IR 05000361/2010010

IR 05000361-10-010 & 05000362-10-010, on 07/12/10 - 07/16/10, San Onofre Units 2 & 3, Focused Baseline Inspection of Substantive Cross-Cutting Issues & Safety Culture

ML102420696
Person / Time
Site:	San Onofre
Issue date:	08/30/2010
From:	Ryan Lantz NRC Region 4
To:	Ridenoure R Southern California Edison Co
References
IR-10-010
Download: ML102420696 (28)

Text

UNITED STATES NU C LE AR RE G ULATO RY C O M M I S S I O N ust 30, 2010

SUBJECT:

SAN ONOFRE NUCLEAR GENERATING STATION - NRC FOCUSED BASELINE INSPECTION OF SUBSTANTIVE CROSS-CUTTING ISSUES INSPECTION REPORT 05000361/2010010 and 05000362/2010010

Dear Mr. Ridenoure:

On July 16, 2010, the U.S. Nuclear Regulatory Commission (NRC) completed an inspection at the Southern California Edisons San Onofre Nuclear Generating Station, Units 2 and 3 Facility.

The enclosed inspection report documents the inspection findings, which were discussed on July 16, 2010, with you, and other members of your staff.

The inspection examined activities conducted under your license as they relate to safety and compliance with the Commissions rules and regulations and with the conditions of your license.

The inspectors reviewed selected procedures and records, observed activities, and interviewed personnel.

The inspectors reviewed your progress associated with the open substantive cross-cutting issues in Human Performance and Problem Identification and Resolution. The Annual Assessment Letter, dated March 3, 2010, identified four persistent themes and three additional themes associated with longstanding substantive cross-cutting issues in Human Performance and Problem Identification and Resolution. In a letter dated March 31, 2010, your staff submitted a revised improvement plan which extended the completion dates for many actions.

The inspectors reviewed the Human Performance and Problem Identification and Resolution improvement plans.

The inspectors reviewed your root cause evaluation of the safety conscious work environment at SONGS, but did not assess the results of the corrective actions, because enough time has not elapsed to determine the impact of the corrective actions. The inspectors concluded that the cause evaluation and corrective action plan appear to be adequate, however, parts of the cause evaluation could be more thoroughly evaluated for underlying cultural causes and some corrective actions are not fully described and defined.

Southern California Edison Company -2-Based on a collective assessment of NRC findings documented this year, current station performance metrics related to the substantive cross-cutting issues, and observations from this team and previous inspection teams, we have concluded that, while improvement has been made in some areas, the station has not demonstrated significant progress in addressing the fundamental behaviors that have resulted in the substantive cross-cutting issues.

The inspectors acknowledge that Southern California Edison has recognized the need to take additional corrective actions to address station performance, and has undertaken new initiatives to address the issues. Examples of these new initiatives include the transition to a new corrective action program management system and the development of project improvement plans to address the substantive cross-cutting issues and safety conscious work environment concerns. The inspectors reviewed some aspects of the new improvement plans but were unable to fully evaluate the effectiveness of these new initiatives because they were not fully approved or implemented during the inspection period.

Additionally, the inspectors conducted a confirmatory order follow-up inspection, in response to your June 25, 2010, letter to the NRC titled, Response to Confirmatory Order EA 07-232 and Notice of Violation EA 07-141 that stated the requirements of Item 2c had been satisfied. To satisfy the requirement of Item 2l, this letter discussed the basis for concluding that the Order had been satisfied. The inspectors determined that all items of Confirmatory Order EA-07-232 were completed. However, due to the duration of the Order, which was issued to SONGS on January 11, 2008, the NRC will conduct an additional inspection to evaluate the sustainability of the corrective actions that you have taken to satisfy the Order. This inspection is planned for the week of October 4, 2010.

This report documents one NRC identified finding of very low safety significance (Green). This finding was determined to involve violations of NRC requirements. However, because of the very low safety significance and because it was entered into your corrective action program, the NRC is treating this finding as a noncited violation, consistent with Section VI.A.1 of the NRC Enforcement Policy. If you contest the violation or the significance of the noncited violation, you should provide a response within 30 days of the date of this inspection report, with the basis for your denial, to the U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, D.C. 20555-0001, with copies to the Regional Administrator, U.S. Nuclear Regulatory Commission, Region IV, 612 E. Lamar Blvd, Suite 400, Arlington, Texas, 76011-4125; the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, Washington, D.C. 20555-0001; and the NRC Resident Inspector at the San Onofre Nuclear Generating Station facility. In addition, if you disagree with the cross-cutting aspect assigned to any finding in this report, you should provide a response within 30 days of the date of this inspection report, with the basis for your disagreement, to the Regional Administrator, Region IV, and the NRC Resident Inspector at San Onofre Nuclear Generating Station.

In accordance with 10 CFR 2.390 of the NRC's Rules of Practice, a copy of this letter, and its enclosure, will be available electronically for public inspection in the NRC Public Document

Southern California Edison Company -3-Room or from the Publicly Available Records component of NRCs 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/

Ryan E. Lantz, Chief Project Branch D Division of Reactor Projects Docket Nos. 50-361; 50-362 License Nos. NPF-10; NPF-15

Enclosure:

NRC Inspection Report 05000361/2010010 and 05000362/2010010 w/Attachments: (1) Supplemental Information (2) Request for Information

REGION IV==

Docket: 50-361, 50-362 License: NPF-10, NPF-15 Report: 05000361/2010010 and 05000362/2010010 Licensee: Southern California Edison Co. (SCE)

Facility: San Onofre Nuclear Generating Station, Units 2 and 3 Location: 5000 S. Pacific Coast Hwy San Clemente, California Dates: July 12-16, 2010 Inspectors: T. Brown, Resident Inspector B. Hagar, Senior Project Engineer E. Ruesch, Reactor Inspector L. Micewski, Project Engineer Approved By: Ryan Lantz, Chief, Project Branch D Division of Reactor Projects-1- Enclosure

SUMMARY OF FINDINGS

IR 05000361; 05000362/2010010; 7/12/2010-7/16/2010; San Onofre Nuclear Generating

Station, Units 2 & 3; Focused baseline inspection of substantive cross-cutting issues and safety culture; confirmatory order follow-up; Problem Identification and Resolution The inspection was conducted by a resident inspector and three region-based inspectors. One Green finding, which was a noncited violation, was identified during the inspection. The significance of most findings is indicated by their color (greater than Green, or Green, White,

Yellow, Red); the significance was determined using Inspection Manual Chapter 0609,

"Significance Determination Process." (SDP); the cross-cutting aspect was determined using Inspection Manual Chapter 0310, Components Within the Cross-Cutting Areas; and findings for which the SDP does not apply may be Green or be assigned a severity level after NRC management review. The NRC's program for overseeing the safe operation of commercial nuclear power reactors is described in NUREG-1649, "Reactor Oversight Process," Revision 4, dated December 2006.

Cornerstone: Initiating Events

Green.

The inspectors identified a noncited violation of Technical Specification 5.5.1.1 for failure to provide a written procedure to define authorities and responsibilities of all work process area operators. Specifically, on July 13, 2010, the work process area had an additional operator, identified on the watchbill as the Control Room Coordinator, who performed activities normally performed by the Work Process Supervisor, including providing oversight for pre-job briefs and authorizing start of tasks. The authority and responsibilities of the Control Room Coordinator were not described in plant procedures, and the Control Room Coordinator routinely performed the duties of the Work Process Supervisor without receiving a turnover and formally accepting the position of Work Process Supervisor. The licensee documented this finding in Nuclear Notification 201014984. The short-term corrective actions included required reading and coaching to instruct Work Process Supervisors not to delegate their authority to authorize work without a formal turnover. The licensee will also add guidance to procedures SO123-0-A-1, Operations Division Procedure and SO123-0-A-2 Operations Division Personnel Responsibilities.

The inspectors concluded that the finding was more than minor because it could be reasonably viewed as a precursor to a significant event. Specifically, lack of a procedure to define the roles, responsibilities, and authorities of all personnel who may simultaneously hold work process area authority may lead to inadequate coordination of concurrent work and inadvertent authorization of multiple activities that could cause a plant transient or reactor trip. The finding is associated with the Initiating Events cornerstone. Using NRC Inspection Manual 0609, Attachment 0609.04, Phase 1-Initial Screening and Characterization of Findings, the inspectors determined the finding to have very low safety significance because it did not contribute to both the likelihood of a reactor trip and the likelihood that mitigation equipment or functions would not be available.

The inspectors determined the finding has a cross-cutting aspect in the area of Human Performance associated with decision-making because the licensee did not make safety-significant decisions using a systematic process, including formally defining the authority and roles for decisions affecting nuclear safety

H.1(a). (Section 4OA2)

Licensee-Identified Violations

None

REPORT DETAILS

OTHER ACTIVITIES

.1 Substantive Cross-cutting Issues

In the 2009 Annual Assessment Letter for San Onofre Nuclear Generating Station, dated March 3, 2010 (ADAMS ML100621410), the NRC identified the fifth consecutive assessment cycle where substantive cross-cutting issues (SCCI) were identified in both Human Performance and Problem Identification and Resolution. The letter identified four persistent themes and three additional themes associated with longstanding substantive cross-cutting issues in Human Performance and Problem Identification and Resolution. The letter identified a new Human Performance theme in the component of work practices associated with ensuring supervisory and management oversight of work activities. Also, the letter identified two new Problem Identification and Resolution themes in the component of the corrective action program, one theme associated with implementing the corrective action program with a low threshold for identifying issues, and the other associated with taking appropriate corrective actions to address safety issues in a timely manner, commensurate with their safety significance.

a. Inspection Scope

In a letter dated March 31, 2010, the licensee submitted a revised improvement plan which extended the completion dates for many actions. The inspectors reviewed the Human Performance and Problem Identification and Resolution improvement plans.

The inspectors reviewed the cross-cutting aspects assigned to findings documented in inspection reports issued in 2010. Also, the inspectors observed maintenance activities in the plant, observed control room and work process area operations, and attended staff and management meetings.

1. Human Performance

The inspectors reviewed the licensees corrective actions to address the five themes supporting the Human Performance SCCI (i.e. H.1(b), H.2(c), H.4(a), H.4(b), and H.4(c)). The inspectors noted that:

• In response to each of the themes, the licensee had completed at least one cause evaluation and had developed corresponding corrective actions.

• The licensee had placed all of the corrective actions from those cause evaluations (a total of 250 actions) into their Site Integrated Business Plan. By June, 2010, many of those corrective actions had been completed.

• In July, 2010, a draft copy of the licensee-prepared Effectiveness Review Challenge Board Report / Human Performance Improvement Plan said that overall, the current initiatives had not been effective in improving the quality of worker human performance to an acceptable level, and that a Human

Performance Strike Team had been formed to address this gap and develop check-and-adjust actions to close it.

In reviewing the activities completed and results produced by the subject Human Performance Strike Team, the inspectors made the following observations:

• The teams assignment had not been made within the licensees corrective action program (CAP); instead, the teams charter had been provided in an e-mail message.

• The teams methodology had not been described within any existing Nuclear Notification or procedure.

• The teams actual activities had not been described within any existing Nuclear Notification. In particular, the team had apparently not documented what they did to enable them to develop corrective actions that corresponded to the problems they had identified.

• The teams results had not been included within any existing Nuclear Notification.

From these observations, the inspectors concluded that the teams activities, which were corrective actions to address long-standing SCCIs, had been assigned, tracked, and results documented outside of the licensees corrective action program.

The inspectors also noted that the gaps identified by the team were described in statements like the following:

• Training actions have been minimally effective.

• The actions to improve operational decision making (including operability determinations) have not provided the needed improvements.

• No written instruction prioritization process has been developed.

• The Leadership Engagement Trending System has not been effective in improving supervisor / management oversight of work activities.

• Personnel are not familiar with the roles and responsibilities defined in the Human Performance procedures.

In short, the gaps identified by the team looked like problems. The inspectors noted that the licensees corrective action program (CAP) procedure SO123-XV-50.CAP-1, Writing Nuclear Notifications for Problem Identification and Resolution, revision 4, required that all personnel discovering problems, or being made aware of problems, or believing that a problem exists, should, in part, write a Nuclear Notification (NN) to document the problem prior to the end of shift. That procedure also specifies that it is not acceptable to create a new task on an existing NN for new problems. Despite those statements in

that procedure, the inspectors observed that the team had not written NNs to document the problems they had discovered.

Taken together, the inspectors observations associated with the Human Performance Strike Team supported the following conflicting conclusions:

• The licensee had self-identified that previously-completed corrective actions had not been effective in improving the quality of worker human performance to an acceptable level, and had formed a strike team to address that issue.

• The strike teams activities, which were corrective actions, were not assigned and documented in the CAP, suggesting that the licensee had not viewed their CAP as a tool that could be used to address Human Performance problems.

The inspectors reviewed the findings documented in inspection reports that have been issued by the NRC since January 1, 2010. The inspectors noted that twenty-four findings were assigned cross-cutting aspects in the area of Human Performance.

Among these findings, ten different cross-cutting aspects were identified as the most significant contributor to the performance deficiencies. The cross-cutting aspects covered all four components of the Human Performance cross-cutting area. The inspectors concluded that these collective findings identify continued challenges that Southern California Edison (SCE) faces in resolving the Human Performance issues.

The inspectors observed plant activities, including maintenance, operations, and management meetings. Observations include:

• The inspectors observed an overall lack of discipline in the use of three-way communications. Three-way communications are an expectation, as defined in the SONGS Excellence Guidebook and SONGS Human Performance Tools Handbook for All Workers. A specific example occurred during an activity when the Work Process Control Operator directed a technician to check sump levels before taking main steam isolation valve reservoir tank oil samples. The technician did not use three-way communications to confirm the assigned action and failed to check the sump levels before proceeding with the maintenance activity.

• The inspectors observed a Corrective Action Review Board (CARB) meeting on July 12, 2010. The agenda included approval of schedule changes to focused assessments and benchmarking, part of the self assessment program. The CARB voted to approve the schedule revisions. The inspectors identified that procedure SO123-SA-1, Self-Assessment Program, revision 6, identifies the Self-Assessment Steering Committee (SASC) as having the responsibility for approval of these schedule revisions. While both groups utilized the same members, the inspectors concluded that SCE did not follow procedure SO123-SA-1 by utilizing the CARB to perform functions of the SASC.

The licensee entered this issue into the corrective action program as Nuclear Notification 201012715.

• The licensee allowed an operator to authorize maintenance activities on plant equipment without properly defining the operators roles and responsibilities.

This issue is further described by the finding documented in Section 4OA2.1.b.3.

• During a surveillance test of a Unit 2 emergency diesel generator, the inspectors observed that operators did not utilize proper procedure placekeeping techniques as defined by procedure SO123-XV-HU-3, Written Instruction Use and Adherence, revision 4. The licensee entered the issue into the corrective action program as Nuclear Notification 201012120.

• The inspectors observed a lack of formality in the Work Process Area.

Specifically, operators used inappropriate language and one watchstander was observed using a personal electronic device, contrary to the requirements of procedure SO123-0-A-1, Operations Division Procedure, revision 27, Section 6.2.2, Control Room Conduct. The licensee entered the issue into the corrective action program as Nuclear Notification 201014989.

• The inspectors also noted that not all employees carried the SONGS Human Performance Tools Handbook for All Workers, an expectation of SCE management.

2. Problem Identification and Resolution

In Nuclear Notification 200758654, dated January 21, 2010, SCE identified two new potential cross-cutting themes in the area of Problem Identification and Resolution, based on the number of NRC findings. The NRC later confirmed these new themes in the 2009 Annual Assessment Letter, dated March 3, 2010. On January 24, 2010, SCE determined that a root cause evaluation was necessary to address the issues and assigned the evaluation to the staff. The inspectors asked to review the root cause evaluation during the inspection, but discovered that the root cause evaluation had yet to be approved by SCE management and therefore was not completed. SCE had extended the root cause evaluation twice, as documented in Nuclear Notification 200806886. Through discussions with the Corrective Action Program Manager, one reason for the extensions was the lack of qualified personnel available to complete the evaluation. The Corrective Action Program Coordinator (CAPCO) reviewed and approved the evaluation on April 9, 2010, which satisfied the timeliness requirements in place at the time. Nuclear Notification 200905083, dated May 3, 2010, identified that the evaluation was still not complete. The notification also documented deficiencies in the corrective action program, and identified Apparent Cause Evaluation (ACE) 200781028 in addressing those issues. The inspectors asked to review the apparent cause evaluation and discovered that it was also not completed and approved. SCE chartered the ACE on May 7, 2010, although the notification was written on February 4, 2010.

The inspectors acknowledge that SCE has revised the timeliness requirements in procedure SO123-XV-50.CAP-3, Corrective Action Program Evaluation and Action Plans, to be more consistent with industry standards. However, the inspectors concluded that SCE has not dedicated the resources and oversight necessary to ensure

the evaluation of the new cross-cutting themes in Problem Identification and Resolution is completed in a timely manner commensurate with its significance.

The inspectors reviewed the findings documented in inspection reports that have been issued by the NRC this year. The inspectors noted that thirteen findings were assigned cross-cutting aspects in the area of Problem Identification and Resolution. Among these findings, four different cross-cutting aspects were identified as the most significant contributor to the performance deficiencies. Twelve of the cross-cutting aspects were in the corrective action program component of the Problem Identification and Resolution cross-cutting area. The inspectors concluded that these collective findings identify continued deficiencies in the corrective action program at SONGS.

The inspectors observed several plant activities, including maintenance, operations, and management meetings. Observations include:

• The inspectors attended three department weekly standup meetings on July 13, 2010. Standup meetings are held every week, to initiate meaningful dialogue on station improvement in a small group setting, as written in the meeting agenda.

The July 13th meetings consisted of disseminating information regarding the stations transition to a new corrective action program database, Action Way.

The station credited these meetings as part of the communication plan for the transition. One inspector observed a meeting that covered the required material and participants that engaged in active discussion regarding the new program.

However, the other inspectors observed meetings that did not meet station expectations. In one instance, the meeting did not cover the required material; participants did not engage in meaningful dialogue; and the duration of the meeting was significantly less than the recommended time duration. Also, licensee personnel initiated Nuclear Notification 201014888 to document another meeting that did not meet the expectations. Additionally, inspectors questioned an operator that had facilitated a different meeting and expressed concern with the lack of training and preparation received by the operator prior to the meeting.

Given the significance placed on these meetings for communicating the transition to Action Way, the inspectors concluded that, in general, the meetings did not meet station expectations to engage everyone on site to drive for station excellence.

• The inspectors identified several instances where problems identified by station personnel were not entered into the corrective action program. For example, one department reconvened the weekly standup meeting, as described above, based on the inspectors feedback. At the beginning of the meeting, one participant identified that many people were not present that had attended the first meeting.

The meetings are mandatory and required for all personnel. The licensee did not enter the issue into the corrective action program until questioned by the inspectors. A second example occurred after discussions with an operator that was concerned with the lack of training and preparation before facilitating the weekly standup meeting, also described above. The licensee did not enter the issue into the corrective action program until questioned by the inspectors.

Section 4OA2.1.b.1 of this report identifies other problems that were not entered

into the corrective action program. The inspectors concluded that, while a significant number of condition reports are documented by the licensee, the station continues to be challenged in promptly identifying, reporting, and documenting problems by writing a Nuclear Notification, as required by procedure SO123-XV-50.CAP-1, Writing Nuclear Notifications for Problem Identification and Resolution, revision 4.

3. Finding

Introduction The inspectors identified a Green noncited violation of Technical Specification 5.5.1.1 for the failure of licensee management to provide a written procedure to define authorities and responsibilities of all work process area operators.

Specifically, the work process area had an additional operator, identified on the watchbill as the Control Room Coordinator (CRC), who performed activities normally performed by the Work Process Supervisor (WPS), including providing oversight for pre-job briefs and authorizing start of tasks. The authority and responsibilities of the Control Room Coordinator were not described in plant procedures, and the Control Room Coordinator routinely performed the duties of the Work Process Supervisor without receiving a turnover and formally accepting the position of Work Process Supervisor. Conduct of Operations Procedure SO123-0-A-2 Operations Division Personnel Responsibilities, revision 22, did not address the roles or responsibilities of the CRC, nor did it allow for the WPS to delegate his authority.

Description On July 13, 2010, an inspector observed work process area activities, including pre-job briefs and authorization of maintenance activities. The inspector observed a pre-job brief during which the WPS was not present, however, the CRC monitored the brief and authorized start of work. The CRC stated that he was an acceptable substitute for the WPS. The inspector also observed activities and interactions when both the CRC and WPS were present in the work process area, and both were authorizing work. The CRC also authorized emergent maintenance on a Unit 2 emergency diesel generator that was out of service at the time.

Based on these observations, the inspectors questioned the licensee on this issue and discovered that a longstanding practice existed to have the CRC assist the WPS in his duties whenever supported by shift manning. Upon further investigation, the inspectors discovered that the CRC authorities and responsibilities were not defined in any procedure, including Conduct of Operations Procedure SO123-0-A-2 Operations Division Personnel Responsibilities. Also, the procedure did not give the WPS authority to delegate his or her authority or responsibility. Additionally, the inspectors noted that the WPS had not conducted a turnover with the CRC, as directed by procedure SO123-XV-HU-2, Human Performance Tools, revision 4, Section 6.5, when handing off responsibility to other people.

The most significant contributing factor to this performance deficiency was the lack of process discipline to ensure the authorities, responsibilities and roles for decisions affecting nuclear safety are defined, communicated and implemented.

The licensee documented this finding in Nuclear Notification 201014984. The short term corrective actions included required reading and coaching to instruct Work Process Supervisors not to delegate their authority to authorize work without a formal turnover.

SCE will revise Conduct of Operations Procedures SO123-0-A-1, Operations Division Procedure, and SO123-0-A-2, Operations Division Personnel Responsibilities, to formally define authorities and responsibilities of the CRC.

Analysis The failure to establish, implement, and maintain procedures governing the roles and responsibilities of personnel in the management of work was a performance deficiency. The finding was more than minor because it could be reasonably viewed as a precursor to a significant event. Specifically, lack of a procedure to define the roles, responsibilities, and authorities of all personnel who may simultaneously hold work process area authority may lead to inadequate coordination of concurrent work and inadvertent authorization of multiple activities that could cause a plant transient or reactor trip. The finding is associated with the Initiating Events Cornerstone. Using the NRC Inspection Manual 0609, Attachment 0609.04, Phase 1-Initial Screening and Characterization of Findings, the finding is determined to have very low safety significance (Green) because it did not contribute to both the likelihood of a reactor trip and the likelihood that mitigation equipment or functions will not be available. The finding has a cross-cutting aspect in the area of Human Performance associated with decision-making because the licensee did not make safety-significant decisions using a systematic process, including formally defining the authority and roles for decisions affecting nuclear safety H.1(a).

Enforcement Technical Specification 5.5.1.1 requires, in part, that written procedures be established, implemented, and maintained covering activities specified in Appendix A, Typical Procedures for Pressurized Water Reactors and Boiling Water Reactors, of Regulatory Guide 1.33, Quality Assurance Program Requirements (Operations), dated February 1978. Specifically, Regulatory Guide 1.33, Appendix A, section 1.b includes administrative procedure for Authorities and Responsibilities for Safe Operation and Shutdown.

Contrary to the above, the licensee failed to establish, implement, and maintain written procedures covering activities specified in Appendix A of Regulatory Guide 1.33, specifically governing the authorities and responsibilities of the Work Process Supervisor and Control Room Coordinator. Because this finding is of very low safety significance and has been entered into the licensees corrective action program as Nuclear Notification 201014984, this violation is being treated as a noncited violation, consistent with Section VI.A of the NRC Enforcement Policy: NCV 05000361;05000362/2010010-01, Failure to Define Authorities and Responsibilities of Work Process Area Operator.

.2 Safety Conscious Work Environment (SCWE)

a. Inspection Scope

In a letter (Chilling Effect), dated March 2, 2010 (ADAMS ML100601272), the NRC identified concerns with the Safety Conscious Work Environment at SONGS. SCE responded in a letter, dated March 31, 2010, with the conclusions and corrective actions

planned as a result of a root cause evaluation that was performed between December 2009 and March 2010. The inspectors reviewed the root cause evaluation as part of this inspection. The inspection team did not perform focus group interviews as part of this inspection since adequate time had not elapsed since the issuance of the March 2, 2010, Chilling Effect letter.

b. Observations The inspectors reviewed the stations Safety Conscious Work Environment Root Cause Evaluation as documented in Nuclear Notification 200709479. Overall, the inspectors concluded that the cause evaluation and corrective action plan appeared to be adequate, however, parts of the cause evaluation could be more thoroughly evaluated for underlying cultural causes and some corrective actions are not fully described and defined.

The evaluation divided the cause analysis into four pillars: Employees Raising Concerns without Fear of Retaliation, Normal Problem Resolution Processes, Alternate Problem Resolution Processes, and Methods to Detect and Prevent Retaliation. The inspectors concluded that the root cause analysis appeared to be of adequate detail and depth for three of the pillars: Normal Problem Resolution Processes, Alternate Problem Resolution Processes, and Methods to Detect and Prevent Retaliation. Corrective actions for these Pillars correlated to the identified causes. However, the inspectors concluded that the analysis appeared to be narrow for Pillar 1: Employees Raising Concerns without Fear of Retaliation, in that the analysis could have been taken further by asking additional Why? questions. The evaluation stopped at the level of process/procedural issues and did not probe deeper into cultural concerns. Also, not all contributing causes appeared to be addressed by the corrective actions listed in the Root Cause Evaluation and associated Corrective Action Plan. The documentation for several corrective actions for Pillar 1 was vague in that planned training was not described in depth. Discussions with licensee staff revealed that supervisors would receive more tailored, in-depth training than the workers, but this was not documented in the Corrective Action Plan.

SCE initiated action to reopen the root cause evaluation to provide clarification and detail in the corrective action plan. The inspectors observations have been entered into the licensees Corrective Action Program as Nuclear Notification 201018461. The planned action was to revise the analysis description for Pillar 1 to show how some of the Pillar 4 causes that went to a deeper level of analysis applied to Pillar 1.

.3 Metrics and Measures to Monitor Improvement

a. Inspection Scope

The inspectors reviewed the indicators and metrics used by the licensee to track progress in improving station performance. The metrics reviewed were associated with commitments made to the NRC in response to

(1) open substantive crosscutting issues in Human Performance and in Problem Identification and Resolution, and

(2) a Chilling Effect letter issued to SONGS on March 2, 2010. The inspectors reviewed these metrics

to evaluate whether they would provide an effective indication of station performance trends.

b. Assessment The inspectors noted that there were several inconsistencies in the data presented in the metrics that were reviewed. Several specific examples were previously discussed in Inspection Report 05000361;05000362/2010006. Additionally, the inspectors noted that the descriptions of the data sources for several metrics were unclear, misleading, or potentially incomplete. Specific examples included:

• The metric Quality of Corrective Action Implementation tracked the percentage of corrective action closure packages which are accepted by the Closure Review Board (CRB) the first time they are presented. Based on observations of CRB meetings, the inspectors determined that the CRB focused more on the quality of documentation of actions performed than on the quality of the implementation of those actions.

• Inspection Report 05000361;05000362/2010006 noted that the metrics tracking the average time to perform cause evaluations was misleading due to the potential for a significant amount of time elapsing between the Evaluation Complete Date and approval by the Corrective Action Review Board (CARB).

While the licensee has since revised this metric to track completion time through CARB approval, the inspectors noted that at least one instance had been identified where a cause evaluation assignment had been delayed several months from the date the associated notification had been generated; this delay was not counted in the metric. Further, the licensee did not update historical data to reflect the revised Evaluation Complete Date.

At the conclusion of this inspection, the licensee was revising several of these metrics to more accurately reflect station performance.

Also, the inspectors concluded that, while some metrics indicate improving performance, many continued to indicate declining performance or a lack of improvement. For example, the metric for open corrective action program notifications (Significance Level 1-4) has indicated unsatisfactory performance (Red) for the period of February through May 2010. The metric for root cause evaluation time to perform metrics indicated unsatisfactory performance and a negative trend since January 2010. The metric for cause evaluation corrective actions open and percent overdue indicated unsatisfactory performance since July 2009. The metric for written instruction use errors indicated unsatisfactory performance since July 2009, and also indicated a significant negative trend since October 2009. The metric for written instruction quality count indicated unsatisfactory performance since July 2009, although the metric indicated a positive trend since February 2010. For each of these metrics, SCE entered the issues into the corrective program and initiated actions to address the unsatisfactory performance.

4OA5 Other Activities: Confirmatory Order Follow-up for EA-07-232 [NRC INSPECTION

REPORT 05000361/2007016; 5000362/2007016, AND OFFICE OF INVESTIGATIONS REPORT 4-2007-016]

1. Inspection Scope

By letter, dated January 11, 2008 (ADAMS ML080110380), the NRC issued a Confirmatory Order to SCE as part of a settlement agreement through the NRCs alternative dispute resolution process. The settlement was in regards to the falsification, by a contract fire protection specialist, of firewatch certification sheets on numerous occasions from April 2001 to December 2006 at SONGS. On December 3, 2008, Inspection Report 05000361;05000362/2008012 documented closure of Items 1, 2d, 2e, 2f, 2i, 2j, 2k, and 3 of the Confirmatory Order.

On November 14, 2008, SCE submitted a letter to the NRC titled, "Response to Confirmatory Order EA 07-232 and Notice of Violation EA 07-141" (ML083230047), in which the licensee defined and established success criteria for closure of each of the Confirmatory Order Items. On January 14, 2009, the licensee submitted a second letter to the NRC titled Response to Confirmatory Order EA 07-232 and Notice of Violation EA 07-141 (ML090210076) which included a report on the status of each Confirmatory Order Item. In this letter, the licensee stated that all items with the exception of Item 2c and Item 2l were closed or ready to close. On July 31, 2009, Inspection Report 05000361;05000362/2009003 documented closure of Items 2a, 2b, 2g, and 2h, of the Confirmatory Order. Items 2c and 2l remained open as an Unresolved Item (URI 05000361;05000362/2008012-04).

On June 25, 2010, SCE submitted an additional letter to the NRC titled, Response to Confirmatory Order EA 07-232 and Notice of Violation EA 07-141 stating that the requirements of Item 2c had been satisfied. Additionally, to satisfy the requirement of Item 2l, this letter discussed the basis for concluding that the Order had been satisfied.

The inspectors used Inspection Procedures 92702 and 71152 to assess the licensees completion of these items and interviewed site personnel regarding related training and communications received. The inspectors also reviewed and assessed for adequacy the programs, processes, and procedures for detecting, addressing, and preventing deliberate non-compliances which the licensee had put in place in response to the Confirmatory Order.

2. Assessment

Based on the information provided by the licensee, the inspectors determined that the licensee demonstrated an adequate basis for closure of the remaining two open items of the Confirmatory Order. Specifically,

• Item 2c of the Confirmatory Order states, "SCE will expand the Corporate Ethics Program to encompass long-term (i.e., greater than 90 days) managers and supervisors of independent contractor workers at SONGS, who will be required to take the integrity training in 2008. SCE will conduct Corporate Ethics Training

for SONGS managers and supervisors in 2008 and other SONGS employees in 2009."

As noted in Inspection Report 05000361;05000362/2008012, SCE expanded the Corporate Ethics Program to encompass long-term (i.e., greater than 90 days)managers and supervisors of independent contractor workers at SONGS. The inspectors verified that as of December 31, 2008, 98.7 percent of the baseline target audience had completed the required training.

In 2009, SCE performed half-day ethics training sessions for all employees. This training included both Corporate Ethics Training and a SONGS-specific case study presented by a SONGS senior manager. The inspectors verified that all of the required baseline target audience had completed the required training.

Additionally, 251 individuals not identified as part of the baseline target audience had completed the required training.

• Item 2l of the Confirmatory Order states, "Upon completion of the terms of the Confirmatory Order, SCE will provide the NRC with a letter discussing its basis for concluding the Order has been satisfied."

On June 25, 2010, the licensee submitted a letter to the NRC stating that SCE had completed all actions required by the Confirmatory Order. The letter further stated that the results of the monitoring program established per Item 2a indicated that processes and procedures which had been put in place to ensure that deliberate non-compliances are detected and addressed had been effective.

The inspectors noted that SCE identified nine instances of deliberate non-compliance between January 11, 2008, when the Confirmatory Order was issued, and the conclusion of the inspection on July 16, 2010. Five of these nine instances occurred between November 2009 and January 2010. In response to these nine deliberate non-compliances, the licensee performed an Apparent Cause Evaluation under Nuclear Notification NN 200894349. This evaluation identified the need to continue the training and monitoring programs which were developed in response to the Confirmatory Order.

The inspectors determined that this large number of deliberate non-compliances indicated that training on ethics and the disciplinary policy had not been fully effective in eliminating deliberate non-compliances. However, the inspectors noted that SCEs prompt identification of and/or attention to these instances of deliberate non-compliance indicated that the programs and processes established to detect and address instances of deliberate non-compliance had been effective.

Through interviews, the inspectors determined that, at the end of the inspection period, SCE management intended to continue to implement the programs and processes developed in response to the Confirmatory Order to detect and address deliberate non-compliance. Additionally, licensee management intended to continue to take actions to prevent further instances of deliberate non-compliance from occurring.

3. Findings The inspectors determined that as of June 25, 2010 all requirements of Confirmatory Order issued as EA-07-232 to SCE had been completed.

URI 05000361;05000362/200812-04, Open Confirmatory Order Items, is closed.

However, due to the duration of the time that the Order has been in effect, the NRC is planning an additional inspection to review the sustainability of the actions that have been taken prior to determining that the Order has been satisfied.

4OA6 Meetings

Exit Meeting Summary

On July 16, 2010, the inspectors presented the inspection results to Mr. Ross Ridenoure, Senior Vice President and Chief Nuclear Officer, and other members of the licensee staff. The licensee acknowledged the issues and findings presented.

The inspectors asked the licensee whether any materials examined during these inspections should be considered proprietary. The licensee confirmed that all proprietary information was returned or destroyed during these inspections.

ATTACHMENT:

SUPPLEMENTAL INFORMATION

KEY POINTS OF CONTACT

Licensee Personnel

D. Bauder, Site Vice President and Station Manager

B. Corbett, Director, Performance Improvement

G. Cook, Manager, Nuclear Regulatory Affairs

S. Gardner, Senior Nuclear Engineer, Maintenance/System Engineering

S. Genschaw, Manager, Maintenance & Construction Services

M. Graham, Manager, Plant Operations

G. Johnson, Jr., Senior Nuclear Engineer, Maintenance/System Engineering

L. Kelly, Engineer, Nuclear Regulatory Affairs

G. Kline, Director, Engineering

A. Martinez, Manager, Performance Improvement

M. McBrearty, Technical Specialist, Nuclear Regulatory Affairs

R. Ridenoure, Senior Vice President and Chief Nuclear Officer

R. Sandstrom, Manager, Special Projects

R. St. Onge, Director, Nuclear Regulatory Affairs

NRC Personnel

G. Warnick, Senior Resident Inspector

J. Reynoso, Resident Inspector

LIST OF ITEMS OPENED, CLOSED, AND DISCUSSED

Opened and Closed

05000361;05000362/2010010-01 NCV Failure to Define Authorities and Responsibilities of Work Process Area Operator (Section 4OA2)

Closed

05000361;05000362/2008012-04 URI Open Confirmatory Order Items (Section 4OA5)

Attachment 1