IR 05000266/2004011

IR 05000266-04-011, IR 05000301-04-011, on 8/16/2004 - 01/19/2005, Nuclear Management Company, Special Inspection, Confirmatory Action Letter Followup

ML050630576
Person / Time
Site:	Point Beach
Issue date:	03/04/2005
From:	Satorius M Division Reactor Projects III
To:	Koehl D Nuclear Management Co
References
FOIA/PA-2010-0209, CAL 3-04-001 IR-04-011
Download: ML050630576 (30)

Text

rch 4, 2005

SUBJECT:

POINT BEACH NUCLEAR PLANT, UNITS 1 AND 2 NRC SPECIAL INSPECTION REPORT 05000266/2004011; 05000301/2004011

Dear Mr. Koehl:

On January 19, 2005, the U.S. Nuclear Regulatory Commission (NRC) completed a special inspection at your Point Beach Nuclear Plant, Units 1 and 2. The purpose of the inspection was to review your progress in meeting the commitments documented in the Confirmatory Action Letter (CAL) dated April 21, 2004. The enclosed report documents the inspection results. The preliminary results were discussed on December 6, 2004, with you and members of your staff.

The inspection examined activities conducted under the CAL and your license as they relate to safety and to compliance with the Commissions rules and regulations and with the conditions of your license. Within these areas, the inspection involved examination of selected procedures and representative records, observations of activities, and interviews with personnel.

The inspectors identified no violations of NRC requirements and no findings.

However, the inspectors identified inconsistency in the quality of the CAL item closure packages and ambiguity with the actual closure status of several of the packages. This ambiguity pertained specifically to closure status and the resolution of significant comments from your Excellence Team and Independent Review Team of packages already signed-off as complete by plant staff and management. These concerns were discussed with you on December 6, 2004. The actions taken by you and your staff to address these concerns were subsequently discussed on January 19, 2005, at a meeting between the NRC and Mr. James McCarthy and other members of your staff. As a result of this meeting, our characterization of the preliminary results of the inspection has not changed from that presented on December 6, 2004. In response to our concerns, Mr. McCarthy stated that Point Beach would notify the NRC in writing when CAL item closure packages had gone through all levels of post-completion signature review and all significant comments were resolved. In addition, Mr. McCarthy stated that a checklist would be developed and used to help ensure consistency of closure packages. If you have any questions regarding the results of the inspection or the issues discussed at January 19th meeting, please contact me or Mr. Patrick Louden of my staff at (630) 829-9627.

In accordance with 10 CFR 2.390 of the NRC's "Rules of Practice," a copy of this letter, its enclosure, and any response you provide will be available electronically for public inspection in the NRC Public Document Room or from the Publicly Available Records System (PARS)

component of NRC's document system (ADAMS). ADAMS is accessible from the NRC Web site at http://www.nrc.gov/reading-rm/adams.html (the Public Electronic Reading Room).

Sincerely,

/RA/

Mark A. Satorius, Director Division of Reactor Projects Docket Nos. 50-266; 50-301 License Nos. DPR-24; DPR-27

Enclosure:

Inspection Report 05000266/2004011; 05000301/2004011 w/Attachment: Supplemental Information

REGION III==

Docket Nos: 50-266; 50-301 License Nos: DPR-24; DPR-27 Report No: 05000266/2004011; 05000301/2004011 Licensee: Nuclear Management Company, LLC Facility: Point Beach Nuclear Plant, Units 1 and 2 Location: 6610 Nuclear Road Two Rivers, WI 54241 Dates: August 16, 2004, through January 19, 2005 Inspectors: M. Kunowski, Project Engineer J. Jacobson, Senior Engineering Inspector J. Giessner, Reactor Engineer Approved by: P. Louden, Chief Branch 5 Division of Reactor Projects Enclosure

SUMMARY OF FINDINGS

IR 05000266/2004011, 05000301/2004011; Nuclear Management Company; on 8/16/2004 -

01/19/2005; Point Beach Nuclear Plant, Units 1 & 2; Special Inspection, Confirmatory Action Letter Followup.

This report covers a special inspection conducted to review the licensees progress in meeting commitments documented in Confirmatory Action Letter (CAL) 3-04-001, dated April 21, 2004.

No findings were identified. The significance of most findings is indicated by their color (Green,

White, Yellow, Red) using Inspection Manual Chapter (IMC) 0609, Significance Determination Process (SDP). Findings for which the SDP does not apply may be Green or be assigned a severity level after NRC management review. The NRCs program for overseeing the safe operation of commercial nuclear power reactors is described in NUREG-1649, Reactor Oversight Process, Revision 3, dated July 2000.

A. Inspector-Identified and Self-Revealed Findings None.

B. Licensee-Identified Findings None.

REPORT DETAILS

1. Background

In the first quarter of 2003, Point Beach Nuclear Plant entered the Multiple/Repetitive Degraded Cornerstone Column (Column IV) of the Action Matrix of NRC Inspection Manual Chapter 0305, Operating Reactor Assessment Program, as a result of a high safety significance (Red) inspection finding. The finding involved the potential for a common mode failure of the auxiliary feedwater system (AFW) following a loss of the instrument air system. This issue was initially identified in November 2001. A second Red inspection finding (Yellow for Unit 1 and Red for Unit 2) was subsequently identified which involved the potential common mode failure of the AFW pumps due to plugging of the recirculation line pressure reduction orifices. This issue was initially identified in October 2002. From July 28 to December 16, 2003, the NRC conducted a three-phase supplemental inspection to review the corrective actions for the two AFW issues, in accordance with NRC Inspection Procedure (IP) 95003, Supplemental Inspection for Repetitive Degraded Cornerstones, Multiple Degraded Cornerstones, Multiple Yellow Inputs, or One Red Input. The results of this inspection were documented in Inspection Report (IR) 05000266/2003007; 05000301/2003007, dated February 4, 2004.

Subsequently, on March 17, 2004, a Notice of Violation and a $60,000 civil penalty were issued for a problem identified during the IP 95003 inspection regarding unauthorized changes to the Emergency Action Level (EAL) scheme in the Point Beach Emergency Response Plan.

On April 21, 2004, Confirmatory Action Letter (CAL) 3-04-001 was issued documenting commitments made by Nuclear Management Company, LLC (NMC) in a March 22, 2004, letter to address areas of regulatory concern identified during the IP 95003 inspection. The basis for these commitments is the NMC Point Beach Excellence Plan, an improvement plan intended to focus the Point Beach organization, site programs, and initiatives on not only the performance issues identified during the IP 95003 inspection but also on issues identified through internal assessments and on areas for meeting NMCs goal of improving performance at Point Beach. Updates of the Excellence Plan were submitted to the NRC on April 1, August 13, and December 28, 2004. The Excellence Plan is composed of Action Plans to address improvement areas. Each Action Plan is composed of Action Steps with corresponding due dates. Of the total 1841 Action Steps in the Excellence Plan, 145 steps were part of the NMC March 22nd commitment letter.

In June 2004, the initial special inspection of the licensees implementation of the commitments in the CAL was conducted (IR 05000266/2004005; 05000301/2004005).

Of the six Action Step closure packages reviewed, two packages had problems indicative of a need for licensee management to provide additional oversight of package quality. An in-progress assessment of additional Action Step closure packages was conducted in July during an NRC Safety System Design and Performance Capability inspection (IR 05000266/2004004; 05000301/2004004). In August and September, Action Step closure packages pertaining to emergency preparedness were reviewed during an inspection (IR 05000266/2004007; 05000301/2004007). As with the inspection in June, additional information for several packages was required in order for the inspectors to conclude that all necessary actions related to emergency preparedness had been completed. And most recently, in late August to early November, eight Action Step closure packages were reviewed during an expanded problem identification and resolution inspection (IR 05000266/2004008; 05000301/2004008). During that inspection, the inspectors concluded that one of the packages, pertaining to the conduct of an interim effectiveness review of improvements and corrective actions for the operating experience program, was closed prematurely.

The main purpose of the current inspection was to review the licensees progress in implementing CAL commitments. The inspection consisted of interviews with personnel, attendance at plant meetings, in-plant observations, and a review of procedures, Action Plan Action Step closure packages, and other plant records. The Action Steps reviewed by the inspectors are discussed below, grouped in four of the five regulatory areas of concern from the April 21, 2004, CAL. In addition to Action Steps specifically committed to in the CAL by the licensee, the inspectors reviewed closure packages for two Action Steps not committed to in the CAL.

2. Review of Completed Excellence Plan Action Plan Action Steps

i. Regulatory Area of Concern: Human Performance

a. Inspection Scope

The inspectors reviewed the following completed Excellence Plan Action Plan Action Steps associated with the CAL human performance area of regulatory concern.

b. Observations Action Plan Title Step OR-01-001 Improve Human Performance and Work Practices 23 This step is not part of the CAL. It included an interim effectiveness review of OR-01-001, which implemented the infrastructure of human performance improvement at the site. The inspector interviewed site personnel, including the human performance coordinator. In addition, various human performance tools, procedures, the interim effectiveness review itself, and internal information from the licensee were reviewed.

Implementation of Action Plan Action Step The effectiveness review, conducted in July 2004, concluded that actions taken as part of the Action Plan had not been fully effective. Inspector followup indicated that since the completion of the July 2004 effectiveness review, the licensees performance had improved as indicated by a reduction in station-wide and departmental human performance clock resets. The licensees human performance (improvement)coordinator stated to the inspectors that the human performance assessment for the 3rd quarter of 2004 had not yet been finalized but had determined, based on the indicators and objective information provided, that improvement continued in this area. From the independent review, the inspectors concluded that, not unexpected with a new process, there were some areas for improvement in consistency and alignment for departmental clock resets, as well as the departmental human performance team engagement. The site had a reasonable plan to ensure the information and analysis being obtained from the corrective action program group and the human performance improvement coordinator could be incorporated into a cohesive, living human performance plan. The inspectors had no significant issues with actions taken to complete this step and consider it closed.

Action Plan Title Step OR-01-004 Individual Behavioral Excellence 26 This step, from the CAL, consisted of establishing a trend report to bin results against the licensees ACEMAN model for human performance improvement. The inspectors reviewed various documents and interviewed the plan owner and primary user of the human performance information, the human performance coordinator.

Implementation of Action Plan Action Step The procedure guideline, OEG 008, provided the guidance and the trend report information. The corrective action program trend report included site analysis of several quarters of performance against the ACEMAN Picture of Excellence barriers for excellence. It was apparent from discussion with the human performance coordinator that the information was being evaluated and used in follow-up sessions with the respective stakeholders. The licensees Independent Review Team (composed of NMC staff from outside Point Beach that review completed Action Step closure packages for quality) identified some enhancements to the guideline to ensure sustainability. The inspectors did not identify any additional problems with the actions taken to complete this step. The site recently adopted a new roll-up report which used the trend information in a more user-friendly and succinct format. This new report was discussed by NMC in a November 23, 2004, letter to the NRC in which several CAL commitments were changed (see Section 3 of this inspection report). This new format maintained the trending required by this step. The licensee completed the Action Plan Action Step as committed in the March 22, 2004, letter and as incorporated in the CAL. The inspectors did not identify any problems with actions taken to complete this step and consider it closed.

ii. Regulatory Area of Concern: Engineering Effectiveness and Design Control

a. Scope

The inspectors reviewed the following completed Excellence Plan Action Plan Action Steps associated with the CAL engineering effectiveness and design control area of regulatory concern.

b. Observations Action Plan Title Step OR-08-005 Improve Human Performance in Engineering 18 This step, which is not part of the CAL, consisted of performing an interim effectiveness review (EFR055643) of the efforts, to date, to improve human performance in engineering.

Implementation of Action Plan Action Step The objectives of this Action Plan were to establish an Engineering Human Performance Improvement Team (HPIT), establish a process for identifying and evaluating human performance events, provide training, and achieve an improving trend in the Engineering Event Clock performance indicator. The HPIT was established by a formal charter contained in ESG 1.8, Engineering Human Performance Improvement Team Charter, Revision 0, and the process for identifying and evaluating human performance events was included in Nuclear Plant Procedures Manual Procedure NP 1.1.10, Human Performance Program, issued in December 2003. Training on use of human performance tools in engineering was also provided to the staff.

A licensee assessment conducted in October 2003 determined that efforts to improve human performance in engineering had not been effective and additional training was recommended. Additional training was conducted in the first quarter of 2004 in response to the recommendation, as well as in response to a noted increase in events during January 2004. Feedback from the training identified some additional actions and an increase in human performance events in May 2004 indicated to the licensee that additional supervisory training was needed.

As of the date of this EFR (September 20, 2004), 65 days had passed without an engineering human performance clock reset. The previous best run had been 26 days in December 2003. The performance indicator (12-month average days between events) was at 7.4, which was an improvement from the earlier months of 2004; however, sustained improved performance will be necessary to reach the 10-day average that the licensee committed to the NRC to meet, and ultimately the 20-day NMC goal. The NRC will continue to monitor licensee efforts to improve human performance in engineering.

Action Plan Title Step OR-08-015 Establish an Engineering Safety and Design Review Board (ESDRG) 7 This step, part of the licensees effort to improve the products of the engineering group, consisted of performing an effectiveness review (EFR055478) to evaluate the impact of the ESDRG on engineering product quality.

Implementation of Action Plan Action Step The ESDRG was created in October 2003 in response to identified weaknesses in the preparation and review of engineering products and understanding of the attributes of a quality independent review. The function of the ESDRG was described in ESG 6.1, Engineering Safety and Design Review Group Charter. The ESDRG was not conceived as a permanent entity; however, no plans have been made, to date, to phase out the group.

The licensees effectiveness review included a series of interviews and an evaluation of the trend for quality scores as determined by the Quality Review Team (QRT) for various engineering products. The EFR was conducted by a four-person team consisting of both Point Beach and Palisades personnel.

The effectiveness review team concluded that reviews of engineering products conducted by the ESDRG appeared to have had an overall positive effect on engineering product quality as evidenced by the trend for improved QRT scores.

While the current trend was improving, the team also noted that ESDRG feedback on engineering products was rarely shared globally within the engineering organization, thus limiting its overall effectiveness. Interviews conducted by the EFR team identified somewhat mixed views among the engineering staff as to the effectiveness of the ESDRG reviews in improving engineering quality. Several recommendations were included in the EFR report and were being tracked in the licensees corrective action by corrective action program document (CAP)059439 and CAP059444.

The licensees EFR was considered a good effort to establish the current effectiveness of the ESDRG in improving engineering product quality. As noted in the EFR, limited data (approximately 9 months) precludes any conclusions at this time regarding the sustainability of engineering product improvement. The EFR team recommended that another review be conducted in approximately 6 months. The NRC will review the ESDRG efforts to improve engineering quality during a future inspection.

Action Plan Title Step OP-14-005 Validate and Integrate Calculations and Setpoints 8 This step consisted of performing an effectiveness review (EFR055453) of the efforts to review, validate, and update safety-related calculations.

Implementation of Action Plan Action Step The purpose of this EFR was to determine if the project was progressing on schedule and accomplishing the goal of upgrading calculations to provide a clear basis for safety-related setpoints and to create a cross-reference for setpoints, calculations, and procedures. The licensee reviewed the calculation database to determine the completion status of the project and conducted interviews with plant discipline leads and the contractor performing the reviews.

At the time of the EFR (August 2004), approximately 77 percent of the original population of approximately 1400 calculations had been reviewed to determine what actions needed to be taken. As of this inspection, approximately 80 percent of the mechanical calculations have been reviewed and all Instrumentation and Calibration (I&C) and electrical calculations have been reviewed. Specific project plans to disposition groups of calculations had not been prepared at the time of the EFR and as of this inspection; while several plans were in draft, none had been approved.

Interviews conducted during the EFR indicated that project communication had not been fully effective and delays in completion of the plant electrical model threatened the schedule for this Excellence Plan commitment. In the March 22, 2004, letter to the NRC, incorporated into the CAL, the licensee committed to revise, validate, and issue all of the calculations by the 2nd quarter of 2005. However, in a November 23, 2004, letter to the NRC, the licensee stated that calculation interdependencies may affect this date and committed to notify the NRC during the 1st quarter of 2005 of a revised completion date for the calculation validation and reconstitution project (see Section 3 of this inspection report).

The licensees EFR was considered a reasonable effort to establish the current status of the project and identify potential barriers to successful completion; however, the EFR did not provide an assessment of the Action Plan effectiveness. Subsequent to NRC review, the licensees Independent Review Team (IRT) reached similar conclusions.

The licensee initiated CAP060659 and planned additional actions to correct the issues related to completion of this Action Step. The NRC will review resolution of this issue during a future inspection.

Action Plan Title Step OP-14-003 Validate Design Basis for High Risk Systems 6.B This step consisted of revalidating and updating the Design Basis Document (DBD) for AFW.

Implementation of Action Plan Action Step Due to a lack of management oversight of the DBD program and identification of setpoint analysis documentation deficiencies, the licensee committed to revalidate and update the DBDs for high risk significant systems. The revalidation effort focused on modifications and NRC correspondence between 1993 (the previous update effort) and July 2004 that could have a direct impact on the AFW design basis. The validation effort consisted of documentation review and system walkdowns.

The AFW Validation Report was submitted to the licensee by a contractor on September 2, 2004, and identified several recommendations, along with six potential open items. The one potential open item deemed significant was subsequently resolved by locating a missing calculation. The remaining potential open items were primarily clarifications which will be evaluated by the licensee, along with the Validation Report recommendations, for inclusion into the AFW DBD.

A somewhat parallel effort DBD-01, Auxiliary Feedwater System Design Basis Document, Revision 9, was issued on September 28, 2004. The DBD was prepared in accordance with NP 7.7.3, Design Basis Document Creation, Revision, and Maintenance, and provided a more usable, streamlined DBD as compared to the previous revision. The licensee completed the Action Plan Action Step as committed in the March 22, 2004, letter and as incorporated in the CAL. The inspectors did not identify any problems with actions taken to complete this step and consider it closed.

Action Plan Title Step EQ - 15-001 AFW Appendix R Firewall Project 14 This step consisted of a modification to install a 3-hour firewall to separate fire zones in the AFW pump room. The firewall was constructed to address issues reported from licensee event report (LER)99-004 with separation of Appendix R redundant safe shutdown equipment and circuits. The inspectors reviewed the modification documentation and performed a walkdown of the installed firewall.

Implementation of Action Plan Action Step The wall was designed to withstand both seismic and high energy line break loads. The modification also installed a fire damper in the ventilation duct and relocated components, such as smoke and heat detectors, electrical cables and piping and their supports, and instrumentation. Review of the halon fire suppression system did not identify any required changes. The inspectors reviewed resolution of Engineering Change Request (ECR) 2003-0047 regarding door jamb-to-concrete anchorage, welding of framing members to existing beam, thickness of a plate member, and grouting of Unistrut issues. These issues were appropriately resolved and the design and installation package was well documented. The inspectors walked down the installation and also reviewed seismic calculation 2002-0020. The seismic calculation utilized appropriate methodology and no issues were identified with the installed wall.

The licensee completed the Action Plan Action Step as committed in the March 22, 2004, letter and as incorporated in the CAL. The inspectors did not identify any problems with actions taken to complete this step and consider it closed.

Action Plan Title Step EQ - 15-012 Manhole and Cable Vault Flooding 8 This step consisted of a modification to install sump pumps in manholes 1 and 2 to prevent groundwater from submerging safety-related cables credited in the Final Safety Analysis Report. Though the licensee evaluated the operability of these cables in a submerged environment and concluded that their performance would not be compromised, cable life would be extended if the sump pumps were installed. The inspectors reviewed the documentation for the modification.

Implementation of Action Plan Action Step The sump pumps were seismically mounted to avoid interaction with the safety-related cables and their supports in the manholes. The pumps discharge piping was routed through the west wall of the pump house and into the service water pump bays. The core bores through the west wall were evaluated, as well as the potential to flood the manholes in the event of high lake water level (such as, from a seiche), and found acceptable. Heat tracing was installed on the discharge piping to prevent freezing in cold weather. The sump pumps were tested after installation and found acceptable.

The licensee completed the Action Plan Action Step as committed in the March 22, 2004, letter and as incorporated in the CAL. The inspectors did not identify any problems with actions taken to complete this step and consider it closed.

Action Plan Title Step EQ - 15-012 Manhole and Cable Vault Flooding 9 This step consisted of performing an effectiveness review (EFR 031055) of the modification to install sump pumps in the manholes. The inspectors reviewed the EFR which had been submitted for the licensees Excellence Team review.

Implementation of Action Plan Action Step The licensee performed this effectiveness review to determine the effectiveness of the installed sump pumps (MR 03-044) to dewater manholes 1 and 2. On August 16, 2004, the manholes were opened and inspected. At that time, manhole 1 was found to contain water at the upper limit of the pump switch setting and the pump was not running. A work order was generated and the manhole was again opened, on August 19, to begin work. At this time, the water level had increased to approximately 2 feet, which was significantly above the pump activation point, and the pump was not running. A portable pump was used to drain the manhole. On August 20, the manhole was again inspected and found to be dry, but the sump pump was running.

Troubleshooting did not identify the cause of the pump malfunction. The manhole was subsequently inspected on August 23 and 26; the pump was not running and the manhole was dry. The effectiveness review concluded that the pump malfunction was an anomaly and that weekly inspections were sufficient; therefore, the modification was deemed effective and results sustainable. The inspectors questioned the conclusions, noting the lack of a basis since the cause of the malfunction had not been found and corrected. The licensee issued CAP059617 to resolve this issue. In a letter dated November 23, 2004, the licensee notified the NRC that the EFR had now concluded that the work performed to date had not been fully effective in resolving the cable vault flooding issues and that additional work was needed. Resolution of the cable vault flooding issue will be reviewed during a future inspection.

iii. Regulatory Area of Concern: Engineering /Operations Interface

a. Scope

The inspectors reviewed the following completed Excellence Plan Action Plan Action Steps associated with the CAL engineering/operations interface area of regulatory concern.

b. Observations Action Plan Title Step OR-08-016 Reduce Operable But Degraded/But Non-Conforming Backlog 3 This step consisted of reducing the number of open Operability Determinations (ODs)from the 32 that were open as of November 2003.

Implementation of Action Plan Action Step The licensees plan to focus on reduction of the number of open ODs began in December 2003. To increase awareness, a list of open ODs was presented weekly at the stations plan-of-the-day meeting. Also in December 2003, a manager was designated as having the responsibility of ensuring continual improvement in reducing the OD backlog. The licensee conducted a screening of open ODs and identified seven which did not appear to meet the current threshold for a condition requiring an operability determination. These issues were subsequently documented, reviewed by the Operations Manager and Plant Manager, and removed from the Operability Tracking List. The inspectors reviewed the justification for removing each of these issues from operable but degraded status and found it acceptable. The inspectors also reviewed the resolution of the OD for increased temperature on the AFW line to Unit 2 A steam generator due to leakage of check valve 2AF-106 (CAP032430) and found it acceptable.

At the time of this inspection, the licensee had resolved several open ODs and currently had 16 open. Acceptable progress had been made on reducing the number of open ODs. The licensee completed the Action Plan Action Step as committed in the March 22, 2004, letter and as incorporated in the CAL. The inspectors did not identify any problems with actions taken to complete this step and consider it closed.

iv. Regulatory Area of Concern: Corrective Action Program

a. Scope

The inspectors reviewed the following completed Excellence Plan Action Plan Action Steps associated with the CAL corrective action program area of regulatory concern.

b. Observations Action Plan Title Step OR-02-001 Nuclear Oversight Effectiveness 4 This step related to creating a problem development sheet (PDS) for nuclear oversight (NOS, quality assurance) to document and assess gaps in the performance at the station. The goal was to ensure that NOS was being intrusive on significant issues.

The inspectors reviewed CAPs written by NOS, NOS quarterly assessments for the last 4 quarters, PDSs for recent emergency planning findings, procedure FP-NO-IA-03, and interviewed the NOS manager and front-line assessors.

Implementation of Action Plan Action Step The licensee originally approved this item April 7, 2004, however, the NRC (during the June 2004 CAL inspection) and the licensees IRT both subsequently identified weaknesses with the PDS itself and with the lack of methodology or guidance for determining issue significance. A CAP was written and the step was again rejected on July 6, 2004. During the current inspection, although the package was incomplete and indicated the step was still rejected, the inspectors verified by use of new fleet procedure FP-NO-IA-03, interviews, and a review of actual PDSs used by the group, that the item has been resolved. The new procedure was required to be used (as opposed to should be used), had intrusive methodology, and determined the significance of the issue. The inspectors did not identify any problems with the final actions taken to complete this step and consider it closed.

Action Pan Title Step OR-02-001 Nuclear Oversight Effectiveness 6 This step was for NOS to execute a process for the integrated assessment of station performance. The plan required devising and then performing an integrated assessment using a formal, documented program. The plan also required ensuring the results of the assessments were discussed (during an assessment exit meeting) with the line organization. The inspectors reviewed products produced by NOS, including exit meeting presentations, and formal assessment documents, as well as interviewed the staff and stakeholders to evaluate this step.

Implementation of Action Plan Action Step The licensee created a procedure, NP 11.1.12, Integrated Assessment of Performance, and performed six quarterly exits using this process. The process was reasonably designed to provide objective assessments as well as an overall station assessment. The presentations and documents reviewed by the inspectors indicated an intrusive methodology, critical comments, and insightful feedback to the line organization as part of the integrated assessments. The inspectors also reviewed the mechanism to track issues identified during the assessment that had not been resolved with NOS and found it reasonable. The licensee completed the Action Plan Action Step as committed in the March 22, 2004, letter and as incorporated in the CAL. The inspectors did not identify any problems with actions taken to complete this step and consider it closed.

Action Pan Title Step OR-02-001 Nuclear Oversight Effectiveness 7.E This step consisted of an effectiveness review of NOS in implementing Steps 1-6 of this Action Plan. The inspectors assessed this area through interviews of station personnel (line and NOS group), review of CAPs, IRT results, NOS self-assessment results from September 2004, and NOS station documents.

Implementation of Action Plan Action Step The licensee used a focused self-assessment to accomplish the effectiveness review.

The completed closure package for this step was approved by the NOS manager on November 15, 2004, and the Excellence Team on November 18. However, the IRT, as documented in a CAP on November 19, noted that the closeout package was not stand alone and that the self assessment scope does not align with the OR-02-001 problem description, objectives, and casual factors. Based on this misalignment the IRT could not determine whether the actions taken have been effective in addressing the issues of OR-02-001. The inspectors agreed with the IRT. Although much progress has been made in NOS, as demonstrated by recent performance in an intrusive inspection of emergency preparedness, the effectiveness review (the NOS self-assessment) was not aligned with the objectives of the Action Plan. Plant staff indicated that resolution of the discrepancy between the review and the Action Plan would be completed by the end of 2004. As such, this Action Plan Action Step will be reviewed by the NRC at a later date.

Action Plan Title Steps OR-05-008 AFW Root Cause Evaluation (RCE) Corrective Actions 1-4 These steps consisted of forming a team and performing an interim effectiveness review (EFR055861) for corrective actions related to 3 root cause evaluations associated with the AFW system, the 13 AFW-related issues from the NRC 95003 inspection (05000266/2003007; 05000301/2003007), and 10 AFW-related ODs.

Implementation of Action Plan Action Step The licensee performed this effectiveness review to determine if corrective actions were completed in a timely manner and for those completed to date, if the actions were effective. The EFR determined that the applicable corrective actions totaled 132 items.

A total of 9 items did not yet have due dates established; however, justification was provided for all 9. A total of 46 items did not meet the original due date, with 37 having adequate justification. At the time of the EFR,11 items had not been completed with 7 having adequate justification, 3 were still open (with adequate interim actions), and 1 item did not provide justification (for which the licensees QRT wrote a CAP). With respect to effectiveness, 15 items were identified as not correcting the problem. Of the 15 items, 8 required additional actions to correct the problem, 3 items were already being addressed by other tracking items, 2 items were duplicates, and 2 items required no additional actions.

With respect to the 13 AFW related issues from the NRC 95003 inspection (05000266/2003007; 05000301/2003007), the EFR concluded that adequate progress was being made to address the concerns and that remaining open items would be evaluated during the final EFR in 2005.

At the time of the EFR, 8 of the applicable 10 AFW-related ODs were complete.

Several administrative issues were identified and CAPs were initiated. Appendix R emergency lighting OBD000154 was still open during the EFR; however, it was subsequently closed on November 1, 2004, with adequate justification. Non-conservative analysis for AFW pump differential pressure OBD000031 remained open with a due date of December 31, 2004, to track final resolution of the issue, which required capacity improvements for the AFW pumps.

This EFR provided a good status of the applicable issues and addressed the effectiveness of completed actions. The EFR resulted in the initiation of 10 CAPs.

Overall, the implementation and management of the applicable AFW issues appeared adequate. The licensees EFR was a detailed, well planned effort. The licensee completed the Action Plan Action Steps as committed in the March 22, 2004, letter and as incorporated in the CAL. The inspectors did not identify any problems with actions taken to complete these steps and consider them closed. The final EFR (OR-05-008, Step 8) is scheduled for completion in the 2nd quarter of 2005.

Action Pan Title Step OP-10-001 Improve CAP Action Request Screening and Prioritization, Operability Determination and Problem Reporting 14 This step consisted of conducting an effectiveness review in the following areas:

Improve CAP Action Request Screening and Prioritization, Operability Determination and Problem Reporting. The effectiveness review was to also look specifically at CAPs categorized as Category A and Category B, the two highest significance levels for CAPs, and determine if they were categorized correctly. The inspectors reviewed the effectiveness review itself, as well as supporting documents. This included performance indicators in the area of corrective action, ODs and requirements, associated procedures, and a sampling of work orders and CAPs. The inspectors attended the daily CAP screening meeting and interviewed the CAP department manager and personnel.

Implementation of Action Plan Action Step The licensee concluded that the actions of the plan were effective in ensuring that CAPs were screened and categorized properly and ODs were properly completed. No category A event had been misidentified, and the Category B events were greater than the licensees key performance indicator of 90 percent. Sustainability was reasonably based on the site performance indicators and proceduralized guidelines in the corrective action program. The IRT provided some comments that when addressed ensured the Action Step closure package could stand alone and provided the necessary detail required for this major effectiveness review. Overall, the IRT agreed (September 14, 2004) with the conclusion of the EFR. The inspectors reviewed the EFR, the comments of the IRT, and the resolution of the comments, and concluded as well that the actions taken by the licensee that were assessed as part of the EFR had been effective.

One item of note from the inspectors review of this Action Step was the writing of CAPs for equipment for which work orders had been written. The inspectors reviewed the most recent 10 corrective maintenance safety-related work orders to determine if CAPs were written for equipment issues that met corrective action program procedural guidelines. For those equipment issues that involved a Technical Specification action condition, CAPs had been written. But based on a few items where CAPs were not written or were written late, the inspectors concluded that there was an inconsistent threshold for writing CAPs for equipment problems that could represent conditions adverse to quality. In these cases, the issues were of minor safety significance but documenting them in CAPs ensures maintenance rule and appropriate cause evaluations were completed. The licensee wrote CAP060854 to address the issue. The licensee completed the Action Plan Action Step as committed in the March 22, 2004, letter and as incorporated in the CAL. The inspectors did not identify any problems with actions taken to complete this step and consider it closed.

Action Pan Title Step OP-10-004 CAP Resolutions Effectively Address Problems 12 This step consisted of an effectiveness review, incorporating employee surveys, of the Technical Review Panel (TRP), Issue Manager program, and efforts to increase station personnel awareness of their roles and responsibilities in the corrective action program.

The effectiveness review was also intended to determine if the corrective action program had led to timely corrective actions that resolve problems and if managers monitor and strive to improve the health of the corrective action program (Step 14). The inspectors reviewed the effectiveness review, documents in the administration of the corrective action program (including Root and Apparent Cause Manuals), performance indicators, survey results, CAPs, corrective actions, TRP scores, Corrective Actions to Prevent Recurrence (CATPRs), and effectiveness reviews of CATPRs from root cause evaluations. Finally, the inspectors interviewed the corrective action program group members, the TRP chairman, and other staff.

Implementation of Action Plan Action Step The effectiveness review concluded that, except for the Issue Manager program, actions taken as part of this Action Plan had been effective. The TRP scores indicated that panel was being intrusive. Interviews and surveys indicated the understanding and sensitivity of employees to the corrective action program was adequate and improving.

Regarding the Issue Manager program, the Excellence Team and the IRT determined that the program was ineffective. The licensee submitted a revision to the CAL in a letter dated November 23, 2004, informing the NRC of the status of the Issue Manager program and the incorporation of the program concept into an industry-proven, structured problem-solving and decision-making process. The inspectors concluded the effectiveness review was reasonable in the areas of TRP and plant awareness was working. The change to the CAL regarding the Issue Manager program was reasonable. The licensee completed the Action Plan Action Step as committed in the March 22, 2004, letter and as incorporated in the CAL. The inspectors did not identify any problems with actions taken to complete this step and consider it closed.

Action Pan Title Step OP-10-004 CAP Resolutions Effectively Address Problems 14 This step, scheduled for completion in the 4th quarter of 2004, consisted of a review of the continued effectiveness of actions that were reviewed as part of Step 12, (discussed above) which was completed in the second quarter of 2004.

Implementation of Action Plan Action Step Although the effectiveness review had been completed and approved by the Action Plan owner and the Focus Area (which comprises several Action Plans) owner, the licensees Excellence Team and the IRT had not yet reviewed this item. The effectiveness review determined that corrective action program improvements had been effective in resolving problems in a timely manner. For most areas evaluated by the effectiveness review, the inspectors agreed that the actions were effective; however, the review was not as intrusive as it could have been and some items were not completely effective in two areas. These areas were Apparent Cause Evaluations (ACEs) and CATPRs. The quality of Apparent Cause Evaluations, which was a key performance indicator for the objective, resulted in a change to ACE scoring and ACE procedures. This item was discussed in the letter from the licensee to the NRC, dated November 24, 2004.

Because the changes to ACE scoring and procedures were only recently made, this area will be reviewed by the NRC at a later date. In the area of CATPRs, there were several issues that necessitated further review of this Action Step by the NRC at a later date. The NRCs problem identification and resolution expanded team inspection in late 2004 identified a problem with the identification of corrective actions that truly prevent recurrence (IR 05000266/2004008; 05000301/2004008), and the licensee, in its interim effectiveness review for AFW corrective actions (discussed above in OR-05-008, Steps 1-4), identified 10 of 14 CATPRs that were not fully effective and 1 CATPR that had been inadvertently undone. Also, one of the licensees performance indicators for effectiveness of corrective actions had been at 80 percent (the minimum for acceptability) for the 3rd quarter of 2004 and less than acceptable for the 2nd quarter.

The inspectors also noted a CAP was recently written which stated that 3rd quarter 2004 data indicated effectiveness was actually at 33 percent, not 80 percent. This CAP had not yet been evaluated by the licensee at the time of the inspection. Finally, NOS had determined that a recent NOS finding in the emergency planning area may be related to ineffective actions to prevent recurrence. Because of the issues with ACEs and CATPR, this Action Step will be reviewed further during a future inspection.

Action Pan Title Step OP-10-006 Effective Root Cause Evaluations 12 This step consisted of performing an evaluation of recent Root Cause Evaluations (RCEs) to verify that multi-disciplinary teams were being used, in keeping with procedural guidance. The inspectors reviewed the evaluation and interviewed the assessors and the manager of the Corrective Action Program.

Implementation of Action Plan Action Step The licensee determined that the actions taken to date have been effective in ensuring that multi-discipline teams were used for RCEs (71 percent of the RCE teams reviewed by the licensee group that completed this Action Step were multi-disciplinary). The inspectors noted that there were three instances where RCE team composition was not multi-discipline during the spring 2004 Unit 2 outage, including the RCE for the potential loss of a reactor coolant system hot leg vent (IR 05000266/2004008; 05000301/2004008). The licensee indicated that resource constraints during the outage were responsible for the three examples. The inspectors agreed with the data used in the evaluation, but was concerned that RCEs conducted during outages should also have the benefit of multi-disciplinary teams. The licensees IRT also rejected this Action Step as being unsatisfactorily completed. A CAP was written to document the rejection and the issue was returned to the plant group that originally completed the Action Step.

This group reviewed its original data, additional data, and the rejection by the IRT and concluded that it had satisfactorily completed the Action Step. The group then closed the CAP without further action and without feedback to the IRT or the stations Excellence Team, which is the manager of the overall CAL item closure effort. This weakness in the licensees control of the CAL item closure effort was discussed with licensee management who stated that actions to remedy this weakness would be taken.

This Action Step will be reviewed further during a future inspection.

Action Pan Title Step OP-10-011 Improve Effectiveness of Self-Assessments 3.D This step consisted of an effectiveness review of the site observation program. The inspectors evaluated the effectiveness review and the data supporting the review. In addition, the inspectors interviewed the station coordinator for self-assessment and improvement.

Implementation of Action Plan Action Step The licensee concluded that the program has been effective in addressing the problems noted. The licensee was entering the data in a common database and trending was being performed and reported. The inspectors considered the use of performance indicators an asset. Although the plan did not directly tie to human performance, key indicators were in use to show how effective the observation program was on overall station performance. The licensee completed the Action Plan Action Step as committed in the March 22, 2004, letter and as incorporated in the CAL. The inspectors did not identify any problems with actions taken to complete this step and consider it closed.

Action Pan Title Steps OP-10-011 Improve Effectiveness of Self Assessments 5.A, 7 These steps consisted of revising the administrative procedure for conducting self-assessments to provide detailed guidance, including specific experience and training criteria for self-assessment leaders, and implementing a site-wide integrated assessment reporting process. The inspectors reviewed the self-assessment procedure (NP 13.1.1), interviewed the program owner, and reviewed three of the most recent assessments.

Implementation of Action Plan Action Step The procedure revision was completed and had acceptable detail. A check of self-assessments indicated adherence to the guidance for the structure of the self-assessments. The program owner was evaluating and scoring the self-assessments as required by the procedure. The site has implemented the integrated reporting process.

The licensee completed the Action Plan Action Steps as committed in the March 22, 2004, letter and as incorporated in the CAL. The inspectors did not identify any problems with actions taken to complete these steps and consider them closed.

Action Plan Title Step OP-10-013 Resolution of 2003 Corrective Action Program Self-Assessment Areas for Improvement 16 This step consisted of performing a self-assessment of the corrective action program to determine whether previous steps of the Action Plan were effective.

Implementation of Action Plan Action Step The inspectors reviewed the self-assessment and related documents and interviewed plant staff. The licensee completed the Action Plan Action Step as committed in the March 22, 2004, letter and as incorporated in the CAL. The inspectors did not identify any problems with actions taken to complete this step and consider it closed.

Action Plan Title Step OP-14-001 Improve the Configuration Management Program 12 This step consisted of performing an effectiveness review (EFR030748) to assess actions taken to date to improve the configuration management program.

Implementation of Action Plan Action Step This Action Plan was established in response to an identified weakness related to maintaining updated plant configuration documentation. Early in 2003, the Engineering Configuration Management Group was formed to provide focus and ownership of the configuration management process. The program scope and responsibilities are documented in Engineering Supplemental Guideline ESG 7.1, Engineering Configuration Management, Revision 0, issued October 10, 2003. On January 30, 2004, CMPM-001, Revision 0, Configuration Management Program Manual, was issued. The purpose of the program manual was to provide a source reference of configuration management principles and practices to help ensure they have been incorporated into appropriate procedures. Modification Turnover and Closeout, FP-E-MOD-10, Revision 0, was issued to implement NMC standards for modification closeout and establish a performance goal of 20 or fewer modifications exceeding a 90-day closeout limit. Also included in this Action Plan was the identification and review of approximately 50 procedures and guidelines affecting configuration management principles and controls as outlined in the Configuration Management Manual. At the time of the EFR, approximately 20 of the 50 procedures had been reviewed.

The EFR concluded that the actions performed to date have been effective in addressing and resolving configuration management weaknesses. The EFR did not, however, assess the current performance of configuration management; therefore, the overall effectiveness of the actions completed to date was unknown. This area will be reviewed during a future inspection.

3. Licensee Update on CAL Commitments

In a letter dated November 23, 2004, the licensee provided written notification of several changes to commitments in the April 21, 2004 CAL. These changes are summarized below.

• OP-09-004, Upgrade Emergency Action Levels (EALs)-In the March 22, 2004, letter incorporated into the CAL, the licensee committed (in Action Step 13) to implement the revised EAL scheme in the 2nd quarter of 2005, within 90 days of NRC approval, following a submittal planned for the 2nd quarter of 2004.

However, because the NRC determined that the submittal (on June 25, 2004)had a number of discrepancies, a revised submittal was made, on October 15, 2004. This unforeseen delay may result in the licensee not meeting the 2nd quarter of 2005 implementation date. In the November 23rd letter, the licensee committed to notify the NRC of the revised implementation date and re-affirmed that the upgraded EALs would be implemented within 90 days of NRC approval.

• OP-14-005, Validate and Integrate Calculations and Set-points-In the March 22, 2004, letter incorporated into the CAL, the licensee committed to revise, validate, and issue a major subset of the stations calculations by the 2nd quarter of 2005.

In addition, the licensee committed to conduct a review of the calculation project progress and develop a calculation cross-reference database, also by the 2nd quarter of 2005. In the November 23, 2004, letter, the licensee indicated that there was a resource allocation problem with the project and committed to provide a revised project completion schedule to the NRC during the 1st quarter of 2005.

• EQ-15-011, Bolted Fault-In the March 22, 2004, letter incorporated into the CAL, the licensee committed to complete calculations to support bolted (three-phase short circuit) fault protection analyses and modifications by the 4th quarter of 2004. In the November 23, 2004, letter, the licensee indicated that because of the complexity of the calculations and the number of comments that need to be resolved, the committed completion date was being changed to the 1st quarter of 2005.

• OP-10-004, CAP Resolutions Effectively Address ProblemsIn the March 22, 2004, letter incorporated into the CAL, the licensee committed to perform effectiveness reviews in the 2nd and 4th quarter of 2004 of the implementation of the Issue Manager concept, for the coordination of licensee efforts to resolve complex problems. The licensee has since concluded that the concept, as implemented, was not effective. In the November 23, 2004, letter, the licensee indicated that the issue manager concept would now be implemented within the context of the Operational Decision-Making Issue model, as committed to in the CAL as Step 1 of Action Plan OR-08-017.

4OA6 Meetings

.1 Exit Meeting

On December 6, 2004, the inspectors presented the preliminary inspection results to Mr. Dennis Koehl and members of Mr. Koehls staff, who acknowledged the findings.

The licensee did not identify any information, provided to or reviewed by the inspectors and likely to be included in the inspection report, as proprietary.

An additional meeting was then scheduled because of inspectors concerns about inconsistency in the quality of the CAL item closure packages and about ambiguity with the actual closure status of several of the packages. This ambiguity pertained specifically to package closure and the resolution of significant comments by the licensees Excellence Team and Independent Review Team of packages already signed-off as complete by plant staff and management.

On January 19, 2005, the inspectors and NRC management met with Mr. James McCarthy and members of his staff to discuss these issues. As a result of this meeting, no additional concerns were identified by the inspectors. The licensee stated that it would notify the NRC in writing when CAL item closure packages had gone through all levels of post-completion signature review and all significant comments were resolved.

In addition, the licensee stated that a checklist would be developed and used to help ensure consistency of closure packages. Finally, the licensee stated it would notify the NRC in writing when it had completed all of the CAL-related Action Plans of the Focus Areas that constitute the five areas of regulatory concern that are discussed in the April 21, 2004, CAL. This notification would not be delayed until all focus Areas were completed but would be made as soon as any particular Focus Area was completed.

4OA7 Licensee-Identified Violation

None.

ATTACHMENT:

SUPPLEMENTAL INFORMATION

KEY POINTS OF CONTACT

Licensee

A. Capristo, Regulatory Affairs Manager (current)

J. Connolly, Regulatory Affairs Manager (former)

B. Dungan, Operations Manager

C. Hill, Assistant Operations Manager

F. Flentje, Regulatory Affairs Principal Analyst

R. Flessner, Excellence Team Manager

D. Hettick, Performance Improvement Manager

M. Holzmann, Nuclear Oversight Manager (former)

R. Hopkins, Internal Assessment Supervisor

C. Jilek, Maintenance Rule Coordinator

T. Kendall, Senior Technical Advisor

D. Koehl, Site Vice-President

R. Ladd, Fire Protection Engineer

K. Locke, Regulatory Specialist

J. McCarthy, Site Director of Operations

R. Milner, Business Planning Manager

S. Nikolai, Performance Assessment

G. Packard, Nuclear Oversight Manager (current)

D. Peterson, Human Performance Coordinator

L. Peterson, Design Engineer Manager

S. Pfaff, Operating Experience Supervisor

C. Richardson, Design Engineer

J. Schroeder, Service Water System Engineer

J. Schweitzer, Site Engineering Director

R. Seipel, Quality Assurance Assessor

J. Shaw, Plant Manager

G. Sherwood, Engineering Programs Manager

C. Sizemore, Training Manager

W. Smith, Performance Manager

N. Stuart, Maintenance Manager

Nuclear Regulatory Commission

C. Pederson, Director, Division of Reactor Safety

S. Reynolds, Deputy Director, Division of Reactor Projects

P. Louden, Chief, Reactor Projects, Branch 5

R. Krsek, Senior Resident Inspector, Point Beach

M. Morris, Resident Inspector, Point Beach

Attachment

ITEMS OPENED, CLOSED, AND DISCUSSED

Opened

None.

Closed

None.

Discussed

None.

Attachment