IR 05000361/2017004

NRC Inspection Report 05000361/2017-004 and 05000362/2017-004

ML17268A393
Person / Time
Site:	San Onofre
Issue date:	09/26/2017
From:	Ray Kellar Division of Nuclear Materials Safety IV
To:	Thomas J. Palmisano Southern California Edison Co
R. Browder
References
IR 2017004
Download: ML17268A393 (27)

Text

UNITED STATES ber 26, 2017

SUBJECT:

SAN ONOFRE NUCLEAR GENERATING STATION - NRC INSPECTION REPORT 05000361/2017-004 AND 05000362/2017-004

Dear Mr. Palmisano:

This letter refers to the U.S. Nuclear Regulatory Commission (NRC) inspection conducted on August 28-31, 2017, at the San Onofre Nuclear Generating Station (SONGS), Units 2 and 3.

The NRC inspectors discussed the results of this inspection with you and other members of your staff during an onsite final exit meeting conducted on August 31, 2017. The inspection results are documented in the enclosure to this inspection report.

This inspection examined activities conducted under your license as they relate to public health and safety, the common defense and security, and to confirm compliance with the Commission's rules and regulations, and with the conditions of your license. Within these areas, the inspection consisted of selected examination of procedures and representative records, observations of activities, and interviews with personnel. Specifically, the inspectors reviewed the decommissioning activities of Units 2 and 3 involving the transition of programs to SONGS Decommissioning Solutions (SDS) the decommissioning agent, synchronous condenser activities, spent fuel safety, fire protection program, corrective action program, safety review and design change programs, and the emergency preparedness program. In addition, the biennial emergency exercise conducted on August 29, 2017, was observed as part of this inspection.

No violations were identified and no response to this letter is required.

In accordance with 10 CFR 2.390 of the NRCs Agency Rules of Practice and Procedure, a copy of this letter, its enclosure, and your response if you choose to provide one, will be made available electronically for public inspection in the NRC Public Document Room or from the NRCs Agencywide Documents Access and Management System (ADAMS). ADAMS is accessible from the NRCs Website at http://www.nrc.gov/reading-rm/adams.html.

To the extent possible, your response should not include any personal privacy or proprietary, information so that it can be made available to the Public without redaction. If you have any questions regarding this inspection report, please contact Rachel Browder at 817-200-1452, or the undersigned at 817-200-1549.

Sincerely,

/RA/

Ray L. Kellar, P.E., Chief Fuel Cycle and Decommissioning Branch Division of Nuclear Materials Safety Docket Nos. 50-361; 50-362 License Nos. NPF-10; NPF-15 Enclosure:

Inspection Report 05000361/2017-004; 05000362/2017-004 w/Attachment: Supplemental Information

U.S. NUCLEAR REGULATORY COMMISSION

REGION IV

Docket No. 05000361; 05000362 License No. NPF-10; NPF-15 Report No. 05000361/2017-004; 05000362/2017-004 Licensee: Southern California Edison Company Facility: San Onofre Nuclear Generating Station (SONGS), Units 2 and 3 Location: 5000 South Pacific Coast Highway, San Clemente, California Dates: August 28 - 31, 2017 Inspectors: Rachel S. Browder, C.H.P., Senior Health Physicist Fuel Cycle and Decommissioning Branch Division of Nuclear Materials Safety Eric Simpson, C.H.P., Health Physicist Fuel Cycle and Decommissioning Branch Division of Nuclear Materials Safety Stephanie Anderson, Health Physicist Fuel Cycle and Decommissioning Branch Division of Nuclear Materials Safety Marlayna Vaaler, Project Manager Reactor Decommissioning Branch Decommissioning, Uranium Recovery, and Waste Programs Office of Nuclear Materials Safety and Safeguards Approved By: Ray L. Kellar, P.E., Chief Fuel Cycle and Decommissioning Branch Division of Nuclear Materials Safety Enclosure

EXECUTIVE SUMMARY San Onofre Nuclear Generating Station, Units 2 and 3 NRC Inspection Report 05000361/2017-004; 05000362/2017-004 This U.S. Nuclear Regulatory Commission (NRC) inspection was a routine, announced inspection of decommissioning activities being conducted at the SONGS Units 2 and 3. In summary, the licensee was conducting these activities in accordance with site procedures, license requirements, and applicable NRC regulations.

Decommissioning Performance and Status Review

• The licensees survey results and soil sample analyses of the southern portion of the switchyard indicated the area was indistinguishable from background radiological levels and therefore met the unrestricted use criteria established under 10 CFR 20.1402. Based on the survey results, the excavated soil had been unconditionally released from the site. The licensee was monitoring and maintaining liquids at the site in accordance with the Updated Final Safety Analysis Report (UFSAR). In addition, the licensee was implementing a systematic approach in the transition of 21 programs to the decommissioning agent as part of its oversight of the decommissioning activities at the site. (Section 1.2)

Spent Fuel Pool (SFP) Safety

• The SONGS Units-2 and -3 SFPs were being maintained in accordance with technical specifications and procedural requirements. The licensee was safely storing spent fuel in wet storage. (Section 2.2)

Radioactive Waste Treatment, Effluent, and Environmental Monitoring

• The licensees radiological environmental monitoring program (REMP) was being conducted in accordance with the appropriate regulatory requirements as prescribed by the SONGS Offsite Dose Calculation Manual (ODCM). (Section 3.2)

Safety Reviews, Design Changes, and Modifications

• The licensees management, contractor oversight, and onsite review committees (OSRC)

were being conducted and maintained in accordance with the appropriate regulatory requirements as prescribed by the SONGS Decommissioning Quality Assurance Plan (DQAP). The licensee has established additional oversight and controls for contractor programs to ensure that activities were being conducted in accordance with the applicable regulatory requirements, license conditions, DQAP procedures, and SONGS management programs being implemented by Southern California Edison (SCE), SONGS Decommissioning Solutions (SDS), or both. (Section 4.2.a)

• The licensees safety review processes, procedures, and training programs were being conducted and maintained in accordance with the appropriate regulatory requirements as prescribed by the SONGS DQAP. The licensee had established 10 CFR 50.59 and 10 CFR 72.48 programs to ensure that activities were being conducted in accordance with the applicable regulatory requirements, license conditions, and DQAP procedures.

Decommissioning activities were being implemented in accordance with the requirements of 10 CFR 50.59, 10 CFR 50.71, 10 CFR 72.48, and 10 CFR Part 50, Appendix B.

(Section 4.2.b)

Self-Assessment, Auditing and Corrective Action

• The licensee had established audit, review, and oversight programs to ensure that activities were being conducted in accordance with the applicable regulatory requirements, license conditions, and DQAP procedures. These programs functioned in a timely, independent, and appropriate manner. (Section 5.2.a)

• The licensee had implementing its corrective action program in accordance with appropriate regulatory requirements as prescribed by the SONGS DQAP, and provided adequate oversight of the SDS corrective action program to ensure that any issues identified by contractor staff were appropriately documented, tracked, and dispositioned by the proper personnel. Based on the sample of documents reviewed and activities observed, the inspectors determined that the licensee adequately implemented its policies and procedures associated with the corrective action program in accordance with the applicable regulatory requirements, license conditions, and DQAP procedures. (Section 5.2.b)

Fire Protection

• The inspectors reviewed the licensees existing fire protection program including implementing procedures, equipment, staffing, and training. The inspectors conducted walk-downs of plant equipment and observed control of combustible materials, housekeeping, and ignition sources. The inspectors concentrated on areas and equipment supporting the SFP and islanding equipment. In summary, the fire protection program was determined to be in compliance with regulatory and license requirements. (Section 6.2)

Decommissioning Emergency Preparedness Scenario Review and Exercise Evaluation

• The inspectors observed a biennial emergency exercise conducted on August 29, 2017, and concluded that the licensees emergency response organization (ERO) effectively implemented its Permanently Defueled Emergency Plan to adequately protect the public health and safety. The licensee demonstrated an adequate management critique process that identified issues and weaknesses, which were entered into the corrective action system for resolution. (Section 7.2)

Decommissioning Emergency Preparedness Program Evaluation

• The inspectors concluded that the licensee appropriately implemented the requirements of 10 CFR 50.54(q)(3) with respect to Permanently Defueled Emergency Plan, Revision 3, Permanently Defueled Emergency Action Levels, Revision 2, and associated procedures.

The inspectors did not identify any reductions in the effectiveness of the Permanently Defueled Emergency Plan. The licensee was implementing its Permanently Defueled Emergency Plan as required and the capability to respond to an emergency was being maintained. (Section 8.2)

Report Details Summary of Plant Status On June 12, 2013, SCE, the licensee, formally notified the NRC by letter that it had permanently ceased power operations at Units 2 and 3, effective June 7, 2013. The document is available in the Agencywide Documents Access and Management System (ADAMS) under Accession No.

(ADAMS Accession No. ML131640201). By letters dated June 28, 2013, (ADAMS Accession No.

ML13183A391) and July 22, 2013, (ADAMS Accession No. ML13204A304) the licensee informed the NRC that the reactor fuel had been permanently removed from Units 3 and 2, respectively.

The licensee submitted its Post-Shutdown Decommissioning Activities Report on September 23, 2014, (ADAMS Accession No. ML14269A033), which is required to be submitted within two-years following permanent cessation of operations under 10 CFR 50.82(a)(4). In response to the licensees amendment request, the NRC issued the Permanently Defueled Technical Specifications on July 17, 2015, (ADAMS Accession No. ML15139A390) along with revised facility operating licenses to reflect the permanent cessation of operations at SONGS Units 2 and 3.

On March 11, 2016, (ADAMS Accession No. ML16055A522) the NRC issued two revised facility operating licenses for SONGS Units 2 and 3, in response to the licensees amendment request dated August 20, 2015, (ADAMS Accession No. ML15236A018). The license amendment allowed for the licensee to revise its Updated Final Safety Analysis Report (UFSAR) to reflect the significant reduction of decay heat loads in the SONGS Units 2 and 3 SFPs resulting from the elapsed time since the permanent shutdown of the units in 2012. The revisions support design basis changes made by the licensee associated with the implementation of cold and dark plant status as described in the PSDAR.

The NRC approved exemptions from certain emergency planning requirements in 10 CFR 50.47(b),

10 CFR 50.47(c)(2) and 10 CFR Part 50, Appendix E, Section IV, which became effective on June 4, 2015, (ADAMS Accession No. ML15082A204). The licensee submitted a license amendment request dated December 15, 2016, (ADAMS Accession No. ML16355A015) to revise the Permanently Defueled Emergency Plan (PDEP) into an Independent Spent Fuel Storage Installation (ISFSI)-Only Emergency Plan, and to revise the Emergency Action Level (EAL) scheme into an ISFSI-only EAL for the SONGS Units 1, 2, and 3. The proposed changes were submitted to the NRC for approval prior to implementation, as required under 10 CFR 50.54(q)(4) and 10 CFR 72.44(f). The license amendment request is under review by the NRCs Office of Nuclear Security and Incident Response.

On December 20, 2016, the licensee announced the selection of AECOM and EnergySolutions as the decommissioning general contractor for SONGS. The joint venture between the two companies will be known as SDS. The SDS will manage the decommissioning activities as the decommissioning general contractor, which is described in the licensees PSDAR.

The spent fuel was being safely stored in the two SFPs. The licensee had completed the installation of the 12-kilovolt, non-safety and seismic Category III, electrical ring bus and associated equipment that will facilitate decommissioning of various plant systems. The construction of the San Diego Gas and Electric synchronous condenser was being conducted during the on-site inspection. The licensee performed its biennial emergency response exercise on August 29, 2017, which involved off-site response by Camp Pendleton Fire Department. In addition, the licensee had completed the construction of the Holtec HI-STORM UMAX

independent spent fuel storage installation (ISFSI) expansion and was finalizing the dry runs of the Holtec multi-purpose canisters (MPC-37), which are inspected by the regional NRC office under a separate inspection program.

1 Decommissioning Performance and Status Review (71801)

1.1 Inspection Scope The inspectors evaluated whether the licensee and its contracted workforce were conducting decommissioning activities in accordance with the license and regulatory requirements.

1.2 Observations and Findings a. Facility Activities The licensee was continuing the construction activities in the southern portion of the switchyard for the San Diego Gas and Electric synchronous condenser that was being installed to compensate for the elimination of SONGS power generation. The licensee continued to perform radiological characterization surveys and collection of NRC split soil samples in the construction area to serve as confirmatory measurements. The data collected will be used to supplement the final status surveys to support license termination at a later date. The licensees survey and soil sample analysis results demonstrated that the excavated soils in the southern portion of the switchyard met the unrestricted use criteria established under 10 CFR 20.1402.

In addition to scanning and soil sample analyses performed by the licensee, composite soil samples were analyzed by NRCs contract laboratory for verification. The composite soil samples were provided through chain-of-custody to the NRCs contractor laboratory, Oak Ridge Associated Universities for analysis. The samples were analyzed by gamma spectroscopy for the radionuclides of concern, which were cobalt-60 (Co-60) and cesium-137 (Cs-137). The sample results were reported in pico-Curies per gram (pCi/g)

and are summarized in the table below, with the corresponding ADAMS accession number for the respective ORAU report.

Soil Sample Results (pCi/g) Collection Date Report Date ADAMS Accession Sample Description Co-60 Cs-137 No.

1 Final Grade < 0.043 0.003 May 18, 2018 July 18, 2018 ML17227A481 00001 2 Final Grade < 0.040 < 0.032 May 18, 2018 July 18, 2018 ML17227A481 00002 3 Final Grade < 0.041 < 0.035 May 18, 2018 July 18, 2018 ML17227A481 00003 4 Final Grade 0.011 < 0.038 May 18, 2018 July 18, 2018 ML17227A481 00004 5 Final Grade 0.006 < 0.038 May 18, 2018 July 18, 2018 ML17227A481 00006 The licensee continued to store liquids in tanks at the site until a processing skid is obtained and placed into service to allow more routine processing as specified in the UFSAR, Section 11.1. The licensee was implementing the liquid waste system as specified in the UFSAR by collecting any liquid waste that was generated since the plant shutdown.

Operations tracked the amount of liquids being held in the tanks and could move water to different storage tanks and processing paths, as needed.

The inspectors performed a plant tour and observed the material condition of structures, systems, and components that supported safe storage of spent fuel, as well as the electrical switchgear room, and components that supported the fire protection system.

The inspectors also observed the status of boundaries, postings, and labeling and determined that the licensee was in compliance with regulatory and procedural requirements. The inspectors conducted independent gamma radiation measurements using a Ludlum Model 2401-S survey meter (NRC No. 079971, calibration due date of March 13, 2018). The inspectors confirmed the survey measurements were comparable to the licensees survey results, specifically around the Units 2 and 3 SFPs.

b. Transition of Programs to the Songs Decommissioning Solutions (SDS)

Since the licensee announced its decommissioning agent, SDS, on December 20, 2016, both the licensee and SDS have been transitioning towards an organizational structure that allows a contracted workforce under SDS to perform the majority of the remaining decommissioning work activities with appropriate licensee oversight. The licensees transition team formulated and implemented a detailed program for the transition that included a desk guide and draft procedures for a comprehensive review, use of subject matter experts, industry peer reviews, and a regulatory compliance matrix. In addition, the licensee developed a list of the necessary elements to implement each program along with a readiness review checklist that would be verified at multiple oversight levels prior to transitioning each program to the SDS.

Separately, the decommissioning general contractor, SDS, formulated its detailed programs and processes necessary for the transition. Finally, through collaboration, the two independently developed plans were merged into a unified, mutually agreeable transition plan for the 21 management system programs that also confirmed there was adequate licensee oversight to ensure continued compliance with regulatory requirements and license conditions. The 21 programs are enumerated below with the corresponding transition date. The licensee emphasized that a qualitative, systematic review of the programs to be transitioned would be satisfactorily performed prior to transitioning each program.

July 27 August 31 September 28 October 26 November 30 Nuclear Safety Occupational Engineering Environmental Security (SCE)

Culture Safety Corrective Action Training Work Control Chemistry Maintenance Program Nuclear Oversight Support Services Operations (SCE) Waste Management Regulatory Affairs/ Utilities Business Emergency Licensing Systems Preparedness (SCE)

Site Facilities Fire Protection Radiation Protection The programs highlighted in Bold text indicate dual programs, which signifies that each company will maintain its own programs such that the licensee and SDS personnel will follow each companys programs and procedures, nevertheless with adequate licensee

interface to ensure continued regulatory compliance. In addition, the programs highlighted with (SCE) after the program name indicates that the respective program will remain under the licensee and not transition to the SDS.

The licensee had transitioned four programs on July 27, as scheduled and transitioned an additional five programs on the last day of the NRC inspection. The licensee communicated information and status of the transition during the daily plan-of-day meeting, flyers that were available around the site, and during site-wide all-hands meetings. These changes support transition of the licensees organizational structure to be better aligned with SDS for the dismantlement and decommissioning activities that will be underway at the site starting in 2018.

1.3 Conclusion The licensees survey results and soil sample analyses of the southern portion of the switchyard indicated the area was indistinguishable from background radiological levels and therefore met the unrestricted use criteria established under 10 CFR 20.1402. Based on the survey results, the excavated soil had been unconditionally released from the site.

The licensee was monitoring and maintaining liquids at the site in accordance with the UFSAR. In addition, the licensee has established a robust program to plan and implement the transition of SONGS management programs from being maintained solely by SCE, to being maintained and implemented by SDS, or by SCE and SDS in tandem.

2 Spent Fuel Pool Safety (60801)

2.1 Inspection Scope The inspectors conducted a review of the SFP operations for SONGS Units 2 and 3, specifically the SFP water level, chemistry, and associated cooling systems to ensure that the licensee was maintaining the pools in accordance with technical specifications and procedural requirements since the last NRC routine decommissioning inspection.

2.2 Observations and Findings Technical Specifications 3.1.1 and 3.1.2 requires the SFP water level be maintained greater than or equal to 23 feet over the top of the irradiated fuel assemblies seated in storage racks, and the SFP boron concentration be maintained greater than or equal to 2,000 parts per million (ppm), respectively. In addition, SONGS UFSAR, Section 9.1.2.3, Safety Evaluation required the SFP coolant temperature be maintained between 50°Fahrenheit (°F) and 160°F.

The licensee had replaced the traditional alarms and annunciators in the command center with computer monitoring with alarm capability for the SFP using the command center data acquisition system (CDAS). The inspectors observed the certified operators test the alarm functions of the SFP monitoring systems for both units. The inspectors determined that the alarm functions had sufficient audible and visual indications in the command center, in the event of a fault or safety significant failure in either of the SFPs.

The SFP alarm functions included low water level alarms and high or low temperature alarms indicating excursions above or below specified temperature levels.

The SONGS Units 2 and 3 SFPs were being maintained at approximately 27 feet above the top of the irradiated fuel assemblies, based on the command center data acquisition system trending. The SFP cooling systems were holding temperatures steady at approximately 68°F in each Unit, which was within the (50 °F - 160 °F) range specified in the UFSAR. This was also consistent with temperatures observed during previous inspections.

The inspectors reviewed the SFP surveillances performed in accordance with licensee Procedure SO123-III-1.23, Chemical Control of SONGS Plant System, Revision 68.

The boron parameter in the SFPs was required to be analyzed weekly to verify the boron concentration. The Unit 2 SFP boron concentration was being maintained between 2,734 and 2,778 ppm since the previous inspection. Likewise, the Unit 3 SFP concentration was maintained between 2,723 and 2,755 ppm. The inspector reviewed the surveillance history since the last inspection and the surveillances were completed as required and no results below the technical specifications requirement specified above, were noted.

The NRC inspectors performed a complete walk-down of the Units 2 and 3 SFPs and the associated piping, pumps, and heat exchangers and determined there was no obvious leakage from the system, based on no notable accumulated of boric acid evident on any of the pipe fittings, valves, or pumps. However, due to ambient conditions of high humidity, there was a lot of accumulated condensation on SFP island piping and walkways within the fuel handling building. The Radiation Protection department had posted numerous slip and trip warning stanchions in the fuel handling building as additional safety precautions. The inspectors also observed the status of SFP radiation and foreign material exclusion boundaries, postings, and labeling to ensure compliance with regulatory and procedural requirements. The NRC inspectors inspected the Units 2 and 3 SFP pipe chase areas beneath the pools and the liner leakage observation compartment for both units. At the time of the inspection, there was no evidence of liner leakage in either the Unit 2 or 3 SFPs. The leakage sump remained dry and there was not any evidence of boric acid accumulation on any of the leak-off lines.

The inspectors reviewed the nine SFP Nuclear Notifications (NN) captured in the corrective action program, which were generated since the previous NRC inspection.

The NNs chronicled several minor issues related to the routine operations of the SFP cooling circuits for both units and excessive boric acid buildup in the Unit 2 SFP liner leakage observation compartment. It should be noted that the NRC looked at this compartment during the current inspection and did not note any boric acid buildup (see above). The NNs reviewed by NRC were well documented and properly categorized based their safety significance. The specified corrective actions were assigned to the licensee's appropriate functional program. Based on the types of conditions identified, the licensee demonstrated a suitably low threshold for problem identification with regard to the maintenance and operation of its SFPs. No NRC safety concerns were identified related to the SFP related NNs selected for review during the inspection.

2.3 Conclusion The SONGS Units-2 and -3 SFPs were being maintained in accordance with technical specifications and procedural requirements. The licensee was safely storing spent fuel in wet storage.

3 Radioactive Waste Treatment, Effluent, and Environmental Monitoring (84750)

3.1 Inspection Scope The inspector reviewed the licensees 2016 Annual Radiological Environmental Operating Report.

3.2 Observations and Findings Technical Specifications Section 5.5.2 for the two licenses require the licensee to establish, implement, and maintain the Offsite ODCM. The ODCM provided detailed guidance for monitoring and controlling liquid and gaseous effluents, as well as calculating offsite doses. In addition, Technical Specifications Section 5.7.1 requires the licensee to submit annual radiological environmental and radioactive effluent release reports to the NRC. The 2016 annual radiological environmental operating report was submitted on May 11, 2016, (ADAMS Accession No. ML17135A360) and reviewed during this inspection. The 2016 annual radioactive effluent release report was submitted on April 25, 2017, (ADAMS Accession No. ML17121A421); therefore, it was previously reviewed and documented in the inspection report dated June 9, 2017, (ADAMS Accession No. ML17158B317).

The REMP data collected and analyzed for calendar year 2016, continued to be representative of background levels of radiation. The licensees program met the requirements set forth in the ODCM for sample collection methodology and locations, quality control and quality assurance of the program, and comparison of data results to pre-operational data results.

The direct radiation measurements were conducted using calcium sulfate (CsSO4)

thermoluminescent dosimeters that were placed at 49 locations and analyzed quarterly in accordance with ANSI-N545, Performance, Testing, and Procedural Specifications for Thermoluminescence Dosimetry. The data results were indistinguishable from background radiation and therefore, the off-site dose calculation was non-detectable.

The NRC inspectors reviewed the environmental sample collection locations and analyses performed by the licensee and concluded that the licensee implemented its environmental monitoring program in accordance with the ODCM. The licensee monitored airborne, ocean water, drinking water, shoreline sediment, ocean bottom sediment, marine species, local crops, soil, and kelp in order to evaluate the effluent release program at the facility.

Based on the air particulate and environmental sample results, there was no accumulation of radioactivity in the environment, as a result of licensed activities.

The licensee documented and tracked each deviation from the ODCM in the licensees corrective action program. The deviations involved the direct radiation program and the air sampling program. The remaining programs experienced no deviations during calendar

year 2016. The licensee stated that the 2016 deviations had no meaningful impact on the REMP database and did not compromise the validity of the reported conclusions. The NRC inspectors concluded that the deviations were within the criteria of the ODCM and did not impact the ODCM program.

3.3 Conclusions The licensees REMP was being conducted in accordance with the appropriate regulatory requirements as prescribed by the SONGS ODCM.

4 Safety Reviews, Design Changes, and Modifications (37801)

4.1 Inspection Scope The inspectors reviewed the organization, composition, and controls implemented for each of the SONGS and SDS management and safety review committees to ensure that the licensee was maintaining effective oversight of decommissioning activities. The inspectors reviewed the safety review processes, procedures, and training to verify compliance with the requirements under 10 CFR 50.59, 10 CFR 50.71, 10 CFR 72.48, and 10 CFR Part 50, Appendix B, and to ensure the safety review program was effective at contributing to the protection of public health and safety and the environment.

4.2 Observations and Findings a. Management, Contractor Oversight, and Onsite Review Committees The overall organizational structure at SONGS was described in the Defueled Safety Analysis Report, as well as in Appendix A of the DQAP, Revision 3. The inspectors verified that the licensee maintained an overall organizational structure that reflected the decommissioning organization described in these licensing documents. The inspectors also reviewed the organizational structure of SDS to ensure that contractor personnel were sufficient to fulfill the roles and responsibilities laid out for licensee and SDS staff as part of the overall SONGS decommissioning project.

The licensee continued to maintain a Management Review Committee (MRC), OSRC, Nuclear Oversight Board, and had recently implemented a Contractor Oversight Review Committee (CORC). Licensee Procedures SO123-XV-60.1, OSRC, Revision 16, and SO123-XII-18.17, Nuclear Oversight Board Functions and Responsibilities, Revision 7, addressed the responsibilities, composition, qualifications, and functions of these two organizations and established the appropriate level of independence to be able to make recommendations to licensee management. The MRC and CORC charters contained similar information and all the review committees were used to ensure that both licensee and contractor staff were performing decommissioning activities in accordance with the appropriate regulatory requirements, license conditions, and decommissioning documents.

In addition, the staff reviewed SDS Procedure SDS-RA1-PCD-0001, Project Operations Review Committee (PORC), Revision 1, which is a committee established by SDS to review matters that may have a bearing on nuclear or radiological safety, and to interface appropriately with the licensee in these matters. The inspectors reviewed the

meeting minutes of the Onsite Review Committee meeting conducted on May 24, 2017, the CORC meeting conducted on August 2, 2017, and attended the MRC meeting conducted on August 31, 2017.

In general, the licensee was appropriately implementing the various oversight committees, and leveraging its oversight of SDS to ensure that all conditions that could impact the safety or quality of decommissioning activities at SONGS were being addressed in a manner commensurate with its potential impact on the overall project.

Specifically, the inspectors noted that implementation of the CORC had established a robust and thorough means for collecting and evaluating the licensee oversight observations, nonconformances, and corrective actions reported by the contractor personnel onsite at SONGS. The CORC was structured to ensure that these issues were appropriately documented, tracked, and trended and utilized as a tool for improving contractor performance issues. Continued use of the CORC will help to ensure that the licensees corrective action program maintains adequate contact with similar contractor programs and that potential issues are addressed by both licensee and contractor personnel as the decommissioning project continues. Finally, the inspectors reviewed the closure of several corrective actions and other oversight committee items to verify that the licensee appropriately implemented or resolved the recommendations of the safety review committees, as required by the applicable decommissioning documents.

b. Design Control and Plant Modifications The SONGS DQAP included design control provisions to control design inputs, processes, outputs, changes, interfaces, records, and organizational interfaces. The design control provisions included requirements for verifying the acceptability of design activities and documents, consistent with their effects on safety for SSCs that have important-to-safety functions. Title 10 CFR 50.59(c)(1) states, in part, that a licensee may make changes in the facility as described in the FSAR (as updated), make changes in the procedures as described in the FSAR (as updated), and conduct tests or experiments not described in the FSAR (as updated) without obtaining a license amendment pursuant to 10 CFR 50.90 in certain situations.

The inspectors reviewed the licensees 10 CFR 50.59 safety evaluation program, as implemented by Procedure SO123-XV-44, 10 CFR 50.59 and 72.48 Program, Revision 20, as well as the complementary SDS Procedure SDS-RA1-PGM-0002, 10 CFR 50.59 and 72.48 Program, Revision 1. The inspectors compared these procedures with the NRC-endorsed acceptable method for complying with the provisions of 10 CFR 50.59, which is the Nuclear Energy Institutes NEI 96 07, Guidelines for 10 CFR 50.59 Implementation, Revision 1, dated November 2000.

The inspectors reviewed several 10 CFR 50.59 screenings where licensee personnel had determined that a full 10 CFR 50.59 evaluation was not necessary. Based on the documents reviewed, the inspectors determined that the licensees safety evaluation program procedure and processes were adequate for complying with the provisions of 10 CFR 50.59 and 10 CFR 72.48.

The inspectors reviewed the meeting minutes of the Onsite Review Committee meeting conducted on May 24, 2017. The inspectors compared the conduct of the meeting with the requirements specified in the SONGS DQAP and licensees

Procedure SO123-XV-60.1, Revision 16. The inspectors determined that the procedure was adequate to implement the licensees commitments provided in the DQAP. Additionally, the inspectors determined that the committee members were properly trained, the committee was properly staffed to conduct meetings, and the committee members fulfilled the charter of the committee as specified in the procedure.

The licensees 10 CFR 50.59 safety evaluation program provided effective periodic training for personnel preparing, reviewing, and approving the associated safety evaluations. In addition, the program established an adequate process to assess training effectiveness.

The inspectors reviewed Procedures SO123-CC-2, Configuration Management Program for Decommissioning, Revision 11, which provided instructions to maintain consistency between the physical configuration and documented configuration of the plant throughout decommissioning, and SO123-XXIV-10.1, Engineering Design Control Process - NECPs, Revision 34, which established controls and provided implementing processes for design changes, tests, experiments, and modifications. The inspectors determined that these procedures provided adequate instructions to assure proper implementation, review, and approval of design changes. The inspectors also verified that when issues were identified during this process the licensee appropriately documented the issue(s) in the SONGS corrective action program.

In addition, the inspectors reviewed ten 10 CFR 50.59 Applicability Determination and Screening Packages that were conducted since the last NRC inspection activity in March 2016. The inspectors performed an in-depth review of three evaluations performed pursuant to 10 CFR 50.59, and verified that the evaluations were adequate and that prior NRC approval was obtained as appropriate. The following list of 10 CFR 50.59 screening packages were reviewed:

• NECP 801279185, Removal of Spent Fuel Cooling System from Service, Revision 0

• NECP 801209947, Remove Legacy Emergency Diesel Generators (2G002 and 3G003) from Service, Revision 0

• NECP 801261393, Addition of Saltwater Dilution Pumps, Revision 0 The inspectors also noted that these evaluations included a section for determining whether the change may impact the requirements of 10 CFR 50.82(a)(6), which states that licensees shall not perform any decommissioning activities that foreclose release of the site for unrestricted use, result in significant environmental impacts not previously reviewed, or result in there no longer being reasonable assurance that adequate funds will be available for decommissioning.

The inspectors reviewed the licensees work activities in Units 2 and 3, which included removal of systems from service that were no longer required to maintain the integrity of the reactor coolant pressure boundary, shutdown the reactor, and maintain the reactor in a shutdown condition. The inspectors confirmed that these activities were completed in accordance with the licensees safety review processes, even when implemented by contractor personnel.

4.3 Conclusions The licensees management, contractor oversight, and onsite review committees were being conducted and maintained in accordance with the appropriate regulatory requirements as prescribed by the SONGS DQAP. The licensee has established additional oversight and controls for contractor programs to ensure that activities were being conducted in accordance with the applicable regulatory requirements, license conditions, DQAP procedures, and SONGS management programs being implemented by SCE, SDS, or both.

The licensees safety review processes, procedures, and training programs were being conducted and maintained in accordance with the appropriate regulatory requirements as prescribed by the SONGS DQAP. The licensee had established 10 CFR 50.59 and 10 CFR 72.48 programs to ensure that activities were being conducted in accordance with the applicable regulatory requirements, license conditions, and DQAP procedures. Decommissioning activities were being implemented in accordance with the requirements of 10 CFR 50.59, 10 CFR 50.71, 10 CFR 72.48, and 10 CFR Part 50, Appendix B.

5 Self-Assessment, Auditing, and Corrective Action (40801)

5.1 Inspection Scope The inspectors reviewed the licensees policies and implementing procedures that govern the implementation of the internal auditing and decommissioning safety review programs to verify compliance with the requirements in the DQAP and technical specifications, and to ensure that significant decommissioning activities were independently and effectively reviewed.

The inspectors reviewed the licensees policies and implementing procedures that govern the corrective action program to verify compliance with the applicable regulatory requirements and decommissioning documents.

5.2 Observations and Findings a. Audits and Self-Assessments The SONGS DQAP established the necessary measures to implement audits to verify that activities covered by the DQAP were performed in conformance with documented requirements and conducted at the prescribed periodicity. Internal audits were conducted to determine that the program and procedures being audited comply with the DQAP. Internal audits were performed with a frequency commensurate with safety significance and in such a manner as to ensure that an audit of all applicable quality assurance program elements was completed for each functional area within a period of two years. The licensees self-assessment and audit programs were proceduralized in SO123-XV-SA-1, Self-Assessment Process, Revision 9, and SO123-XII-18.1, Audit Program Implementation, Revision 24, which described the licensees requirements for the planning, performance, and documentation of self-assessments and quality assurance audit activities, including qualification of personnel.

External audits of suppliers providing important-to-safety materials, parts, equipment or services were scheduled and performed based on the importance of the activity in order to determine the adequacy of a suppliers or contractor's quality assurance program.

External audits took place at a frequency not to exceed three years. The licensee ensured that audits were documented and audit results were reviewed. The licensee also ensured that it responded to all audit findings and initiated appropriate corrective actions. In addition, where corrective actions were indicated, the licensee documented follow-up of applicable areas through inspections, review, re-audits, or other appropriate means to verify implementation of assigned corrective actions.

The inspectors reviewed a sample of internal audits to evaluate the implementation of the SONGS audit program and verified that the licensee had prepared and approved plans that identified the audit scope, focus, and applicable criteria before the initiation of the audit activity. The inspectors confirmed that the audit reports contained a review of the relevant decommissioning activities and associated documentation. Specifically, the audit forms were used to verify multiple areas including the environmental program, procedures, emergency response, external dosimetry, nuclear materials accountability program, and air sampling for occupational workers. For audits that resulted in findings, the inspectors verified that the licensee had established a plan for corrective action, that the MRC had reviewed and approved the corrective action, and then verified its satisfactory completion and proper documentation.

The inspectors verified that the SONGS DQAP and associated procedures provided guidance for the indoctrination and training of auditors and lead auditors. These documents prescribed the minimum experience and training requirements for auditors and lead auditors and provided that they be certified based on education, experience, training, examination, audit participation, and communication skills. Each auditor was trained to the applicable quality assurance procedures, as well as other applicable nuclear related codes, standards, regulations, and regulatory guides. The inspectors reviewed a sample of the training and qualification records of the SONGS auditors and lead auditors and confirmed that auditing personnel had completed all required training and maintained qualification and certification in accordance with the licensees policies and procedures. The inspectors also verified that audit teams were sufficiently qualified to evaluate areas within the scope of the audit and that members of the MRC had the necessary knowledge and experience in areas important to decommissioning.

b. Corrective Action Program The SONGS DQAP established the necessary measures to assure that conditions adverse to quality, such as failures, malfunctions, deficiencies, defective material and equipment, and nonconformances, were promptly identified, evaluated and corrected, as well as to promptly identify, control, document, classify, and correct conditions adverse to quality. Nonconformances were evaluated for their impact on the operability of important-to-safety structures, systems, and components (SSCs) to ensure that the final condition did not adversely affect safety, operation, or maintenance of the item or service. The DQAP required personnel to identify known conditions adverse to quality to determine what corrective actions were appropriate. Reports of conditions adverse to quality were analyzed to identify trends. The results of evaluations of conditions adverse to quality were analyzed, documented, and reported in accordance with applicable

procedures. Significant conditions adverse to quality were documented and reported to responsible management.

The licensees corrective action program was proceduralized in SO123-XV-50, Corrective Action Program, Revision 40, which established provisions to ensure the NNs, which has recently been renamed Action Requests (ARs), produced as a result of the program provided: (1) adequate documentation and description of significant conditions adverse to quality; (2) an appropriate analysis of the cause of these conditions and the corrective actions taken to prevent recurrence; (3) direction for review and approval by the responsible authority; (4) a description of the current status of the corrective actions; and (5) the follow-up actions necessary to verify timely and effective implementation of the corrective actions. In addition, the procedure identified that the timeliness of corrective actions should be commensurate with the safety significance of the item, and that the extent of corrective actions should be determined as appropriate for the circumstances. The SDS corrective action program was proceduralized in SDS Procedure SDS-RA1-PGM-0005, SDS Corrective Action Program (CAP), Revision 1, and provided for the prompt identification, evaluation, disposition, and reporting of adverse conditions that require corrective actions. The procedure applied to discrepancies identified by SDS that were determined to be significant adverse conditions, adverse conditions, and potential weaknesses which, if left unresolved, could develop into conditions adverse to quality or for areas of improvement that were not necessarily deviations.

At SONGS, each NN/AR received a review during one or more of the management and safety review committee meetings described in Section 4.2, which consisted of quality assurance, health physics, radiation protection, regulatory compliance, engineering, contractor, and inspection personnel, as appropriate. The review included evaluation and disposition of the NNs/ARs in accordance with the SCE and/or SDS process and documenting the bases for the decisions, as needed. The inspectors attended an MRC meeting and reviewed the meeting minutes of a CORC meeting to verify implementation of the SONGS corrective action program. It was noted that contractor representatives readily participated in both meetings. In addition, the licensees attendees were prepared and knowledgeable of the corrective actions being reviewed.

During the CORC meeting, reported issues were reviewed. The reported issues could be from field condition reports (utilized by Holtec International, which is responsible for construction and loading of spent fuel into the SONGS independent spent fuel storage installation (ISFSI) expansion) or from oversight observations that were dispositioned into the SONGS and/or SDS corrective action programs, as appropriate. For any action determined to be a Level 1 (significant condition adverse to quality) or Level 2 (condition adverse to quality), each issue was also tracked in the SONGS corrective action program and, once completed, the issue was closed in both programs.

The inspectors observed that the licensees oversight of the contractors corrective action program involved close monitoring, review, and evaluation of the SDS program using a combination of individual communications, use of the applicable oversight committees, as well as by the ongoing involvement of the corrective action program manager. Starting with the implementation of the CORC, the licensee was expected to continue to identify opportunities for improvement in the oversight of contractor programs.

Finally, the inspectors conducted numerous discussions with SONGS and SDS personnel, including licensing engineers, design engineers, quality assurance personnel, and audit representatives, to verify that all licensee and contractor personnel were aware of the corrective action process, recognize when and how to enter into the process, and understand the types of disposition that could result from a NN/AR. The inspectors concluded that all of the SCE and SDS personnel interviewed had adequate knowledge of the SONGS corrective action program.

5.3 Conclusions The licensee had established audit, review, and oversight programs to ensure that activities were being conducted in accordance with the applicable regulatory requirements, license conditions, and DQAP procedures. These programs functioned in a timely, independent, and appropriate manner.

The licensee had implementing its corrective action program in accordance with appropriate regulatory requirements as prescribed by the SONGS DQAP, and provided adequate oversight of the SDS corrective action program to ensure that any issues identified by contractor staff were appropriately documented, tracked, and dispositioned by the proper personnel. Based on the sample of documents reviewed and activities observed, the inspectors determined that the licensee adequately implemented its policies and procedures associated with the corrective action program in accordance with the applicable regulatory requirements, license conditions, and DQAP procedures.

6 Fire Protection Program (64704)

6.1 Inspection Scope The inspectors evaluated the overall adequacy and implementation of the licensees fire protection program.

6.2 Observations and Findings The NRC regulation under 10 CFR 50.48(f) states, in part, that the licensee shall maintain a fire protection program to address the potential for fires that could cause the release or spread of radioactive materials, or result in a radiological hazard. In addition, Section 5.5.1.1.d of the Technical Specifications, Appendix A to the two licenses, states that written procedures shall be established, implemented, and maintained for the fire protection program. The inspectors reviewed the licensees fire protection program for compliance with regulatory and license requirements.

Regulatory Guide 1.191, Fire Protection Program for Nuclear Power Plants During Decommissioning and Permanent Shutdown, describes the methods acceptable to the NRC for complying with the NRCs regulations for fire protection programs for licensees in decommissioning. This regulatory guide is referenced in the licensees implementing procedures, and the inspectors compared the licensees fire protection program to the guidance provided in the regulatory guide.

The licensees fire protection program records included a fire hazards analysis. This document provides an analysis of the various plant areas and the fire protection

requirements for those areas. The licensee also developed a detailed fire protection program document (Fire Protection Program SO123-FP-1, Revision 28) that described staff responsibilities, program elements, and record requirements. In addition, procedures were developed to implement the various program attributes such as system operations, maintenance, design control, staffing, and training.

According to 10 CFR 50.48(f), the objectives of the fire protection program are to:

(1) reasonably prevent fires that could result in a radiological hazard from occurring; (2) rapidly detect, control, and extinguish those fires that do occur; and (3) ensure that the risk of fire-induced radiological hazards to the public, environment and plant personnel is minimized. The inspectors compared the licensees fire protection program against the objectives provided in the regulations.

To prevent fires from occurring, the licensee established and implemented administrative procedures for control of combustible material, transient fire loads, ignition sources, housekeeping, barriers, and impairments.

The inspectors conducted site tours to confirm that the procedure controls were being implemented. In particular, the inspectors toured the areas where the Unit 2 SFP, SFP islanding, and associated electrical switchgear equipment were located. The inspectors concluded that the licensee was effectively controlling combustible material, ignition sources, barriers, and impairments in these areas in accordance with procedure requirements and good housekeeping practices.

The inspectors reviewed the licensees ability to rapidly detect, control, and extinguish fires. The licensee installed and maintained equipment to detect fires including various types of smoke detectors and fire detection sensors. Fire suppression systems were in service including water storage tanks, pumps, valves, distribution piping, hose stations, sprinklers, and fire extinguishers throughout the plant. The inspectors observed fire protection equipment in the field and confirmed that plant parameters, including system pressures and tank levels, were within procedural limits. The inspectors also confirmed that the licensee implemented a surveillance and preventive maintenance program for the equipment in service.

The inspectors reviewed the licensees staffing of the fire brigade.Section IV.D.2.b of the Fire Protection Program (SO123-FP-1, Revision 28) and Section 2.3 of the Updated Fire Hazards Analysis, Revision 30, provide the requirements for fire brigade staffing.

The onsite fire brigade consisted of a minimum of two individuals; however, the inspectors determined that the licensee routinely assigned at least three individuals per shift to the fire brigade. The fire brigade program procedure described the duties and responsibilities of the fire brigade during emergency situations.

The onsite fire brigade could be supplemented by offsite emergency staff, based on the specifics of the emergency. The inspectors confirmed that the licensee had established a Memorandum of Agreement with the Camp Pendleton Fire Department for support services during certain emergencies. Site security and radiation protection staff were available to support the fire brigade as needed. For example, site security could help expedite the onsite arrival of offsite support services.

The inspectors confirmed that the licensee had established a training program for fire brigade members, which included routine drills. The licensee maintained a list of qualified individuals who could be assigned to the fire brigade. The licensee also assigned a qualified individual to the position of fire marshal, separate from the fire brigade. The fire marshal was responsible for implementing portions of the fire protection program and to support the fire brigade as needed.

The inspectors reviewed the licensees program for maintenance and surveillances of fire protection equipment. The licensee established maintenance and surveillance instructions for major plant components. The inspectors confirmed that the routine surveillances and preventive maintenance tasks were scheduled at the frequencies established in site procedures. The surveillances and preventive maintenance activities included pump tests, flow tests, and equipment operability checks. Also, the licensee established and implemented procedures for routine inspection of combustibles, transient fire loads, and fire doors.

Finally, the third regulatory objective for the fire protection program was to ensure that the risk of fire-induced radiological hazards to the public, environment, and plant personnel were minimized. The licensee utilized a defense-in-depth concept to minimize the consequences and probability of fire events resulting in radiological releases. The defense-in-depth concept included a combination of administrative controls, physical fire protection features, emergency response capabilities, and protection of critical systems and components such as the SFPs and support equipment.

As noted above, the licensee implemented a fire brigade, emergency response instructions, and training program to help minimize the risks of radiological releases caused by fires. Critical equipment such as hoses and smoke clearing fans were staged in various areas to support emergency response operations.

6.3 Conclusions The inspectors reviewed the licensees existing fire protection program including implementing procedures, equipment, staffing, and training. The inspectors conducted walk-downs of plant equipment and observed control of combustible materials, housekeeping, and ignition sources. The inspectors concentrated on areas and equipment supporting the SFP and SFP islanding equipment. In summary, the fire protection program was determined to be in compliance with regulatory and license requirements.

7 Emergency Preparedness Scenario Review and Exercise Evaluation (82401)

7.1 Inspection Scope The inspectors observed an emergency preparedness drill on August 29, 2017, to evaluate the adequacy of the Licensees conduct of the biennial exercise and its capability to assess drill performance through a formal critique process in order to identify and correct weaknesses associated with planning standard 10 CFR 50.47(b)(14). The inspectors reviewed the drill scenario, observed the drill from the control room and the emergency response activities in the field, and attended the post-exercise management critique.

7.2 Observations and Findings The inspectors reviewed the drill scenario for the August 29, 2017, biennial exercise, which contained a progression of events that provided opportunities for the ERO to demonstrate skills necessary to implement the Permanently Defueled Emergency Plan.

The scenario included a simulation of a fire in the Unit 2 Independent SFP Cooling chiller Sea Van, subsequent loss of power to the Unit 2 Independent SFP Island, off-site fire brigade response by Camp Pendleton Fire Department, and discovery of a simulated incendiary device to demonstrate the licensees capability to implement its emergency plan under conditions of uncertain physical security.

The inspectors determined that the scenario events provided the site ERO opportunities to demonstrate two emergency classifications, two notifications to appropriate offsite authorities, the protection of emergency workers in the protected area, dispatch of Camp Pendleton Fire Department, and security response procedures. Together, these simulated events provided a basis to determine whether the ERO remained capable of implementing appropriate measures to protect the health and safety of the public.

The inspectors verified that the licensees emergency classifications, off-site notifications, and protective action recommendations were appropriate and timely.

The licensee dispatched the Camp Pendleton Fire Department, who responded in a timely manner. Throughout the simulated emergency, the site ERO demonstrated good knowledge of the site emergency plan and procedures, quickly recognized events requiring emergency response, and addressed those events to ensure health and safety of the public. The site Fire Brigade Leader took sufficient control and coordinated with the Camp Pendleton Fire Department at the fire emergency scene.

The inspectors observed the licensees post-exercise management critique conducted on August 31, 2017, to determine whether the licensee identified the performance weakness and other issues that occurred during the August 29, 2017, exercise. The inspectors compared the issues and weaknesses identified by the licensee with those independently identified by the NRC inspectors. The licensee identified one weakness, several issues and improvement items, which were each entered into the corrective action program for resolution. There was no deficiency identified during the management critique associated with the biennial exercise. The inspectors concluded that the licensee identified all of the performance issues and weaknesses that occurred during the exercise, as identified by the NRC inspectors.

7.3 Conclusions The inspectors observed a biennial emergency exercise conducted on August 29, 2017, and concluded that the licensees ERO effectively implemented its Permanently Defueled Emergency Plan to adequately protect the public health and safety. The licensee demonstrated an adequate management critique process that identified issues and weaknesses, which were entered into the corrective action system for resolution.

8 Decommissioning Emergency Preparedness Program Evaluation (82501)

8.1 Inspection Scope The inspectors evaluated the licensees implementation of its emergency preparedness program to determine whether it was being maintained in a status of operational readiness.

8.2 Observations and Findings The NRC regulations under 10 CFR 50.47, Emergency Plans and Appendix E to 10 CFR Part 50, Emergency Planning and Preparedness for Production and Utilization Facilities, continue to apply to nuclear power reactors that have permanently ceased operation and have removed all fuel from the reactor vessel. The licensees Procedure SO123-VIII-ADMIN-4, 10CFR50.54(q) Screenings and Evaluations, Revision 0, provided the guidance to ensure that changes to the Permanently Defueled Emergency Plan (PDEP-1), Emergency Action Level Technical Bases Manual (PDEP-2),

and the implementing procedures were maintained in accordance with 10 CFR 50.54(q)

to prevent a reduction in the effectiveness of the emergency plan.

The inspectors reviewed several 10 CFR 50.54(q) screenings and evaluations performed in accordance with the licensees Procedure SO123-VIII-ADMIN-4, including:

• PDEP-1, Permanently Defueled Emergency Plan, Revision 3 (NN 203338328, Task 7)

• PDEP-2, Emergency Action Level Technical Bases Manual, Revision 2 (NN 203362618, Task 5)

• SO123-VIII-ADMIN-1, Emergency Preparedness Program Maintenance, Revision 3 (NN 203395776, Task 3)

• SO123-VIII-ADMIN-2, Emergency Preparedness Program Training, Revision 2 (NN 203338328. Task 8)

• SO123-VIII-ADMIN-3, Emergency Preparedness Program Drill Development and Evaluation, Revision 1 (NN 203232420, Task 32)

The licensees 10 CFR 50.54(q) evaluators were qualified and maintained current training requirements in accordance with Procedure SO123-VIII-ADMIN-4. The inspectors concluded that the changes reviewed did not reduce the effectiveness of the Permanently Defueled Emergency Plan. In addition, the Permanently Defueled Emergency Plan, Technical Bases, and supporting procedures continued to meet the requirements of 10 CFR 50.47(b) and 10 CFR Part 50, Appendix E. This review was not documented in a safety evaluation report and does not constitute approval of licensee-generated changes; therefore, these revisions are subject to future inspection.

The inspectors reviewed the licensees implementation and maintenance of its emergency preparedness program in accordance with the prescribed review of emergency preparedness documents as specified in Procedure SO123-VIII-ADMIN-1.

The documents reviewed included surveillances of emergency response equipment, inventory of emergency kits onsite and offsite at the hospital, communication checks with offsite agencies, and onsite emergency siren systems tests. The inspectors determined that when the licensee identified any discrepancy, then the discrepancy was placed into the corrective action program and the licensee initiated corrective actions, such as immediately replacing batteries, replacing emergency response cell phones, and ensuring the emergency kits were replenished as required. The licensee adequately demonstrated that it was maintaining its emergency preparedness program in a status of operational readiness.

The inspectors reviewed the licensees letters of agreement or memorandums of understanding, as appropriate, with Camp Pendleton, Tri-City Medical Center, Mission Hospital, Air Methods Corporation, and Orange County Fire Authority. These agreements were reviewed on an annual basis as required by the Permanently Defueled Emergency Plan, Section P.4, Emergency Plan and Agreement Revisions. The annual reviews were performed in March 2017, with certification request letters sent to each organization. Emergency Preparedness personnel had received signed concurrences from three of the entities and were tracking the completion of the two remaining concurrences.

The inspectors reviewed approximately 100 ARs summaries associated with the Emergency Preparedness program. The ARs ranged from administrative requirements, tracking of critique items during drills, exercises, and table tops; to procedure changes, and performance of emergency preparedness equipment. The identified performance issues either did not impact the functionality of the equipment, or the equipment had compensatory measures in place that were functional in order to meet the Permanently Defueled Emergency Plan requirement or a functional planning standard under 10 CFR 50.47.

The Emergency Response Organization (ERO) minimum staffing requirements were provided in the Permanently Defueled Emergency Plan that supported the requirement under 10 CFR 50.47(b)(2). The ERO was determined to be adequately staffed and was maintained through a review of the ERO shift assignments and verification of training records. The command center has controlled books for ERO staffing, in addition to computer access listing of qualified personnel to fulfill the required positions. The licensee maintained a 5-team rotation for on-shift personnel, which fulfills the ERO minimum staffing requirement. In the event it was necessary to augment the staffing levels, the Shift Manager would notify the Duty ERO Coordinator and direct the individual to initiate the ERO recall, as specified in Procedure SO123-VII-ERO-2, Revision 2, Shift Manager/ Emergency Director Checklist. This was successfully demonstrated during the biennial exercise observed by the inspectors on August 29, 2017.

The Nuclear Oversight Division conducted an emergency preparedness audit (SCES-007-17) between June 19 and July 6, 2017, and issued the audit report on August 3, 2017. This audit was conducted within 12 months of the last audit, as specified under 10 CFR 50.54(t)(1). The audit was comprised of four auditors, and reviewed the emergency preparedness program in conformance with 10 CFR 50.54(t); 10 CFR 50.47, Emergency Plans; 10 CFR 50.54, Conditions of Licensees; and 10 CFR Part 50, Appendix E, Emergency Planning and Preparedness for Production and Utilization

Facilities. The inspectors reviewed the audit and concluded that it was a comprehensive and thorough review of the Emergency Preparedness Program. The audit team concluded that the licensees program satisfactorily implemented the Permanently Defueled Emergency Plan in accordance with the regulatory requirements.

8.3 Conclusions The inspectors concluded that the licensee appropriately implemented the requirements of 10 CFR 50.54(q)(3) with respect to Permanently Defueled Emergency Plan, Revision 3, Permanently Defueled Emergency Action Levels, Revision 2, and associated procedures. The inspectors did not identify any reductions in the effectiveness of the Permanently Defueled Emergency Plan. The licensee was implementing its Permanently Defueled Emergency Plan as required and the capability to respond to an emergency was being maintained to ensure health and safety protection of the public.

9 Exit Meeting Summary On August 31, 2017, the NRC inspectors presented the final inspection results to Mr. T. Palmisano, Vice President and Chief Nuclear Officer, and other members of the licensees staff. The inspectors asked the licensee whether any materials examined during the inspection should be considered proprietary. No proprietary information was identified.

SUPPLEMENTAL INSPECTION INFORMATION KEY POINTS OF CONTACT Licensee Personnel A. Bates, Regulatory and Oversight R. Benson, Fire Protection Engineering J. Davis Operations Manager D. Evans, Regulatory Affairs K. Gallion, Emergency Preparedness S. Mannon, SDS B. Metz, Environmental Manager J. Peattie, Nuclear Oversight S. Vaughan, Project Manager INSPECTION PROCEDURES USED IP 71801 Decommissioning Performance and Status Review at Permanently Shutdown Reactors IP 60801 Spent Fuel Pool Safety at Permanently Shutdown Reactors IP 84750 Radioactive Waste Treatment, Effluent, and Environmental Monitoring IP 40801 Self-Assessment, Auditing, and Corrective Action at Permanently Shutdown Reactors IP 37801 Safety Reviews, Design Changes, and Modifications IP 64704 Fire Protection Program IP 82401 Decommissioning Emergency Preparedness Scenario Review and Exercise Evaluation IP 82501 Decommissioning Emergency Preparedness Program Evaluation LIST OF ITEMS OPENED, CLOSED, AND DISCUSSED Opened/Closed None Discussed None Attachment

LIST OF ACRONYMS ADAMS Agencywide Documents Access and Management System AR Action Request CFR Code of Federal Regulations CORC Contractor Oversight Review Committee DQAP Decommissioning Quality Assurance Plan ERO Emergency Response Organization MRC Management Review Committee NRC Nuclear Regulatory Commission ODCM Offsite Dose Calculation Manual OSRC Onsite Review Committee PSDAR Post-Shutdown Decommissioning Activities Report REMP Radiological Environmental Monitoring Program SCE Southern California Edison SDS SONGS Decommissioning Solutions (decommissioning agent)

SFP Spent Fuel Pool SONGS San Onofre Nuclear Generating Station UFSAR Updated Final Safety Analysis Report

ML17268A393 SUNSI Review ADAMS: Sensitive Non-Publicly Available Keyword By: RSB Yes No Non-Sensitive Publicly Available NRC-002 OFFICE DNMS/FCDB FCDB FCDB NMSS/DUWP/RDB C:FCDB NAME RBrowder ESimpson SAnderson MVaaler RKellar SIGNATURE /RA/phone /RA/email /RA/email /RA/email /RA/

DATE 9/25/17 9/22/17 9/22/17 9/22/17 9/26/17