IR 05000361/2010011
| ML103560014 | |
| Person / Time | |
|---|---|
| Site: | San Onofre  |
| Issue date: | 12/22/2010 |
| From: | Ryan Lantz NRC/RGN-IV/DRP/RPB-D |
| To: | Peter Dietrich Southern California Edison Co |
| References | |
| EA-08-296, FOIA/PA-2011-0157 IR-10-011 | |
| Download: ML103560014 (14) | |
Text
ber 22, 2010
SUBJECT:
SAN ONOFRE NUCLEAR GENERATING STATION - NRC INSPECTION PROCEDURE 95001 SUPPLEMENTAL INSPECTION REPORT 05000361/2010011; AND INTERIM ASSESSMENT LETTER
Dear Mr. Dietrich:
On November 15 through November 19, 2010, the U.S. Nuclear Regulatory Commission staff performed the on-site portion of a supplemental inspection pursuant to Inspection Procedure 95001, Inspection for One or Two White Inputs in a Strategic Performance Area, at your San Onofre Nuclear Generating Station, Unit 2 facility. This inspection was performed following notification to the NRC on August 23, 2010, of your staffs readiness for this inspection. The enclosed inspection report documents the inspection results. Preliminary inspection results were discussed with Mr. J. Sheppard, Senior Vice President and Chief Nuclear Officer, and other members of your staff on November 19, 2010. Final inspection results were discussed with you and your staff at an exit meeting conducted on December 21, 2010.
As required by the NRC Reactor Oversight Process Action Matrix, this supplemental inspection was performed because a finding of low to moderate safety significance (White) under the Mitigating Systems cornerstone was identified in the 4th quarter of 2008. The White finding was associated with the failure to establish appropriate instructions and performance oversight for replacement of the Unit 2 safety-related battery 2B008 output breaker which resulted in the battery being inoperable due to loose breaker bolts from May 2004 to March 2008. This issue was documented previously in NRC Inspection Report 05000361; 362/2008013. A supplemental inspection was completed on December 4, 2009, and documented in NRC Inspection Report 0500361; 362/2009008. The supplemental inspection concluded that objective numbers 1 and 2 of NRC Inspection Procedure 95001 were met, but that objective number 3 was not met in that the NRC lacked assurance that your corrective actions were fully developed and that their implementation would be effective.
Southern California Edison Company -2-The objective of this supplemental inspection was to provide assurance that objective number 3; Corrective actions were or will be sufficient to address and preclude repetition of the root and contributing causes, of NRC Inspection Procedure 95001 was met. The inspection consisted of examination of activities conducted under your license as they related to safety, compliance with the Commissions rules and regulations, and the conditions of your license.
Based on the results of this inspection, no findings of significance were identified. The NRC determined that the corrective actions implemented to address the deficiencies leading to the White finding and to prevent recurrence were adequate to address the technical as well as organizational performance issues. Therefore, the White finding (05000361/2008013-05),
Failure to Establish Appropriate Instructions is closed. This finding will continue to be considered for evaluation of NRC Action Matrix column status until December 31, 2010, in accordance with NRC Manual Chapter 0305, Operating Reactor Assessment Program. As a result, the NRC determined the performance at San Onofre Nuclear Generating Station, Unit 2, to be in the Licensee Response Column (Column 1) of the Reactor Oversight Process Action Matrix as of the date of this letter. San Onofre Nuclear Generating Station, Unit 3 remains in the Licensee Response Column.
In accordance with 10 CFR 2.390 of the NRC's "Rules of Practice," a copy of this letter, its enclosure, and your response (if any) will be available electronically for public inspection in the NRC Public Document Room or from the Publicly Available Records (PARS) component of NRC's document system, Agencywide Documents Access and Management System (ADAMS).
ADAMS is accessible from the NRC Website 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 No.: 50-361 License No.: NPF-10
Enclosure:
Inspection Report 05000361/2010011 w/ Attachment: Supplemental Information
REGION IV==
Docket: 50-361 Licenses: NPF-10 Report No.: 05000361/2010011 Licensee: Southern California Edison Company (SCE)
Facility: San Onofre Nuclear Generating Station, Unit 2 Location: 5000 South Pacific Coast Highway San Clemente, California Dates: November 15, 2010 through December 21, 2010 Inspectors: N. Hernandez, Reactor Inspector S. Graves, Senior Reactor Inspector Approved By: R. Lantz, Chief Project Branch D Division of Reactor Projects-1- Enclosure
SUMMARY OF FINDINGS
Inspection Report 05000361/2010011; 11/15/2010 - 12/21/2010; San Onofre Nuclear
Generating Station, Unit 2, Supplemental Inspection - Inspection Procedure (IP) 95001.
The inspection was performed by a senior reactor inspector and a reactor inspector from the NRC Region IV office.
The significance of most findings is indicated by their color (Green, White, Yellow, or Red) using Inspection Manual Chapter 0609, Significance Determination Process.
Findings for which the significance determination process 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.
NRC-Identified Findings and Self-Revealing Findings
Cornerstone: Mitigating Systems
The NRC staff performed this follow up supplemental inspection (Inspection Procedure 95001, Inspection for One or Two White Inputs in a Strategic Performance Area,) to assess the licensees effectiveness and progress in the broad corrective actions that were developed as a result of the White finding associated with the failure to establish appropriate instructions and performance oversight for replacement of the Unit 2 safety-related battery 2B008 output breaker in March 2004. The inspectors determined that the corrective actions were adequate to address the root and contributing causes of the White finding, and to prevent recurrence. Therefore, the White finding (05000361/2008013-05), Failure to Establish Appropriate Instructions is closed.
Findings No findings were identified.
Licensee-Identified Violations
None
REPORT DETAILS
OTHER ACTIVITIES
4OA4 Supplemental Inspection
a. Inspection Scope
The NRC staff performed this supplemental inspection in accordance with portions of Inspection Procedure (IP) 95001 to assess the licensees corrective actions for a low to moderate safety significant (White) inspection finding, which affected the mitigating systems cornerstone in the reactor safety strategic performance area. The inspection objective was to provide assurance that the licensees corrective actions for risk-significant performance issues were sufficient to address the root and contributing causes and to preclude recurrence. This objective was accomplished by direct inspection, using section 02.03, Corrective Actions, of Inspection Procedure 95001.
The licensee entered the Regulatory Response Column of the NRCs Action Matrix in the 4th quarter of 2008 as a result of an inspection finding of low to moderate safety significance (White). The White finding was associated with a violation of 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, involving the failure to establish appropriate instructions for performing maintenance activities on safety-related 125 Vdc station battery breaker 2D201, which resulted in a degraded condition that existed for approximately 4 years. The White finding was found as part of a special inspection tasked with examining station activities associated with deficient electrical connections having the potential to adversely affect the safety function of multiple safety systems used for accident mitigation. The final significance determination, performed by the regional senior reactor analyst and approved by the NRC significance and enforcement review panel, determined the finding was of low to moderate safety significance, and was discussed in NRC inspection report 05000361;362/2008013.
In response to this white finding the NRC conducted a supplemental inspection from November 30, 2009 to February 24, 2010. This supplemental inspection concluded that objective numbers 1 and 2 of Inspection Procedure 95001 were met; however, for objective number 3, corrective actions needed more time to be fully developed and implemented.
Therefore a follow up supplemental inspection would be conducted in calendar year 2010.
Your staff informed the NRC on August 23, 2010 of their readiness for this supplemental inspection.
In preparation for the inspection, the licensee performed trending analysis to determine the effectiveness of the corrective actions and to identify weaknesses that existed in their organizational culture and processes that should be further addressed. The inspectors reviewed numerous corrective actions that were taken to address the identified root and contributing causes. The inspectors also held discussions with licensee personnel to assess whether the root and contributing causes were understood and corrective actions taken were appropriate to address the causes and preclude repetition.
.1 Evaluation of the Inspection Requirements
Corrective Actions A.
IP 95001 requires that the inspection staff determine if the licensee specified appropriate corrective actions for each root and/or contributing cause.
The licensees root cause evaluations developed over 100 corrective actions to be implemented for the white finding, including the technical issue of the loose battery breaker bolts, and the associated human performance deficiencies. The root cause evaluations and corrective actions associated with the loose bolts were determined to be appropriate based on the supplemental inspection performed from November 30, 2009 - February 24, 2010 and documented in NRC inspection report 05000361;362/2008013. For the human performance deficiencies, one root cause and five contributing causes were identified.
Examples of corrective actions for the root cause included:
- Change maintenance procedures to add requirements to immediately notify the control room and back out of tasks pending further guidance when surveillances fail
- Conduct stand-down meetings with all leaders for the purpose of reviewing policies governing procedure use and procedure adherence. This meeting emphasizes that procedure compliance is necessary to ensure continued operation of the station
- The human performance program has been strengthened by redesigning procedures to incorporate the results of industry benchmarking
- Add conservative decision making in initial and annual refresher training
- Management to communicate and reinforce to employees the expectation that work instructions and procedures will be followed verbatim, or work stopped until the procedure issue is resolved
- Trend procedure non-compliance issues Similarly, examples of the corrective actions taken or planned for the contributing causes included:
- Communicate revised expectations for technical specification surveillance implementation and communication within operations, maintenance, and work control
- Develop and institutionalize an integrated risk management program to include identification of risk significant activities and evolutions, risk assessment guidance for emergent activities and operations awareness of all risk sensitive activities
- Develop and implement metrics for written instruction use and adherence and quality, and create a quality measurement process procedure to be used by procedure writers for consistent review of procedure quality Revise the Human Performance procedure to define a list of potential error traps for written instructions and expectations for use and adherence
- Develop guidance for Shift Managers to communicate the need for absolute clarity when approving work flow methodology during emergent work that impacts the safe and reliable operation of the plant
- Communicate to employees that SONGS personnel must act to prevent non-conservative decision making at all levels by emphasizing:
o Proper procedure use and adherence o Notify the control room whenever something goes wrong or is amiss in the field o A questioning attitude o Need to move away from the presumption of operable mindset o Significance of NRC Enforcement Actions The inspectors determined that the corrective actions for the root and contributing causes were appropriate and addressed each root and contributing cause.
B. IP 95001 requires that the inspection staff determine if the licensee prioritized corrective actions with consideration of risk significance and regulatory compliance.
The licensees corrective actions to address the root and contributing causes for the human performance deficiencies reflected the licensees understanding that significant corrective actions were required to address the cultural issues. The senior management team has adequately changed the stations behaviors to reflect best industry practices, and placed appropriate emphasis on returning the station to excellence. The inspectors reviewed the corrective actions and found that they were appropriately prioritized with respect to risk-significance and regulatory compliance.
C. IP 95001 requires that the inspection staff determine if the licensee established a schedule for implementing and completing the corrective actions.
The licensees root cause evaluation provided cross reference between the root and contributing causes to the corrective action items associated with each. The licensee developed tables indicating the priority, assigned owner, required completion date and a description of each action item. The licensee established due dates and assignments for the corrective actions in accordance with their corrective action procedure SO123-XV-50, "Corrective Action Program."
D. IP 95001 requires that the inspection staff determine if the licensee developed quantitative and/or qualitative measures of success for determining the effectiveness of the corrective actions to preclude repetition.
As documented in the associated RCEs, the licensee established measures for determining the effectiveness of the corrective actions. These measures included the following:
- Monitoring the number of work plans that are issued with missed critical steps and without defense-in-depth steps
- An assessment of the adequacy of supervisory oversight of the maintenance personnel. The review includes field observation of pre-job briefs, critical step identification, critical step verification by supervisors and use of procedures in the field, emphasizing procedure adherence
- Performance of an effectiveness review of the corrective actions to confirm the safety culture aspects identified in this RCE have been addressed
- Review of critical step verification for proper torquing of bolts and fasteners required in work orders through sampling of work orders generated in the last 2 years
- An assessment to identify potentially loose electrical connections and determine, based on risk to the plant, if follow-up activities are necessary to verify connection integrity The licensee staff entered these issues into their corrective action program to ensure that effectiveness reviews and enhanced monitoring were performed.
The inspectors determined that quantitative and qualitative measures of success had been developed for determining the effectiveness of the corrective actions to preclude repetition.
b. Findings
No findings were identified.
4OA6 Meetings
Exit Meeting Summary
On November 19, 2010, the inspectors presented the preliminary inspection results to Mr. J. Shepherd, Chief Nuclear Officer, and other members of his staff. Mr. Shepherd acknowledged the information, and that regional management would review the information to make a final decision on status of the White finding. On December 21, 2010, the final inspection results were presented in a teleconference with Mr. P. Dietrich, and members of his staff. The inspectors asked the licensee if any proprietary material had been examined during the inspection. The licensee did not identify any proprietary information.
ATTACHMENT:
SUPPLEMENTAL INFORMATION
KEY POINTS OF CONTACT
Licensee
P. Dietrich Senior Vice President and Chief Nuclear Officer
J. Shepherd Senior Vice President and Chief Nuclear Officer (Temp)
D. Bauder Site Vice President and Station Manager
- R. St. Onge Director, Nuclear Regulatory Affairs
- R. Corbett Director, Performance Improvement
- G. Kline Senior Director, Engineering and Support Services
T. McCool Plant Manager
- B. Wallace Director, Nuclear Training
- E. Hubley Director, Maintenance and Construction
- K. Johnson Manager, Design Engineering
- C. Williams Manager, Inspections
- M. McBrearty Engineer, Nuclear Regulatory Affairs
- S. Ryba Project Manager, Performance Improvement
- S. Chun Manager, Mechanical Engineering
- C. Mell Manager, Maintenance
- T. OMeara Manager, Nuclear Safety Culture
Nuclear Regulatory Commission
G. Warnick Senior Resident Inspector
M. Young Resident Inspector
J. Reynoso Resident Inspector
LIST OF ITEMS OPENED, CLOSED, AND DISCUSSED
Opened
None
Closed
- 05000361/2008013-05 VIO Failure to Establish Appropriate Instructions
Discussed
None
-1- Attachment