IR 05000440/2006017

IR 05000440-06-017, on 10/23/2006 - 12/13/2006, Perry, Confirmatory Action Letter (CAL) Followup Inspection

ML063520411
Person / Time
Site:	Perry
Issue date:	12/18/2006
From:	Satorius M Division Reactor Projects III
To:
References
CAL 3-05-001 IR-06-017
Download: ML063520411 (49)

Text

ber 18, 2006

SUBJECT:

PERRY NUCLEAR POWER PLANT CONFIRMATORY ACTION LETTER FOLLOWUP INSPECTION HUMAN PERFORMANCE ACTION ITEM EFFECTIVENESS SUPPLEMENTAL IP 95002 ISSUES ACTION ITEM EFFECTIVENESS NRC INSPECTION REPORT 05000440/2006017

Dear Mr. Pearce:

The purpose of this letter is to provide you with Inspection Report (IR) 05000440/2006017, detailing the results of Confirmatory Action Letter (CAL) followup inspections in the Human Performance and IP 95002 Issues areas. During this inspection, we assessed the effectiveness of the actions that you completed to address issues in the Human Performance area of our September 28, 2005, Confirmatory Action Letter. We also performed a supplemental review of the effectiveness of your actions to address the Maintenance Procedure Adequacy aspect of the IP 95002 Issues area of the CAL, which were previously identified as indeterminate in NRC Inspection Report 50-440/2006014. You and other members of your staff attended the December 13, 2006, public exit meeting held at the Quail Hollow Resort in Painesville, Ohio, during which the results of these CAL followup inspection activities were presented. A summary of the public meeting was documented in a letter to you dated December 15, 2006.

As a result of poor performance, the Nuclear Regulatory Commission (NRC) designated the Perry Nuclear Power Plant as a Multiple/Repetitive Degraded Cornerstone column facility in the NRCs Action Matrix in August 2004. Accordingly, a supplemental inspection was performed in accordance with Inspection Procedure (IP) 95003, Supplemental Inspection for Repetitive Degraded Cornerstones, Multiple Degraded Cornerstones, Multiple Yellow Inputs, or One Red Input. As documented in IP 95003 Supplemental Inspection Report 50-440/2005003, the NRC determined Perry was being operated safely. However, the inspectors identified problems similar to those previously identified at your Perry facility, particularly in the area of human performance. By letters dated August 8, 2005, and August 17, 2005, you responded to the findings and observations detailed in the NRC's IP 95003 supplemental inspection report. As discussed in these letters, the Perry management team reviewed the achievements realized by the Performance Improvement Initiative (PII), NRC findings documented in the IP 95003 supplemental inspection report, and the conclusions from various assessments, and developed updates to the PII. The Perry management team restructured the PII into the Phase 2 PII, which contained six new initiatives with the overall purpose of implementing lasting actions to improve the overall performance at the Perry Nuclear Power Plant. These actions included actions to address human performance issues.

On July 11, 2006, the NRC completed a CAL Followup inspection in the Human Performance area that reviewed selected Commitments and Action Items described in the Perry Phase 2 PII Detailed Action and Monitoring Plan (DAMP) and your August 8 and August 17, 2005, letters.

The NRC concluded, during this previous inspection, that all four of your CAL Commitments in the Human Performance area were adequately implemented. The NRC also determined that all Action Items associated with the Human Performance area that we reviewed were adequately implemented. A complete discussion of the findings and other observations from this inspection is documented in NRC Inspection Report 50-440/2006012.

The purpose of this inspection was to review the overall effectiveness of your actions to address the Human Performance area of our September 28, 2005, Confirmatory Action Letter and determine whether any additional inspection in this area beyond that prescribed by the Reactor Oversight Process (ROP) baseline inspection program is required. As such, the inspection objectives were to: 1) Determine whether human performance tools are adequately implemented through direct observation of plant evolutions; 2) Determine whether personnel, such as first-line supervisors, are actively reinforcing and monitoring the use of human performance tools during plant evolutions; and 3) Determine whether human performance monitoring tools, such as Key Performance Indicators (KPIs), reflect a sustained improvement in human performance and whether corrective actions are identified and implemented, as required, based upon the KPI data that is collected.

Based upon our overall observations of the use of human performance error prevention tools conducted in the plant during this inspection, our observations of supervisors during their opportunities to monitor and reinforce the use of these tools, and our review of human performance related KPIs, the NRC concluded that your corrective actions have been effective in improving human performance. As a result, the NRC currently plans no additional inspections in this area beyond that which is normally prescribed by the ROP baseline inspection program. Notwithstanding this overall conclusion, the inspectors continued to identify some human performance issues during the inspection, including one issue that was determined to be a finding of very low safety significance.

In addition, on August 15, 2006, the NRC completed a CAL Followup inspection in the IP 95002 Issues area that assessed the overall effectiveness of your actions to address the IP 95002 issues identified in a previous inspection and determined whether any additional inspection in this area beyond that prescribed by the Reactor Oversight Process (ROP) baseline inspection program was required. As such, the inspection objectives were to: (1) Determine whether your corrective actions to address maintenance procedure adequacy issues were effective; (2) Determine whether your corrective actions to address emergency service water (ESW)

pump coupling assembly concerns were effective; and (3) Determine whether your corrective actions to address deviations from training in stressful circumstances were effective.

Although your corrective actions in the areas of ESW pump coupling assembly and training deviations in stressful circumstances were determined to be effective, in the Maintenance Procedure Adequacy area, we were not able to fairly assess the overall effectiveness of your corrective actions due to an incomplete supplemental procedure review effort that you initiated following our IP 95002 Issues Action Item Implementation inspection. In addition, we identified two maintenance revision process vulnerabilities that we concluded could represent a challenge to your ability to sustain improvement efforts in this area.

As a result, during this CAL Followup inspection we also completed our assessment of the overall effectiveness of your actions to address the Maintenance Procedure Adequacy aspect of the IP 95002 Issues area and determined whether any additional inspection beyond that prescribed by the ROP baseline inspection program is required.

Overall, we concluded that your corrective actions have been effective in addressing the Maintenance Procedure Adequacy aspect of the IP 95002 Issues area. Although we identified, in the sample of the procedures reviewed, some minor procedure enhancements that could improve the ease of use of the procedures, the NRC concluded that you had significantly improved the overall quality of your maintenance procedures. The NRC also concluded that based upon the maintenance procedure revision processes and procedures that have been established, that maintenance procedures could be maintained at an adequate level of overall quality. As a result, the NRC currently plans no additional inspections in this area beyond that which is normally prescribed by the ROP baseline inspection program.

Based on the results of this inspection, one finding of very low safety significance that involved a violation of NRC requirements was identified. However, because of its very low safety significance and because this issue has been entered into your corrective action program, the NRC is treating this violation as a non-cited violation (NCV) in accordance with Section VI.A.1 of the NRCs Enforcement Policy.

If you contest the subject or severity of this non-cited 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, DC 20555-0001, with a copy to the Regional Administrator, U.S. Nuclear Regulatory Commission - Region III, 2443 Warrenville Road, Suite 210, Lisle, IL 60532-4352; the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001; and the Resident Inspector Office at the Perry Nuclear Power Plant.

Notwithstanding our conclusions regarding the effectiveness of your actions to address human performance and IP 95002 issues, the NRC will continue to provide any necessary increased oversight of activities at your Perry Nuclear Power Plant until you have demonstrated that your corrective actions are lasting as well as effective. Consistent with Inspection Manual Chapter (IMC) 0305 guidance regarding the oversight of plants in the Multiple/Repetitive Degraded Cornerstone column of the NRCs Action Matrix, the NRC will continue to assess performance at Perry and will consider at each quarterly performance assessment review the following options: (1) declaring plant performance to be unacceptable in accordance with the guidance in IMC 0305; (2) transferring the facility to the IMC 0350, Oversight of Reactor Facilities in a Shutdown Condition Due to Significant Performance and/or Operational Concerns process; and (3) taking additional regulatory actions, as appropriate. Until you have demonstrated lasting and effective corrective actions, Perry will remain in the Multiple/Repetitive Degraded Cornerstone column of the NRCs Action Matrix.

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

Sincerely,

/RA/

Mark A. Satorius, Director Division of Reactor Projects Docket No. 50-440 License No. NPF-58 Enclosure: Inspection Report 05000440/2006017 w/atts: 1. Supplemental Information 2. Perry Performance Background 3. Perry IP 95003 Inspection Results 4. Summary of Phase 2 PII Initiatives DISTRIBUTION:

See next page

EXECUTIVE SUMMARY

The purpose of this inspection was to review the overall effectiveness of the licensees actions to address the Human Performance area and the Maintenance Procedure Adequacy aspect of the IP 95002 Issues area of the NRCs Confirmatory Action Letter (CAL) that was issued to FirstEnergy Nuclear Operating Company (FENOC) on September 25, 2005 and determine whether any additional inspection beyond that prescribed by the Reactor Oversight Process (ROP) baseline inspection program was required in these areas.

As such, in the Human Performance area, the inspection objectives were to:

• Determine whether human performance tools were adequately implemented through direct observation of plant evolutions;

• Determine whether personnel, such as first-line supervisors, were actively reinforcing and monitoring the use of human performance tools during plant evolutions; and

• Determine whether human performance monitoring tools, such as Key Performance Indicators (KPIs), reflected a sustained improvement in human performance and whether corrective actions were identified and implemented, as required, based upon the KPI data that was collected.

Based upon the overall observations of the use of human performance error prevention tools conducted in the plant during this inspection, the observations of supervisors during opportunities to monitor and reinforce the use of these tools, and the review of human performance related KPIs, the inspectors concluded that the licensees corrective actions have been effective in improving human performance. As a result, the NRC currently plans no additional inspections in this area beyond that which is normally prescribed by the ROP baseline inspection program.

Notwithstanding this overall conclusion, the inspectors continued to identify some human performance issues during the inspection, including one issue that was determined to be a finding of very low safety significance. Although these human performance weaknesses were not considered to be significant, overall, the inspectors concluded the following:

• Although the licensees staff had been sufficiently trained in the use of human performance error prevention tools, at times the staff failed to apply knowledge that had been gained through the training that had been provided;

• Although supervisors and managers were actively observing plant activities, the licensee had not always taken full advantage of potential performance improvements resulting from these observations; and

• Although some performance indicators reflected a significant improvement in human performance, other performance indicators did not provide performance insights.

In the Maintenance Procedure Adequacy aspect of the IP 95002 Issues area, the inspection objectives were to:

• Determine whether licensee actions to improve the quality of maintenance procedures were effective; and

• Determine whether licensee actions to address previously identified vulnerabilities in the maintenance procedure revision process were adequate.

Based upon the results of this inspection, the inspectors concluded that the licensees corrective actions have been effective in addressing the Maintenance Procedure Adequacy aspect of the IP 95002 Issues area and, as a result, the NRC currently plans no additional inspections in this area beyond that which is normally prescribed by the ROP baseline inspection program.

Although the inspectors identified, in the sample of the procedures reviewed, some minor procedure enhancements that could improve the ease of use of the procedures, the inspectors concluded that the licensee had significantly improved the overall quality of maintenance procedures. The inspectors also concluded that based upon the maintenance procedure revision processes and procedures that had been established, that maintenance procedures could be maintained at an adequate level of overall quality.

SUMMARY OF FINDINGS IR 05000440/2006017; 10/23/2006 - 12/13/2006; Perry Nuclear Power Plant; Confirmatory Action Letter (CAL) Followup Inspection - Human Performance Action Item Effectiveness Inspection; CAL Followup Inspection - Supplemental Maintenance Procedure Adequacy Inspection in IP 95002 Issues area.

This report covers a 2-week period of supplemental inspection by resident and headquarters-based inspectors. This inspection identified one Green finding, which involved a non-cited violation of NRC requirements. The significance of most findings is indicated by their color (Green, White, Yellow, Red) using Inspection Manual Chapter (IMC)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 NRCs program for overseeing the safe operation of commercial nuclear power reactors is described in NUREG-1649, "Reactor Oversight Process," Revision 3, dated July 2000.

NRC-Identified

and Self-Revealed Findings

Cornerstone: Mitigating Systems

Green.

A finding of very low safety significance and a non-cited violation of Technical Specification 5.4, Procedures, was self revealed after licensee personnel failed to adhere to clearance procedures affecting the Division 1 emergency diesel generator (EDG) room ventilation system. While performing a clearance instruction, licensee personnel erroneously removed a fuse that disabled a required remote shutdown function associated with the Division 1 EDG ventilation system. The error was discovered during the clearance restoration process. As part of their immediate corrective actions, the licensee counseled involved personnel regarding procedure adherence expectations. The finding affected the cross-cutting area of human performance because licensee personnel failed to follow the established decision-making process when faced with the decision to remove a fuse that was not listed on the clearance instruction.

The finding was more than minor because the failure to adhere to procedures associated with the maintenance of safety-related equipment, if left uncorrected, could become a more significant safety concern. In this case, the removal of a fuse contrary to the clearance procedure affected the remote shutdown capability of the Division 1 EDG. Because the finding only affected the remote shutdown operations capability of the EDG, the finding was determined to be of very low safety significance. (Section 3.1)

Licensee-Identified Violations

None.

REPORT DETAILS

1.0 Background 1.1 Multiple/Repetitive Degraded Cornerstone Designation As a result of poor performance, the Nuclear Regulatory Commission (NRC) designated the Perry Nuclear Power Plant as a Multiple/Repetitive Degraded Cornerstone column facility in the NRCs Action Matrix in August 2004. A summary of the performance issues that resulted in this designation is discussed in Attachment 2, Perry Performance Background, of this report.

1.2 Inspection Procedure 95003 Discussion and Inspection Results In accordance with Inspection Manual Chapter (IMC) 0305, Operating Reactor Assessment Program, a supplemental inspection was performed in accordance with Inspection Procedure (IP) 95003, Supplemental Inspection for Repetitive Degraded Cornerstones, Multiple Degraded Cornerstones, Multiple Yellow Inputs, or One Red Input. As documented in IP 95003 Supplemental Inspection Report 50-440/2005003, the NRC determined Perry was being operated safely.

Notwithstanding this overall conclusion, the NRC determined that the performance problems that occurred were often the result of human performance errors. In particular, the IP 95003 inspection team determined that a number of self-revealed findings related to procedure adherence had a strong human performance contribution.

The IP 95003 inspection team reviewed the events that occurred during the IP 95003 inspection and identified that the procedure adherence problems had a number of common characteristics. In a number of cases, personnel failed to properly focus on the task at hand. Although pre-job briefings were held prior to many events, and procedures were adequate to accomplish the intended activity, personnel failed to sufficiently focus on the individual procedure step being accomplished and performed an action outside of that prescribed by the procedure. In some cases, the team determined that a lack of a questioning attitude contributed to the procedure problems that occurred.

Although information was available to personnel that, if fully considered, could have prevented the procedure adherence issues that occurred, that information was not sought out or was not questioned. The presence of supervisors with the necessary standards to foster good procedure adherence could have acted as a significant barrier to prevent some of the problems that occurred; however, adequate supervisory oversight was not always available or used. Further, the team identified that available tools for assessing human and organizational performance had not been effectively used.

With regard to the NRC's review of issues associated with the previous IP 95002 inspection, the IP 95003 inspection team determined that actions to address procedure adequacy and ESW pump failures were still in progress at the end of the IP 95003 inspection. In particular, the IP 95003 team identified that one of the licensees corrective actions to address the verification of the quality of ESW pump work was inadequate. In addition, in light of the continuing problems in human performance and the impact on procedure adherence, the team concluded that actions to address procedure adherence had not been fully effective. Finally, actions to address training were also still in progress at the end of the IP 95003 inspection. In this case, the licensees corrective actions to address this issue had not been timely and at the conclusion of the IP 95003 inspection, had not yet been implemented. As a result, the NRC concluded that the open White findings associated with the IP 95002 inspection would continue to remain open pending additional licensee actions and the NRCs review of those actions. A summary of all of the IP 95003 inspection results is discussed in Attachment 3, "Perry IP 95003 Inspection Results," of this report.

1.3 FENOC Plant Performance Improvement Activities By letter dated September 30, 2004, and prior to the NRCs IP 95003 inspection activities, FirstEnergy Nuclear Operating Company (FENOC) advised the NRC that actions were underway to improve plant performance. To facilitate these performance improvements, FENOC developed the Perry Performance Improvement Initiative (PII).

As documented in the IP 95003 supplemental inspection report, in the assessment of the performance improvements planned and implemented through the PII, the NRC determined that the PII had a broad scope and addressed many important performance areas. The IP 95003 inspection team also observed that although substantially completed, the PII had not resulted in a significant improvement in plant performance in several areas, including human performance.

By letters dated August 8, 2005, "Response to NRC Inspection Procedure 95003 Supplemental Inspection, Inspection Report 05000440/2005003," and August 17, 2005, "Corrections for Response to NRC Inspection Procedure 95003 Supplemental Inspection, Inspection Report 05000440/2005003," the licensee responded to the inspection results documented in the IP 95003 supplemental inspection report.

As discussed in these letters, the Perry leadership team reviewed the achievements realized by the PII, the results of the NRC's IP 95003 supplemental inspection activities, and the conclusions from various additional assessments, and developed updates to the Perry PII. The Perry leadership team restructured the PII, referred to as the Phase 2 PII, into the following six initiatives that are briefly described in Attachment 4, "Summary of Phase 2 PII Initiatives," of this report:

• Corrective Action Program Implementation Improvement

• Excellence in Human Performance

• Training to Improve Performance

• Effective Work Management

• Employee Engagement and Job Satisfaction

• Operational Focused Organization In addition to a discussion of the Phase 2 PII, the licensee's August 8 and August 17 letters also included actions planned to address the NRC's findings and observations detailed in the IP 95003 supplemental inspection report. Attachment 3, "Actions to Address Key Issues Identified in the IP 95003 Inspection Report," of these letters focused on the following areas and summarized the actions that FENOC had taken or planned to take to address those issues:

• Implementation of the Corrective Action Program

• Human Performance

• IP 95002 Inspection Followup Issues

• Emergency Planning

• Performance Improvement Initiative 1.4 Confirmatory Action Letter Followup Inspection Activities and Results To Date On July 11, 2006, the NRC completed a Human Performance Action Item Implementation inspection that reviewed selected Commitments and Action Items described in the Perry Phase 2 PII Detailed Action and Monitoring Plan (DAMP) and the licensees August 8 and August 17, 2005, letters. The NRC concluded during this inspection that all four Commitments in the Human Performance area were adequately implemented. In particular, the NRC concluded that the roles and responsibilities of the Site Leadership Team in implementing the human performance program were adequately defined and communicated; that Site Training Advisory Committee meetings have had a strong focus on human performance; that the purpose and key activities of the human performance program had been communicated to site personnel; and that the scope and content of initial and continuing training needs on human performance fundamentals and error prevention tools were identified, and adequate training was provided to the plant staff. The NRC also determined that all Action Items associated with the Human Performance area that were reviewed were adequately implemented.

A complete discussion of the findings and other observations from this inspection is documented in NRC Inspection Report 50-440/2006012.

On March 14, 2006, the NRC completed an IP 95002 Issues Action Item Implementation inspection that determined whether the Commitments and Action Items in the IP 95002 Issues area were adequately implemented. The specific purposes of this inspection were to:

(1) Determine whether the licensees corrective actions to address maintenance procedure adequacy issues were adequate;

(2) Determine whether the licensees corrective actions to address emergency service water (ESW) pump coupling assembly concerns were adequate; and

(3) Determine whether the licensees corrective actions to address training issues were adequate. Overall, the NRC concluded that the licensee satisfactorily implemented the Commitments and Action Items that were reviewed. Notwithstanding this overall conclusion, the NRC also identified some cases where the licensees implementation of these actions was weak, which potentially impacted the licensees overall ability to effectively resolve the issues in this area.

On August 15, 2006, the NRC completed an IP 95002 Issues Action Item Effectiveness inspection that assessed the overall effectiveness of the licensees actions to address the IP 95002 Issues area and determined whether any additional inspection in this area, beyond that prescribed by the Reactor Oversight Process (ROP) baseline inspection program, was required. As such, the inspection objectives were to:

(1) Determine whether the licensees corrective actions to address maintenance procedure adequacy issues were effective;

(2) Determine whether the licensees corrective actions to address emergency service water (ESW) pump coupling assembly concerns were effective; and

(3) Determine whether the licensees corrective actions to address deviations from training in stressful circumstances were effective.

With regard to the overall inspection results, the licensees corrective actions in the areas of ESW pump coupling assembly and training deviations in stressful circumstances were determined to be effective and no additional inspection, beyond that prescribed by the ROP baseline inspection program, was planned. However, in the Maintenance Procedure Adequacy area, the NRC was not able to fairly assess the overall effectiveness of the licensees corrective actions due to an incomplete supplemental procedure review effort that the licensee initiated following the IP 95002 Issues Action Item Implementation inspection. In addition, the inspection identified two maintenance revision process vulnerabilities that could represent a challenge to the licensees ability to sustain improvement efforts in this area. The first vulnerability involved the performance of procedures in the field that had been previously identified as deficient, and the second concerned the exceptions to procedure guidance and a management expectation that procedure steps be accomplished in the order prescribed by the procedure.

2.0 Inspection Scope - Human Performance Action Item Effectiveness The purpose of this inspection was to assess the overall effectiveness of the licensees actions to address the Human Performance area of the Perry Confirmatory Action Letter (CAL) and determine whether any additional inspection beyond that prescribed by the ROP baseline inspection program was required.

As such, the inspection objectives were to:

• Determine whether human performance tools were adequately implemented through direct observation of plant evolutions;

• Determine whether personnel, such as first-line supervisors, were actively reinforcing and monitoring the use of human performance tools during plant evolutions; and

• Determine whether human performance monitoring tools, such as Key Performance Indicators (KPIs), reflected a sustained improvement in human performance and whether corrective actions were identified and implemented, as required, based upon the KPI data that was collected.

To accomplish these objectives, the following activities were performed:

2.1 Human Performance Observations During Plant Evolutions In the area of Human Performance, the IP 95003 inspection team determined that a number of self-revealed findings relating to procedure adherence occurred that had a strong human performance contribution. To address this issue, the licensee implemented a number of DAMP Action Items. During the Human Performance Action Item Implementation CAL Followup inspection, the team confirmed that these DAMP Action Items had been adequately implemented.

During this inspection, the inspectors determined whether the licensees actions to address the use of human performance tools during plant evolutions were effective. To perform this assessment, the inspectors observed plant evolutions from the control room and in the field, such as surveillance and in-service testing activities, maintenance and post-maintenance testing, clearance hanging and removal, and other plant configuration changes. The inspectors determined whether a sufficient questioning attitude was exhibited and whether the level at which human performance error prevention tools such as self-checking, peer checking, independent verification, three-way communication were being utilized adequately to accomplish the activity.

2.2 Review of Human Performance Monitoring Tools During the IP 95003 inspection, the inspection team identified that available tools for assessing human and organizational performance had not been effectively used. To address this issue, the licensee implemented DAMP Item 1.3.11: Conduct parallel observations with managers or other supporting supervisors to cross-calibrate each other on effective observation techniques. Managers should conduct parallel observations with each of their direct report supervisors and through 4th quarter 2005.

The intent of this corrective action is to improve supervisors abilities to coach workers on expected behaviors - correcting inappropriate behaviors and reinforcing desired behaviors. The parallel observations should reinforce these coaching and observation skills. During the Human Performance Action Item Implementation CAL Followup inspection, the team confirmed that DAMP Item 1.3.11 was implemented.

During this inspection, the inspectors determined whether the the licensees actions to address the use of tools to assess human and organizational performance were effective. To perform this assessment, the inspectors observed supervisors in the field and determined whether the supervisors exhibited the necessary standards to foster good procedure adherence through the feedback they provided to the staff being observed. In addition, the inspectors reviewed a sample of supervisor scorecards for activities observed in the field by supervisors and determine whether the results of these scored activities in the human performance area indicated that supervisors were effectively monitoring and providing feedback regarding the use of human error prevention tools during plant activities. Finally, the inspectors reviewed the results of recent self-assessments, external assessments, and Quality Assurance department assessments in this area and determined whether the results of those assessments indicated an improvement in performance in this area, and for issues identified during the assessments, whether appropriate corrective actions had been identified and implemented.

2.3 Review of Human Performance Key Performance Indicators During the IP 95003 inspection, the inspection team identified that available tools for assessing human and organizational performance had not been effectively used. To address this issue, the licensee developed Key Performance Indicators (KPIs) to measure the success of human performance improvement initiatives. In particular, the licensee implemented DAMP Item 2.2.1: Refine metrics for monitoring station and section human performance. During the Human Performance Action Item Implementation CAL Followup inspection, the team confirmed that DAMP Item 2.2.1 had been implemented and that the Human Performance KPIs were adequate.

During this inspection, the inspectors determined whether human performance monitoring tools, such as KPIs, reflected a sustained improvement in human performance and whether corrective actions are identified and implemented, as required, based upon the KPI data that is collected. To perform this assessment, the inspectors reviewed the results of human performance KPIs, condition reports that identified human performance issues, audits, and assessments. The inspectors determined whether appropriate corrective actions have been identified and implemented to address those issues, and whether human performance had improved, overall.

3.0 Inspection Results - Human Performance Action Item Effectiveness 3.1 Human Performance Observations During Plant Evolutions

a. Inspection Scope

A review of the effectiveness of the implemented initiatives was performed through the observation of activities in the field and the main control room. In particular, the inspectors conducted the following activities to determine whether a sufficient questioning attitude was exhibited and whether the level at which human performance error prevention tools, such as self-checking, peer checking, independent verification, and three-way communication were being utilized adequately to accomplish the activity:

• The inspectors conducted 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> of observations of activities from the main control room;

• The inspectors accompanied non-licensed operators (NLOs) on three operator rounds of activities;

• The inspectors observed nine routine surveillances and in-service testing activities that involved safety-related and/or risk-significant equipment;

• The inspectors observed five maintenance activities associated with safety-related and/or risk-significant equipment;

• The inspectors observed four post-maintenance testing activities associated with safety-related and/or risk-significant equipment; and

• The inspectors observed six clearance hanging or removal activities associated with safety-related and/or risk-significant equipment.

The inspectors also reviewed the results of 28 recent self-assessments, external assessments, and Quality Assurance department assessments in the Human Performance area. The inspectors determined whether the results of those assessments indicated an improvement in performance in this area and for identified issues whether appropriate corrective actions had been identified and implemented.

b. Observations and Findings

Main Control Room Observations During the inspection, the inspectors observed main control room operators perform reactivity management and power ascension activities following a plant downpower for a rod pattern adjustment, main turbine bypass valve operability testing, and main turbine valve testing.

No findings of significance were identified. The inspectors observed consistent use of appropriate human performance tools during control room observations with the exception of two instances. The inspectors also identified a human performance vulnerability associated with the marking up of procedures. Both issues, which were considered minor in nature, are summarized below:

• One operating crew was observed in two instances to not utilize three-way communications as prescribed by NOBP-LP-2603, Human Performance Tools and Verification Practices. Specifically, the receiver of a message did not repeat back the message, but instead simply stated that the message was understood. In both cases, however, the issue was identified and corrected by the Senior Reactor Operator.

• The inspectors identified a number of examples in which pencil markings that annotated the completion of actions in a procedure at the main control boards, such as Alarm Response Instructions and Off Normal Instructions, had not been erased prior to re-using the procedure. The inspectors concluded that the failure to erase markings from these procedures could confuse an operator, resulting in the failure to complete a required action. Licensee personnel generated Condition Report (CR) 06-9074 to enter this issue into the corrective action program.

Observations of Non-Licensed Operators During Operator Rounds No findings of significance were identified. The inspectors observed consistent use of appropriate human performance error prevention tools during all observed operator rounds.

Surveillance and In-Service Testing Observations No findings of significance were identified. The inspectors observed consistent use of appropriate human performance tools during surveillance and in-service testing activities with the exception of the following instances, which were considered minor in nature:

• During observations of a routine surveillance to functionally test the A scram discharge volume water level instrument, the inspectors identified inconsistent use of operating experience during the pre-job briefing. Examples of external operating experience applicable to this activity were discussed using printed event reports.

However, the review of internal operating experience was conducted as an open discussion, based on personal knowledge and experience. The inspectors determined that this method for the review of plant-specific operating experience may not completely and consistently identify error-likely situations.

The inspectors also noted some inconsistencies in the use of three-way communications during performance of this surveillance activity. When activity tasks required communications between personnel in the field and operators in the control room, proper three-way communication techniques were consistently observed. However, during face-to-face communications between personnel conducting peer-checking activities, the required repeat back or paraphrasing of the message by the receiver, and the acknowledgment of the repeat back by the sender, did not consistently occur.

• In one case the inspectors identified that an NLO performed procedure steps to verify valve positions without the reference procedure. Specifically, Step 5.1.2.10 of PTI-P45-P0009-A, ESW [Emergency Service Water] Forebay Low Level Functional For P45-D004A, required a verification that the ESW sluice gate seals were deflated per SOI P45/49, Emergency Service Water and Screen Wash Systems.

The NLO performed the SOI without referring to the procedure. Licensee personnel generated CR 06-8983 to enter this issue into the corrective action program.

Maintenance and Post-Maintenance Testing Observations No findings of significance were identified. The inspectors observed generally consistent use of appropriate human performance tools during maintenance and post-maintenance testing activities, with the exception of the following instances that were considered minor in nature:

• The inspectors observed that during the pre-job briefing for a loop calibration check, the technician performing the activity was asked to request a peer check prior to completing a particular job step. However, during the performance of the actual work, the technician did not ask another technician for a peer check until after the work was completed. When the second technician checked the work, he determined that the performing technician had attached an electrical lead to an incorrect terminal. At the post-job briefing, participants discussed the error and its discovery, but no one involved in the briefing, including the supervisor, challenged the timing of the peer check activity.

This activity yielded the following observations related to the use of human performance tools:

< Personnel performing the pre-job briefing did not discuss how the peer check should be obtained.

< The performing technician did not effectively self-check his work.

< Although both technicians believed that they had performed a peer check, their actions were not consistent with the intent of a peer check as defined in NOBP-LP-2603, Human Performance Tools and Verifications Practices.

Although NOBP-LP-2603 described peer checking as steps taken to ensure that errors are detected before they occur, in this case, the second technician did not perform the peer check until after the performing technician completed the work.

Therefore, the action requested of and completed by the technician was essentially an independent verification, which as described in NOBP-LP-2603, was intended to detect errors after they have occurred.

• While observing a pressure transmitter loop calibration check, the inspectors identified that personnel did not use appropriate flagging techniques when lifting an energized lead from a terminal board. Subsequently, during restoration, the technician landed the lifted lead on the wrong terminal board contact. Following this error, the technician requested verification of the step from a peer and the error was identified. The lead was then re-landed on the correct terminal contact, and the supervisor was notified. This issue was discussed during the post-job critique, and licensee personnel generated CR 06-8879 to enter this issue into the corrective action program.

• During a work activity to shift the Unit 2 turbine power complex fans, the inspectors observed inconsistent use of flagging. Specifically, although a technician used flagging to identify a switch prior to its operation in one case, the technician did not use flagging for a subsequent switch during the same job.

• While observing GEI-009, ABB Low Voltage Power Circuit Breaker Types K-600 and K-600s Through K-3000 and K-3000s Maintenance, a worker erroneously marked a step concerning breaker counter-rotation as unsatisfactory although the results were, in fact, satisfactory. When questioned by the inspectors, the documentation error was immediately corrected.

Clearance Hanging and Removal Observations During the review of licensee clearance hanging and removal activities, the following issue was identified that was determined to be a finding of very low safety significance:

Introduction:

A finding of very low safety significance and an associated non-cited violation (NCV) of Technical Specification (TS) 5.4, Procedures, was self revealed after licensee personnel failed to adhere to clearance procedures affecting the Division 1 emergency diesel generator (EDG) room ventilation system.

Description:

On October 23, 2006, licensee personnel performed a maintenance instruction to hang clearance tags on the Division 1 EDG room ventilation system in preparation for scheduled maintenance to inspect auxiliary ventilation system exhaust fan dampers. The EDG room ventilation system was required to function during EDG operation. The clearance instruction specified the removal of control power fuse 1M43F0070A/71A FU-L for the dampers to be inspected. The dampers to be inspected were associated with a nonsafety-related ventilation auxiliary exhaust fan. Licensee personnel identified an additional fuse, 1M43F0070A/71A FU-E, located near fuse 1M43F0070A/71A FU-L and erroneously determined that it needed to be removed as well. The operators performing the clearance instruction mistakenly concluded that the removal of the additional fuse was necessary to meet the intent of the clearance instruction. The removal of fuse 1M43F0070A/71A FU-E, which was not listed on the clearance instruction, disabled remote power to the Division 1 EDG ventilation supply fan dampers and affected their associated remote shutdown functions required by TS 3.3.3.2, Remote Shutdown System.

On October 24, 2006, licensee personnel performing the restoration of the clearance instruction noted that the number of fuses removed exceeded the number specified in the clearance instruction to be re-installed. Upon further investigation, licensee personnel determined that fuse 1M43F0070A/71A FU-E had been erroneously removed when clearance tags were hung on October 23. Operators discovered that this error affected a required remote shutdown function of the system and determined that licensee personnel had not recognized that a limiting condition for operation (LCO)associated with TS 3.3.3.2 should have been entered when the fuse was removed.

Operators then entered TS 3.3.3.2, action statement A.1., which required the restoration of the required function. Licensee personnel promptly replaced the fuse, restored the affected function, and exited the LCO.

The licensee investigated the circumstances surrounding this event and determined that the personnel hanging the clearance tags had become confused by the clearance instruction and the configuration of the fuses in the field. The licensee determined that contributing causes included a general deficiency in operations personnel knowledge of fuse and wire marks, deficiencies in equipment labeling, and general deficiencies in the clearance instruction content and process.

As part of their immediate corrective actions, the licensee counseled the personnel involved, revised the affected clearance instruction to add additional information and the appropriate system drawing, provided training to operations personnel, and took steps to enhance the labeling of the affected fuses. The licensee also planned to include fuse and wire training as part of the formal training program for operators and planned to revise the site clearance process associated with fuses. The licensee also implemented a policy that required system drawings to be included with all clearance instructions.

The inspectors determined that the failure of licensee personnel to adhere to maintenance procedures affecting safety-related equipment was a performance deficiency warranting a significance evaluation.

Analysis:

The inspectors concluded that the finding was greater than minor in accordance with Appendix B, Issue Screening, of IMC 0612, Power Reactor Inspection Reports. Specifically, the failure to adhere to maintenance procedures affecting safety-related equipment would become a more significant safety concern if left uncorrected. The primary cause of this finding was related to the cross-cutting area of human performance because licensee personnel failed to follow an established decision-making process and failed to stop work and seek additional guidance when confronted with the question of removing a fuse that was not listed on the clearance instruction.

The inspectors completed a significance determination of this issue using Appendix A, Determining the Significance of Reactor Inspection Findings for At-Power Situations, of IMC 0609, Significance Determination Process (SDP), dated November 22, 2005.

The inspectors determined that the issue was of very low safety significance, in accordance with the Phase 1 screening worksheet, because:

(1) it did not represent an actual loss of safety function of a system;

(2) it did not represent an actual loss of safety function of a single train for greater than its TS allowed outage time;

(3) it did not represent an actual loss of safety function of one or more non-TS trains of equipment designated as risk-significant per 10 CFR 50.65 for greater than 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />; and

(4) it did not screen as potentially risk significant due to a seismic, fire, flooding, or severe weather initiating event.

Enforcement:

Technical Specification 5.4, Procedures, required the implementation of the applicable procedures recommended in Regulatory Guide 1.33, Quality Assurance Program Requirements (Operation), Revision 2, dated February 1978.

Regulatory Guide 1.33, Appendix A, Part 9a, stated, Maintenance that can affect the performance of safety-related equipment should be properly preplanned and performed in accordance with written procedures, documented instructions, or drawings appropriate to the circumstances. Contrary to this requirement, on October 23, 2006, licensee personnel failed to adhere to maintenance procedures affecting the safety-related Division 1 EDG when a clearance instruction was performed and a fuse that was not specified in the instruction was removed. However, because of the very low safety significance of the issue and because the issue has been entered into the licensees corrective action program (CR 06-8702), the issue is being treated as an NCV consistent with Section VI.A.1 of the NRC Enforcement Policy (NCV 05000440/2006017-01).

Other Clearance Hanging and Removal Observations During the remainder of the inspection of this area, the inspectors observed generally consistent use of appropriate human performance tools during clearance hanging and removal activities with the exception of the following instances during pre-job briefings for clearance-hanging activities that were considered minor in nature:

• During one pre-job briefing, the NLO performing the briefing did not discuss industrial safety, as listed on the Operations pre-job briefing card. In addition, during this same briefing, the unit supervisor was distracted several times and had to excuse himself from the briefing to attend to alarms in the main control room.

• During another pre-job briefing, the NLO performing the briefing referenced the operating experience (OE) topic in the Operations pre-job briefing card, but did not discuss any specific OE because he could not recall any OE items related to hanging clearances. Following the pre-job briefing and in response to an inspectors question, the NLO who performed the briefing said that although he knew where to find OE items from several sources, he did not search for clearance-related OE items prior to the briefing.

Assessment Review Observations No findings of significance were identified. The inspectors determined that the results of self-assessments, external assessments, and Quality Assurance department assessments reflected an overall improvement in the human performance area and that human performance issues had been properly identified and addressed, with the exception of the following issues that were considered minor in nature:

• While reviewing Radiation Protection (RP) Integrated Performance Assessment (IPA) 200207434-0150, which assessed RP performance for the first 6 months of 2006, the inspectors identified that the assessment did not include a discussion of the results of previous actions that had been implemented to reduce dose, did not document external audit findings concerning High Radiation Area access, and did not reference CRs or any other tracking mechanisms. Licensee personnel generated CR 06-9289 to enter this issue into the corrective action program.

• Nuclear Oversight Assessment Quarterly Audit Report PY-C-06-01 (1st quarter 2006 assessment) identified several issues, such as weaknesses in the feedback mechanisms for evaluating station performance improvements; however, these issues were not summarized in the key issues section of the assessment, and condition reports were not generated to enter those issues into the corrective action program. This example appeared to be an isolated case since all subsequent quarterly assessment observations were captured in condition reports.

• SA847-PYHU-2006, Procedure Use and Adherence, documented four Noteworthy Items; however, condition reports were not generated to enter those items into the corrective action program. This was not consistent with NOBP-LP-2001, FENOC Self-Assessment/Benchmarking, which required a notification for Noteworthy Items.

Licensee personnel generated CR 06-9319 to enter this issue into the corrective action program.

3.2 Review of Human Performance Monitoring Tools

a. Inspection Scope

A review of the effectiveness of the licensees actions to address the use of tools to monitor human and organizational performance was conducted through the observation of activities in the field as well as through the review of licensee field observation cards.

In particular, the inspectors conducted the following activities:

• The inspectors observed four activities observed by supervisors and determined whether the supervisors exhibited the necessary standards to foster good procedure adherence through the feedback they provided to the staff being observed.

• The inspectors reviewed in excess of 50 supervisor scorecards for activities observed in the field by supervisors and determined whether the results of these scored activities in the human performance area indicated that supervisors were effectively monitoring and providing feedback regarding the use of human error prevention tools during plant activities.

b. Observations and Findings

Supervisory Reinforcement of Human Performance Tools No findings of significance were identified. All supervisors that were observed by the inspectors fostered good procedure adherence through the issues that they identified and the feedback they provided to the staff and documented on field observation cards (scorecards).

Scorecard Review Results No findings of significance were identified. The following issues that were considered minor in nature were identified:

• The inspectors identified that some scorecards had all attributes assessed as Satisfactory although it was unlikely, based upon the scope of the activity, that all attributes was able to be observed and assessed. Licensee personnel generated CR 06-9192 to enter this issue into the corrective action program.

• Several examples of incomplete documentation were identified by the inspectors.

For example, although several scorecards contained attributes that were rated as Needs Improvement, there was insufficient information provided in the comments field of the scorecard to understand the issue that resulted in this rating. In addition, in some cases coaching was not identified on the scorecard to have been conducted following a Needs Improvement rating although coaching was required to be performed.

• In some of the scorecards that identified problems or recommended actions, condition reports were not generated. Therefore it was unclear if the issues were addressed. The following specific examples were identified:

< Scorecard PYF2006-2020 documented a drawing deficiency; however, no followup actions or CRs were referenced. Licensee personnel stated that the observer recalled being told that a CR was already in place to address the issue; however, that CR was not referenced in the scorecard, and no followup actions were listed to verify that the CR existed or that the issue had been addressed.

< Scorecard PYF2006-1968 documented that the superintendent was to follow up on an issue, and a supervisor was to check on procedural requirements.

Licensee personnel stated that both of the actions were performed and no followup actions were required; however, the accomplishment of the actions was not documented.

< The inspectors noted that observation comments for areas in which coaching was provided to emphasize positive behavior were not consistently documented in the scorecard database as required by NOBP-LP-2607, Observation and Coaching Program, Revision 1.

3.3 Review of Human Performance Key Performance Indicators

a. Inspection Scope

The inspectors determined whether human performance monitoring tools, such as KPIs, reflected a sustained improvement in human performance and whether corrective actions were identified and implemented, as required, based upon the KPI data that was collected. In particular, the inspectors conducted the following activities:

• The inspectors reviewed KPI data and determined whether the data indicated that the licensees actions to improve human performance had been effective.

• The inspectors reviewed condition reports associated with human performance events and determined whether the frequency and significance of those events were consistent with the KPI data and indicated that the licensees actions to improve human performance had been effective.

• The inspectors reviewed the results of recent self-assessments, external assessments, and Quality Assurance department assessments in the human performance KPI area and determined whether appropriate corrective actions had been identified and implemented for identified issues.

b. Observations and Findings

Review of KPI Data for Human Performance Improvements No findings of significance were identified. The Station Clock Reset KPI reflected a significant and steady decline in Station Clock Reset events during the previous 7 calendar quarters. The inspectors observed that in response to a negative trend in the Section Clock Reset KPI, licensee personnel implemented several corrective actions. For the 3 calendar quarters since those actions were completed, the Section Clock Reset KPI reflected a steady decline in the rate of Section Clock Reset events; however, the inspectors also observed that some lower-level KPIs, such as section error rates, had not produced clear trends that could lead to meaningful insights and improvements.

Comparison of Condition Report Information to KPI Data No findings of significance were identified. A review of CRs did not indicate any significant adverse trends in human performance. The frequency and significance of events identified in these CRs were consistent with KPI data, and the corrective actions appeared appropriate to address the problems described.

Comparison of Assessment Information to KPI Data No findings of significance were identified. The inspectors determined that appropriate corrective actions were identified and implemented for identified issues.

4.0 Overall Assessment - Human Performance Action Item Effectiveness

a. Inspection Scope

Based upon the inspectors observations during this inspection, and the review of human performance related KPIs, the inspectors completed an overall assessment of the licensees actions to address the area of human performance.

b. Observations and Findings

Based upon the observations of the use of human performance error prevention tools conducted in the plant during this inspection, the observations of supervisors during opportunities to monitor and reinforce the use of these tools, and the review of human performance related KPIs, the inspectors concluded that the licensees corrective actions have been effective in improving human performance.

Notwithstanding this overall conclusion, the inspectors continued to identify human performance issues during the inspection, including one issue that was determined to be a finding of very low safety significance. Although these human performance weaknesses were not considered to be significant, the inspectors concluded the following:

• Although the licensees staff had been sufficiently trained in the use of human performance error prevention tools, at times the staff failed to apply knowledge that had been gained through the training that had been provided;

• Although supervisors and managers were actively observing plant activities, the licensee had not always taken full advantage of potential performance improvements resulting from these observations; and

• Although some performance indicators reflected a significant improvement in human performance, other performance indicators did not provide performance insights.

5.0 IP 95002 Issues - Maintenance Procedure Adequacy

a. Inspection Scope

The purpose of this inspection was to assess the overall effectiveness of the licensees actions to address the Maintenance Procedure Adequacy aspect of the IP 95002 Issues area and determine whether any additional inspection beyond that prescribed by the ROP baseline inspection program was required.

In order to determine the effectiveness of the licensees corrective actions to address maintenance procedure adequacy issues, the inspectors observed the performance of the revised procedures in the field, reviewed work packages that incorporated revised procedures, and performed in-office reviews of selected revised maintenance procedures. The inspectors also interviewed procedure writers responsible for the development of the revised procedures and maintenance personnel who utilized the revised procedures in the field. These interviews focused on evaluating the nature of the process used to revise the procedures and the ease of use of the revised procedures. The interviews also provided insights into the perceived level of management support for the revision effort. In-field observations focused on the ease of use of the procedures in the field, clarity of instructions, and the ability of workers to perform the procedures as written. In-office maintenance procedure reviews focused on the technical adequacy of the procedure, whether an appropriate level of detail existed, and whether procedural steps were logically sequenced. The inspectors used technical manuals and other references cited in the procedures to evaluate technical adequacy.

The following specific activities were accomplished:

• The inspectors observed a sample of maintenance activities performed in the field that were associated with the 118 maintenance procedures that were revised, focusing on the adequacy of the maintenance procedure to accomplish the required task.

In particular, the inspectors observed the performance of the following procedures:

< PMI-0109, V-belt and Sheave Inspection

< PMI-0050, Preventive Maintenance Lubricating Guidelines

< GMI-0073, V-belt and Sheave Maintenance

< GEI-0009, ABB Low Voltage Power Circuit Breaker Types K-600 and K-600s Through K-3000 and K-3000s Maintenance

< PMI-0030, Maintenance of Limitorque Valve Operators

• The inspectors performed an in-office review of the documentation of the results of maintenance activities associated with a sample of the 118 maintenance procedures for maintenance conducted after the maintenance procedures were re-revised, focusing on the adequacy of the maintenance procedures to accomplish the required task.

In particular, the inspectors reviewed the documentation of the results of work activities associated with the following maintenance procedures:

< PMI-0109, V-belt and Sheave Inspection

< CMI-0016, Division 1 and 2 Emergency Diesel Generator Starting Air Valve Repair

< PMI-0050, Preventive Maintenance Lubricating Guidelines

• The inspectors performed an in-office review of a sample of the 118 maintenance procedures that were re-revised, focusing on the adequacy of the maintenance procedures to accomplish the required task.

In particular, the inspectors reviewed the following revised maintenance procedures:

< GEI-0136, ABB Power Circuit Breakers 15KV Type 15HK1000 Maintenance

< PTI-R43-P0006-A, Division 1 Diesel Generator Pneumatic Logic Board Functional Check

< GEI-0007-A, Instructions for Cable and Wire Terminations

• During the IP 95002 Issues - Action Item Effectiveness inspection, the inspectors identified two maintenance revision process vulnerabilities that potentially challenged the licensees ability to sustain their maintenance procedure improvement efforts.

The first maintenance procedure revision process vulnerability involved the performance of procedures in the field that had been previously identified as deficient in a document change request (DCR), condition report, or on a marked-up hard copy of the procedure. In this case, the inspectors identified that licensee personnel had not established any mechanism to inform maintenance supervisors and workers of these identified procedure issues so that they could be discussed during pre-job briefings. In addition, in a number of cases, licensee personnel had not expeditiously addressed the procedure deficiencies nor placed the procedures on hold. As a result, the inspectors identified that in some cases, workers had performed maintenance activities in the field using procedures that had been previously identified as requiring revision, but which had not been revised. In addressing this issue, on an interim basis, licensee personnel planned to insert pink sheets in WO packages to alert maintenance personnel to the issue and later planned to add a requirement for maintenance personnel to check for open DCRs for a procedure prior to performing the procedure in the field.

A second maintenance procedure revision process vulnerability concerned the exceptions to procedural guidance and management expectations that procedure steps be accomplished in the order prescribed by the procedure. In one case, the inspectors identified a statement in several procedures that provided the provision for maintenance personnel, at the discretion of the first line supervisor, to perform procedure steps out of sequence. This statement had originally been provided in 69 of the 118 maintenance procedures. The licensees ongoing supplemental maintenance procedure review effort had eliminated this statement from all but 2 of the 69 procedures; however, due to difficulties in performing several procedures as written, licensee personnel re-incorporated this statement into 4 of the procedures without management approval. Licensee personnel generated CR 06-03307 to enter this issue into the corrective action program.

During this inspection, the inspectors reviewed the licensees actions to address these issues.

b. Observations and Findings

Review of Maintenance Procedures No findings of significance were identified. The inspectors did not identify any procedure deficiencies that prevented the fulfillment of the intent of the procedure, would have led to equipment damage, or presented a personnel hazard. In addition, field observations indicated that the procedures could be effectively used to accomplish the intended activity. Also, personnel were generally satisfied with the level of detail provided in the procedures as well as procedure clarity, and workers believed their comments on procedures would be addressed and had taken a larger ownership role in ensuring procedure quality.

Notwithstanding this conclusion, the inspectors identified some examples where additional procedural enhancements could improve procedure use and clarity.

These examples, which were considered to be minor in nature, are as follows:

• GEI-0009, ABB Low Voltage Power Circuit Breaker Types K-600 and K-600s Through K-3000 and K-3000s Maintenance: Steps to determine acceptance criteria for DC [direct current] breakers were poorly worded and the format of the associated data sheet made it difficult to determine where to record measured data.

• PMI-0109, V-belt and Sheave Inspection: Steps that described the actions necessary to ensure that sheaves of unequal widths were properly aligned were unclear.

• PMI-0030, Maintenance of Limitorque Valve Operators: The procedure directed that the valve stem protector be removed and re-installed twice although it was only necessary to remove the valve stem protector at the beginning of the activity and re-install the valve stem protector at the end of the activity.

• PTI-R43-P0006A, Division 1 Diesel Generator Pneumatic Logic Board Functional Check: A required 0-100 pounds per square inch gauge (psig) pressure gage was not included in the required equipment list.

• GEI-0136, ABB Power Circuit Breakers 15Kv Type 15HK1000 Maintenance: The list of required tools omitted a carborundum stone and a scotch brite pad.

Review of Maintenance Procedure Process Vulnerabilities No findings of significance were identified and the inspectors determined that these issues were adequately addressed. The following specific actions were identified and verified to have been adequately implemented:

• Review of Actions to Address the Continued Use of Deficient Procedures In addition to the actions implemented at the end of the previous inspection, licensee personnel reviewed the entire procedure revision backlog and placed all procedures that were identified to be deficient on hold. The licensee considered a procedure deficiency to exist if the successful performance of the procedure could not satisfy the desired outcome, if the performance of the procedure would damage equipment, or if the performance of the procedure presented a personnel hazard. In addition, the licensee established a procedure change request screening process to identify deficient procedures to be placed on hold pending revision prior to use. This process also required the generation of a condition report for any procedure identified to be deficient.

The licensee included the requirement to identify deficient procedures and place them on hold in NOP-SS-3001, Procedure Review and Approval.

• Review of Actions to Address the Performance of Procedure Steps Out of Sequence To address this issue, the provision for maintenance personnel to perform procedure steps out of sequence at the discretion of the first line supervisor was removed from all maintenance procedures. The inspectors determined whether this had been accomplished through a review of a sample of the revised maintenance procedures.

The inspectors did not identify any provisions for performing steps out of sequence in the procedures that were reviewed. In addition, licensee personnel revised PAP-0500, Perry Technical Procedure Writers Guide, to provide specific, narrowly focused criteria to permit steps to be performed out of sequence.

6.0 Overall Maintenance Procedure Adequacy Assessment

a. Inspection Scope

Based upon the observation of a sample of maintenance activities in the field associated with the 118 maintenance procedures that were revised; a review of documentation of the results of maintenance activities associated with a sample of the 118 maintenance procedures for maintenance conducted after the maintenance procedures were revised; the in-office review of a sample of the 118 maintenance procedures that were revised; and a review of the licensees corrective actions to address previously identified maintenance procedure revision process vulnerabilities, the inspectors completed an overall assessment of the licensees actions to address the Maintenance Procedure Adequacy aspect of the IP 95002 Issues area.

b. Observations and Findings

Based on the results of this inspection, the inspectors concluded that the licensees corrective actions had been effective in addressing the Maintenance Procedure Adequacy aspect of the IP 95002 Issues area.

Although the inspectors identified, in the sample of the procedures reviewed, some procedure enhancements that could improve the ease of use of the procedures, the inspectors concluded that the licensee had significantly improved the overall quality of maintenance procedures. The inspectors also concluded that based upon the maintenance revision processes and procedures that had been established, that maintenance procedures could be maintained at an adequate level of overall quality.

7.0 Exit Meeting On December 13, 2006, the inspectors presented the inspection results to Mr. L.

Pearce, Vice President, and other members of his staff, who acknowledged the findings and observations.

The inspectors asked the licensee whether any materials examined during the inspection should be considered proprietary. No proprietary information was identified.

SUPPLEMENTAL INFORMATION

KEY POINTS OF CONTACT

Licensee

G. Leidich, Chief Nuclear Officer, FENOC

D. Pace, Senior Vice President, Fleet Engineering and Services, FENOC

J. Hagan, Chief Operating Officer, FENOC

L. Pearce, Vice President, Perry

B. Allen, Plant Manager, Perry

F. Cayia, Director, Performance Improvement, Perry

K. Howard, Manager, Design, Perry

J. Lausberg, Manager, Regulatory Compliance, Perry

G. Halnon, Director, Performance Improvement Initiative, Perry

LIST OF ITEMS OPENED, CLOSED, AND DISCUSSED

Opened

05000440/2006017-01 NCV Improper Fuse Removal During Clearance Hanging

Closed

05000440/2006017-01 NCV Improper Fuse Removal During Clearance Hanging Attachment 1