possible, your response, if youchoose to provide one, should not include any personal privacy, proprietary, or safeguardsinformation so that it can be made available to the Public without redaction.

Sincerely,/RNWilliam M. DeanRegional Adm inistratorDocket No. 50-336License No. DPR-65

Enclosures:

1. Notice of Violation2. Regulatory Conference Agenda/List of Attendees (M1112000518)3. Dominion Regulatory Conference Presentation (ML1 12000536)cc w/encl: Distribution via ListServSUNSI Review Complete: MMM Reviewe/s Initials)DOCUMENT NAME:S:\Enf-allg\Enforcement\Proposed-Actions\Regionl\Revised EA-11-047 Millstone App M White FlNAL.docxAfter declaring this document "An Ofiicial Agency Record' it gi!!@released to the Public.Accession No.: MLI 12200394To receive a copy of this document, indicate in the box: "C" =without attachm enuenclosure "E"with attachmenvendosure "N' =NoOFFICERI/ORARI/DRSRI/DRPRI/DRPRI/DRSNAME MMcLaughlin / MMM'SHansell/SLH'DJackson/ DEJ'DRoberts / DJRw/comments'CMiller/ CGMw/comments'DATE 7t22t117t22t117t25t117t26t117t26t11OFFICE RY ORARI/ ORAHQ/OEHO/NRRRI/ORANAME KFarrar / KLF'DHolody / DJHtG Gulla via emailS Lee with comment. viaemailWDeanDATE 71281117t28t117t29t118t2t1108t08t2011* Concurrence on Previous PageOFFICIAL RECORD COPY D. HeacockDISTRIBUTION w/encl:(via email)ADAMS (PARS)SECYOEMAILOEWEBW. Borchardt, EDOM. Virgilio, DEDRJ. McHale, OEDOR. Zimmerman, OEL. Trocine, OEN. Hilton, OEM Ashley, OEN Hasan, OEE Leeds, NRRF. Brown, NRRC. Sanders, NRR PMM. Ashley, NRREnforcement Coordinators Rll, Rlll, RIV(C. Evans, S. Orth, H. Gepford)C. Scott, OGCE. Hayden, OPAH. Bell, OIGC. McCrary, OlS. Titherington-Buda, OCFOM. Williams, OCFOW. Dean, RA/RID. Lew, DRA/RID. Screnci, PAO-RIi N. Sheehan, PAO-RID. Roberts, DRPJ. Clifford, DRPR. Bellamy, DRPS. Shaffer, DRPC. Miller, DRSP. Wilson, DRSD. Jackson, DRSK. Farrar, RlD. Holody, RlA. DeFrancisco, RlM. McLaughlinCO.Daniell, RlROPreports Resource@nrc. govRegion I OE Files (with concurrences)

ENCLOSURENOTICE OF VIOLATIONDominion Nuclear Connecticut, Inc.Millstone Power Station Unit 2Docket No. 50-336License No. DPR-65EA-2011-047During an NRC special inspection conducted at the Dominion Nuclear Connecticut, Inc.(Dominion) Millstone Power Station (Millstone) Unit 2 between February 22,2011, andApril 14, 2011, for which an exit meeting was held on April 14, 2011 , violations of NRCrequirements were identified. In accordance with the NRC Enforcement Policy, the violationsare listed below:A. Millstone Unit 2 Technical Specification 6.8, "Procedures," states, in part, that writtenprocedures shall be implemented covering the applicable procedures recommended inAppendix 'A' of Regulatory Guide (RG) 1.33, February 1978.RG 1.33, "Quality Assurance Program Requirements (Operation), Rev. 2, Feb. 1978,Appendix A, Paragraph 1, "Administrative Procedures," specifies safety-related activitiesthat should be covered by written procedures, including authorities and responsibilitiesfor safe operation and shutdownContrary to the above, on February 12, 2011, during the conduct of main turbine controlvalve testing, Millstone Unit 2 operators failed to implement written procedures regardingtheir authorities and responsibilities for safe operation and shutdown, and therebycaused and/or exacerbated an unanticipated eight percent reactor power increase, asevidenced by the following examples:1. Dominion Procedure OP-AP-300, "Reactivity Management," states, in part, that theReactor Operator (RO) will stop and question unexpected situations involvingreactivity, criticality, power level, or core anomalies, and will meet the anomalousindication with conservative actions.However, on February 12,2011, when the Millstone Unit 2 Balance of Plant (BOP)RO encountered an unexpected situation involving reactivity and power level, theBOP RO failed to either stop or to othenrvise take conservative action. Specifically,when the BOP RO placed Millstone Unit 2 turbine first stage pressure in service andnoted an increase in first stage pressure, the BOP RO incorrectly pressed the turbineload set INCREASE button instead of the DECREASE button. When the BOP ROidentified that first stage pressure did not decrease, the BOP RO pressed theINCREASE button three more times, and then pressed the DECREASE button twice.The actions by the BOP RO resulted in a rapid, unintended rise in Millstone Unit 2reactor power.

Notice of Violation2. Dominion Procedure OP-AP-300, "Reactivity Management," states, in part, that theReactivity Senior Reactor Operator (SRO) reports to the Unit Supervisor, has noconcurrent duties, directly monitors the reactivity change, and will provide peerchecks for the RO for all reactivity manipulations.However, on February 12,2011, the Millstone Unit 2 Reactivity SRO performed aconcurrent duty and did not monitor reactivity changes. Specifically, when the SMdirected the Reactivity SRO to withdraw a bank of control rods by four steps, theReactivity SRO (who had been monitoring the RCS dilution) did not identify that anunanticipated reactor power increase was already occurring. The Reactivity SROstopped monitoring the RCS dilution and withdrew the control rods, thereby addingadditional positive reactivity and exacerbated the unanticipated power increase.Additionally, as reactor power increased toward the reactor protection system (RPS)Variable High Power Trip (VHT) setpoints, the Reactivity SRO (believing reactorpower was increasing due to minor power fluctuations) reset the setpoints to highervalues four times, thereby preventing an automatic reactor trip. The Reactivity SROdid not recognize the reactivity change and did not inform anyone on shift at the timeof his actions to reset the VHT.3. Dominion Procedure OP-AA-100, "Conduct of Operations," in part, establishes theexpectation that the Shift Manager (SM) will maintain a broad perspective of plantoperations as the senior management representative on shift.Dominion Procedure OP-AP-300, "Reactivity Management," Attachment 2, "SpecificReactivity Management Requirements," states, in part, that adding positive reactivityis never an appropriate way to address unstable plant conditions, and that it is non-conservative to withdraw control rods in an attempt to restore primary coolanttemperature during a transient.However, on February 12, 2011, the Millstone Unit 2 SM did not maintain a broadperspective of plant operations and the SM addressed unstable plant conditions byadding positive reactivity. Specifically, the SM failed to recognize that anunanticipated power increase was occurring. Upon noting that the turbine bypassvalve had automatically closed (per design, in response to the power increase), theSM directed the Millstone Unit 2 Operator at the Controls (OATC) RO to re-open thevalve. Additionally, upon noting that Reactor Coolant System (RCS) temperaturewas lowering (also due to the power increase), the SM directed the Millstone Unit 2Reactivity SRO to withdraw a bank of control rods by four steps. These actionsadded positive reactivity and exacerbated the unanticipated reactor power increase.4. Dominion Procedure OP-AP-300, "Reactivity Management," states, in part, that anRO will stop and question unexpected situations involving reactivity, criticality, powerlevel, or core anomalies, and will meet the anomalous indication with conservativeactions.However, on February 12, 2011, the Millstone OATC RO, who was adding positivereactivity by diluting the Millstone Unit 2 reactor coolant system in preparation for themain turbine control valve test, failed to meet an unexpected situation involving Notice of Violationreactivity and power level with conservative action. Specifically, the OATC ROfollowed the direction of the SM to reopen the turbine bypass valve, thereby addingadditional positive reactivity and exacerbated the unanticipated power increase.Dominion Procedure OP-AA-100, "Conduct of Operations," states, in part, that theUnit Supervisor (US) will provide oversight of plant operations and ensure the plant isoperated safely in accordance with procedures.Dominion Procedure OP-AP-300, "Reactivity Management," states, in part, that theUS will direct reactivity changes and ensure reactivity manipulations are made in adeliberate, carefully controlled manner.However, on February 12,2011, the Millstone Unit 2 US did not provide effectiveoversight of plant operations, and reactivity manipulations were made in a mannerthat was neither deliberate nor carefully controlled. Specifically, the US was focusedon the conduct of main turbine control valve testing, and did not monitor and controlthe overall plant response to the unanticipated power increase. Additionally, the USdid not question or object to the directions provided by the SM that added additionalpositive reactivity and exacerbated the unanticipated power increase.Dominion Procedure OP-AP-300, "Reactivity Management," states, in part, that theShift Technical Advisor (STA) will provide engineering expertise to shift operators, asrequired, during periods of significant reactivity changes.However, on February 12,2Q11, the Millstone Unit 2 STA was peer checking themain turbine control valve test, and did not provide engineering expertise to shiftoperators during the unanticipated power increase.Dominion Procedure OP-AA-106, "lnfrequently Conducted or Complex Evolutions,"states, in part, that the Senior Operations Manager assigned to oversight of a testwill ensure that the test is conducted in a manner that maximizes the margin ofsafety of the Unit.However, on February 12,2011, the licensed SRO who was assigned to theMillstone Unit 2 control room to provide operations management oversight of themain turbine control valve test failed to ensure that the test was conducted in amanner that maximized the margin of safety of the Unit. Specifically, the SRO didnot identify that the multiple positive reactivity additions made during theunanticipated reactor power increase were inappropriate during the event and did nottake action to prevent their occurrence.B. Millstone Unit 2 Technical Specification 6.8, "Procedures," states, in part, that writtenprocedures shall be developed, covering the applicable procedures recommended inAppendix A of RG 1.33, February 1978.Contrary to the above, as of February 12,2011, Millstone did not have adequateprocedures developed that covered the applicable procedures recommended inAppendix A of RG 1.33, February 1978, which caused andior exacerbated an5.6.7.

Notice of Violation 4unanticipated eight percent reactor power increase during the conduct of main turbinecontrol valve testing on February 12,2011, as evidenced by the following examples:1. RG 1.33, "Quality Assurance Program Requirements (Operation), Rev. 2, Feb. 1978,Appendix A, Paragraph 3, "Procedures for Startup, Operation, and Shutdown ofSafety-Related PWR Systems," specifies safety-related activities that should becovered by written procedures, including, instructions for energizing, filling, venting,draining, startup, shutdown, and changing modes of operation, as appropriate, forthe Reactor Control and Protection System.However, on February 12, 2011, Millstone Unit 2 had no procedural guidance thatprohibited resetting the VHT setpoint under any unexpected transient conditions. Asa result, during the unanticipated reactor power transient, as reactor power increasedtoward the RPS VHT setpoints, the Reactivity SRO (believing reactor power wasincreasing due to minor power fluctuations) reset the setpoints to higher values fourtimes, thereby preventing an automatic reactor trip.2. RG 1.33, "Quality Assurance Program Requirements (Operation), Rev. 2, Feb. 1978,Appendix A, Paragraph 6, "Procedures for Combating Emergencies and OtherSignificant Events," specifies safety-related activities that should be covered bywritten procedures, including other expected transients that may be applicable.However, on February 12,2011, Millstone Unit 2 did not have a procedure forresponding to multiple, concurrent, positive reactivity additions during poweroperations. Specifically, during the unplanned reactor power increase, Millstone Unit2 operators implemented three additional positive reactivity additions (RCS dilution,re-opening a turbine bypass valve, and withdrawing control rods), and there was noprocedural guidance regarding the concurrent execution of these activities.These two violations are associated with a White SDP finding.The NRC has concluded that information regarding the reason for the violations, the correctiveactions taken and planned, and the date when full compliance was achieved is alreadyadequately addressed on the docket in NRC Inspection Report 05000336/201 1008 and in theinformation Dominion provided at a regulatory conference conducted on July 19, 2011(ML1 12000150). Therefore, Dominion is not required to respond to this Notice of Violation(Notice). However, Dominion is required to submit a written statement or explanation pursuantto 10 CFR 2.201if the description therein does not accurately reflect Dominion's correctiveactions or its position. In that case, or if Dominion chooses to respond, clearly mark theresponse as a "Reply to a Notice of Violation; EA-2Q11-047," and send the response to theU.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555-0001 with a copy to the Regional Administrator, Region 1,475 Allendale Rd., King of Prussia,PA 19406, and a copy to the NRC Resident Inspector at Millstone Power Station, within 30 daysof the date of the letter transmitting this Notice.lf Dominion contests this enforcement action, Dominion should also provide a copy of itsresponse, with the basis for its denial, to the Director, Office of Enforcement, United StatesNuclear Regulatory Commission, Washington, DC 20555-0001.

Notice of Violation 5lf Dominion chooses to respond, its response will be made available electronically for publicinspection in the NRC Public Document Room or from the NRC's Agency-wide DocumentsAccess and management System (ADAMS), accessible from the NRC Web site athttp://www.nrc.qov/readino-rm/adams.html. Therefore, to the extent possible, the responseshould not include any personal privacy, proprietary, or safeguards information so that it can bemade available to the Public without redaction.In accordance with 10 CFR 19.11, Dominion may be required to post this Notice within twoworking days of receipt.Dated this 8th day of August, 201 1 NRC REGULATORY CONFERENCEMillstone Nuclear Power StationJuly 19, 2011, 1:00 PMNRC Region l, Public Meeting RoomAGENDAREGULATORY CONFERENCEOpening Remarks & Attendee lntroductionsDiscussion of Regulatory ProcessFinding Details and Significance DeterminationDominion Provides Additional InformationNRC Questions and DialogueCaucus (Non-Public)Vll.Closing RemarksPUBLIC QUESTIONS TO THE NRCNRC Staff:DominionRepresentatives:W. Dean, NRCM. McLaughlin, NRCS. Hansell, NRCDominion RepresentativesDominion Representatives & NRC StaffNRC StatfW. Dean; Dominion RepresentativesLil.il1.tv.V.vt.ATTENDEESW. Dean, Region l (Rl)AdministratorC. Miller, Director, Division of Reactor Safety (DRS), RlD. Roberts, Director, Division of Reactor Projects (DRP), RlS. Hansell, Chief, Operations Branch, DRS, RlJ. Circle, Acting Chief, PRA Operational Support Branch, Office of NuclearReactor Regulation (NRR)C. Cahill, Senior Reactor Analyst, DRSM. Mclaughlin, Senior Enforcement Specialist, RlA.J. Jordan, Millstone Site Vice PresidentJ. Semancik, Millstone Plant ManagerK. Grover, Millstone Operations ManagerB. McCollum, Millstone Unit SupervisorR. MacManus, Millstone Director Nuclear Station Safety and LicensingL. Armstrong, Millstone Training ManagerB. Willkens, Millstone Nuclear SpecialistW. Bartron, Millstone Licensing Supervisor ffi*minion.A]M i I lstone Power StationNRC Region IRegulatory GonferenceJuly 19 ,201 1Safe - Reliable - World Class Operation

1. "ominion.M/llillstone Power StationSkip Jordan, Site Vice PresidentJeff Semancik, Plant ManagerKen Grover, Operations ManagerBill McCollum, Unit SupervisorSafe - Reliable - World Class Operation

1. "ominion,Conservative Operationo Nuclear safety is our first priority.o We take our obligation to protect thehealth and safety of the public veryseriously through safe, conservativeplant operation.. For this test, we specifically reducedpower to less than 90o/o.Safe - Reliable - World Class Operation

1. "ominionDesig n Pa rameters Mai ntai ned. Reactor power remained less than97o/o.Plant equipment functioned asexpected and designed.Maintained plant and fuel designlimits within margin.AISafe - Reliable - World Class Operation HF*minion'ilfLearning Organizationo Crew performance during this event didnot meet our standards,. We identified gaps in performance andimplemented corrective actions.o We shared insights and lessons learnedwith the industry.Safe - Reliable - World Class Operation ffi"ominion,Timely& Appropri ate Responseo Initiated a Prompt lssue Response Team.o Re-created the event on the simulator.. Established senior station managementoversight in the control room.o Suspended crew qualifications.o Established a root cause evaluation team.Safe - Reliable - World Class Operation DilF"onrinion'Root/lJctionsCause/Corrective Ao Root Cause:The crew performance management programwas ineffective in correcting observedperforman ce defici enci es.o Corrective Actions to Prevent Recurrence:Added rigor to the performance managementprogram.Safe - Reliable - World Class Operation

1. "ominion'fiJlmprovi ng Crew PerformanceAdded rigor to the performancemanagement program, including.- Evaluation and mapping of crew performance.- Remediation based on individual performance.- Reinforcement of license holders' ownershipand accountability for crew performance.Safe - Reliable - World Class Operation

1. "ominion*Nuclear Safety r Top PriorityWe are committed to safe, conservativeoperation of Millstone Station.Performance during the event did notmeet our standards and expectations.Response to the event was timely andthorough; we investigated what occurred\and acted decisively on the facts.AfSafe - Reliable - World Class Operation