IR 05000440/2012009

IR 05000440-12-009, on 08/27/2012-11/16/2012; Perry Nuclear Power Plant; Supplemental Inspection Procedure (IP) 95002, Supplemental Inspection for One Degraded Cornerstone or Any Three White Inputs in a Strategic Performance Area

ML12363A137
Person / Time
Site:	Perry
Issue date:	12/28/2012
From:	O'Brien K Division of Reactor Safety III
To:	Kaminskas V FirstEnergy Nuclear Operating Co
References
EA-11-148, EA-12-228 IR-12-009
Download: ML12363A137 (62)

Text

ber 28, 2012

SUBJECT:

PERRY NUCLEAR POWER PLANT - NRC 95002 SUPPLEMENTAL INSPECTION REPORT 05000440/2012009

Dear Mr. Kaminskas:

The U.S. Nuclear Regulatory Commissions (NRC's) staff conducted a supplemental inspection pursuant to Inspection Procedure (IP) 95002, Inspection for One Degraded Cornerstone or Any Three White Inputs in a Strategic Performance Area, at the Perry Nuclear Power Plant, Unit 1 from August 27 through November 16, 2012. The enclosed inspection report documents the inspection results, which were discussed at an exit meeting on November 16, 2012, with you and other members of your staff.

In accordance with the NRC Reactor Oversight Process (ROP) Action Matrix, this supplemental inspection was performed to assess FirstEnergy Nuclear Operating Companys (FENOCs)

evaluation associated with a finding with low to moderate safety significance which occurred in the second quarter of 2011 and a White Performance Indicator (PI) which affected the Occupational Radiation Safety Cornerstone in the radiation safety strategic performance area.

The finding involved a Notice of Violation (NOV) that was previously documented in NRC Inspection Report No. 05000440/2011014. You last informed the NRC staff on August 9, 2012, of your readiness for this supplemental inspection.

The objectives of this supplemental inspection were to: (1) provide assurance that the root and contributing causes of individual and collective (multiple White inputs) risk-significant performance issues were understood; (2) provide assurance that the individual and collective (multiple White inputs) risk-significant performance issues were identified; (3) independently determine whether safety culture components caused or significantly contributed to the individual and collective (multiple White inputs) risk-significant performance issues; and (4) provide assurance that corrective actions were or will be sufficient to address and preclude repetition of the root and contributing causes. The staff concluded that FENOC did not provide assurance that the corrective actions for performance issues associated with the Occupational Exposure Control Effectiveness PI were sufficient to address the root and contributing causes and prevent recurrence. The NRC further concluded that your staff did not adequately address corrective actions for the White NOV.

Specifically, the NRC determined that events occurred following your initial implementation of corrective actions for the White PI and White NOV, which had similar root causes as the White PI and White NOV. Additionally, the NRC inspection staff identified an additional Non-Cited Violation (NCV) of your Technical Specification regarding establishing adequate controls for locked high radiation areas during the performance of the IP 95002 inspection that exhibited a similar causal factor of both the White NOV and the White PI. Taken collectively, the issues associated with the White finding represented a significant weakness, as discussed in IP 95002, and your actions to date have not provided the assurance level required to meet the inspection objectives. In accordance with NRC Inspection Manual Chapter (IMC) 0305, "Operating Reactor Assessment Program," a parallel PI inspection finding is assigned the same safety significance as the initiating PI. Similarly, the White finding associated with NOV 05000440/2011014-01 will be held open. You will be notified by the NRC in separate correspondence of our determination of Perry Nuclear Power Plant's location in the NRCs ROP Action Matrix as a result of the parallel PI White inspection finding and the held open White finding associated with the NOV.

When informed of your readiness, a future inspection will be conducted to verify that the corrective actions that your staff has put in place to address and preclude a repetition of the root and contributing causes of the multiple Occupational Exposure Control Effectiveness occurrence PIs. Also, the NRC will assess whether the White NOV can be closed. During the performance of this IP 95002 supplemental inspection, the inspection team did not complete its independent review of the extent of condition and extent of cause for the issues due, in part, to the significant weaknesses noted in your corrective action for the White PI and White NOV.

Therefore, the NRC will complete its independent review of the extent of condition and the extent of cause during this future inspection.

Based on the results of this inspection, the NRC also identified issues that were evaluated under the risk significance determination process has having very low safety significance (Green). The NRC determined that violations were associated with these issues. These violations are being treated as Non-Cited Violations (NCVs), consistent with Section 2.3.2 of the Enforcement Policy. These NCVs are described in the subject inspection report. If you contest the violation(s) or significance of these NCVs, you should provide a response within 30 days of the date of this inspection report, with the basis for your denial, to the Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555-0001, with copies to:

(1) the Regional Administrator, Region III; (2) the Director, Office of Enforcement, United States Nuclear Regulatory Commission, Washington, DC 20555-0001; and Mark Marshfield, NRC Senior Resident Inspector at Perry Nuclear Power Plant.

In accordance with 10 CFR 2.390 of the NRC's "Rules of Practice," a copy of this letter, its enclosure, and your response, if you choose to respond, will be available electronically for public inspection in the NRC Public Document Room or from the Publicly Available Records System (PARS) component of NRC's Agencywide Documents Access and Management System (ADAMS), accessible from the NRC Web site at http://www.nrc.gov/reading-rm/

adams.html (the Public Electronic Reading Room). Please contact Mr. Billy C. Dickson at (630) 829-9827 to notify the NRC of your readiness for a follow-up of the supplemental inspection and with any questions you have regarding this letter.

Sincerely,

/RA by Patrick Louden Acting for/

Kenneth G. OBrien, Acting Director Division of Reactor Safety Docket No. 50-440 License No. NPF-58

Enclosure:

Inspection Report No. 05000440/2012009 w/ Attachment: Supplemental Information

REGION III==

Docket No: 50-440 License No: NPF-58 Report No: 05000440/2012009 Licensee: FirstEnergy Nuclear Operating Company Facility: Perry Nuclear Power Plant, Unit 1 Location: Perry, OH Dates: August 27 through November 16, 2012 Inspectors: John Cassidy, Senior Health Physicist (Team Lead)

John Ellegood, Senior Resident Inspector, D.C. Cook Alex Garmoe, Resident Inspector, Braidwood Molly Keefe, Human Factors Specialist Mark Mitchell, Health Physicist Observers: Steven Garry, Senior Health Physicist (Observer)

Gregory Hansen, Physical Security Inspector (Observer)

Approved by: Billy Dickson, Branch Chief Health Physics and Incident Response Branch Division of Reactor Safety Enclosure

SUMMARY OF FINDINGS

Inspection Report (IR) 05000440/2012009; 08/27/2012 - 11/16/2012; Perry Nuclear Power

Plant; Supplemental Inspection - Inspection Procedure (IP) 95002, Supplemental Inspection for One Degraded Cornerstone or any Three White Inputs in a Strategic Performance Area.

This inspection was conducted by two regional inspectors, two resident inspectors, and a specialist from NRC Headquarters. The inspectors identified one White parallel Performance Indicator (PI) inspection finding and two Green Non-Cited Violations (NCVs). The significance of most findings is indicated by their color (Green, White, Yellow, Red) using Inspection Manual Chapter (IMC) 0609, "Significance Determination Process (SDP)." Cross-cutting aspects are determined using IMC 0310, "Components Within the Cross-Cutting Areas." Findings for which the SDP does not apply may be Green or be assigned a severity level after NRC management review. The NRC's program for overseeing the safe operation of commercial nuclear power reactors is described in NUREG-1649, "Reactor Oversight Process," Revision 4, dated December 2006.

NRC-Identified

and Self-Revealed Findings

Cornerstone: Occupational Radiation Safety

White.

The inspectors identified a White parallel PI inspection finding for the failure to provide assurance that the corrective actions for performance issues associated with the Occupational Exposure Control Effectiveness PI were sufficient to address the root and contributing causes and to prevent recurrence. This finding has been entered into the licensees Corrective Action Program (CAP) as Condition Report (CR)-2012-18695.

In accordance with IP 95002 and IMC 0305, "Operating Reactor Assessment Program," the parallel PI inspection finding is assigned the same safety significance as the initiating PI. Because the initiating PI had a low to moderate safety significance (White), this parallel inspection finding has been assigned a low to moderate safety significance (White). This finding was not assessed for cross-cutting aspects.

(Section 4OA4.02.03.f(1))

Green.

The inspectors identified a finding of very low safety significance and multiple examples of an associated NCV for failure to comply with Technical Specification (TS)5.4.1. Specifically, the inspectors identified that the licensee failed to implement multiple procedural requirements associated with a spill of radioactive material in the Radioactive Waste Building. The failure to implement these procedural requirements occurred across multiple organizations (Radiation Protection, Work Control, and Operations).

The licensee entered this issue into their CAP as CR-2012-09447.

The performance deficiency was determined to be more than minor because it could reasonably be viewed as a precursor to a significant event (lack of proper protection of workers from potential exposures), was related to the Programs and Process attribute of the Occupational Radiation Safety Cornerstone, and adversely affected the cornerstone objective to ensure the adequate protection of worker health and safety from exposure to radiation from radioactive material during routine reactor operation. Therefore, the performance deficiency was determined to be a finding or more than minor safety significance. The finding was not subject to traditional enforcement because it was not associated with a violation that impacted the regulatory process and did not contribute to actual safety consequences. The finding was assessed using IMC 0609, Appendix C,

Occupational Radiation Safety SDP, and was determined to be of very low safety significance (Green) because it was not related to As-Low-As-Is-Reasonably-Achievable (ALARA), did not result in an overexposure or a substantial potential for overexposure, and did not compromise the licensee's ability to assess dose. This finding was associated with a cross-cutting aspect in the decision-making component of the human performance cross-cutting area. Specifically, the licensee failed to use conservative assumptions in their decisions affecting response to a radiological spill, which resulted in failure to adequately control the area for several days (H.1(b)).

(Section 4OA4.02.03.f(2))

Green.

The inspectors identified a finding of very low safety significance and an associated NCV of TS 5.7.2 for the failure to control and establish barriers that would prevent unauthorized entry to an area that was accessible to personnel with radiation levels, such that a major portion of the whole body could receive in 1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br />, a dose greater than or equal to 1000 mRem. Specifically, the inspectors determined that the barriers used to control access to an identified Locked High Radiation Area (LHRA)around the work platform erected to support dry fuel storage cask loading and transport, did not provide reasonable assurance that the area was secure against unauthorized access and could not be circumvented. The licensee entered this issue into their CAP as CR-2012-14884. The licensee also took immediate corrective actions, which included posting an additional access control guard in the area, documenting Radiation Protection (RP) Manager standing orders for control of the area, controlling keys to operate the person-lift by the RP staff, and providing additional physical barriers to the lower areas of the scaffolding to prevent use of natural ladders of the scaffolding.

The performance deficiency was determined to be more than minor based on Example 6.g of IMC 0612, Appendix E, Examples of Minor Issues," because LHRA conditions were actually present. As a result, the inspectors determined that the performance deficiency was a finding of more than minor safety significance. The finding was not subject to traditional enforcement because it was not associated with a violation that impacted the regulatory process and did not contribute to actual safety consequences. The finding was assessed using IMC 0609, Appendix C, Occupational Radiation Safety SDP, and was determined to be of very low safety significance (Green) because it was not related to ALARA, did not result in an overexposure or a substantial potential for overexposure, nor was the ability to assess dose compromised.

This finding was associated with a cross-cutting aspect in the operating experience component of the problem identification and resolution cross-cutting area. Specifically, the licensee failed to implement and institutionalize operating experience through changes to station processes, procedures, equipment and training programs (P.2 (b)).

(Section 4OA4.02.03.f(3))

Licensee-Identified Violations

No violations were identified.

REPORT DETAILS

4OA4 Supplemental Inspection

===.01

=

The NRC staff performed this supplemental inspection in accordance with Inspection Procedure (IP) 95002 to assess FirstEnergy Operating Company's (FENOCs)evaluation associated with a White finding and Performance Indicator (PI), which affected the Occupational Radiation Safety Cornerstone in the Radiation Safety strategic performance area. The inspection objectives were to:

Provide assurance that the root and contributing causes of risk-significant issues were understood;

Provide assurance that the extent of condition and extent of cause of risk-significant issues were identified and to independently assess the extent of condition and extent of cause of individual and collective risk-significant issues;

Independently determine if safety culture components caused or significantly contributed to the risk-significant issues; and

Provide assurance that the licensees corrective actions for risk-significant issues were or will be sufficient to address the root and contributing causes and to preclude repetition.

In the second quarter of 2011, the licensee accrued four Occupational Exposure Control Effectiveness PI occurrences in the Occupational Radiation Safety Cornerstone. In the third quarter of 2011, the NRC completed a significance determination of one of the occurrences and issued a White Notice of Violation (NOV) in the Occupational Radiation Safety Cornerstone. The White PI and White NOV constituted two White inputs in one cornerstone, and the licensee entered Column 3 (Degraded Cornerstone) of the NRCs Action Matrix.

The performance deficiencies and associated violations for the events, that were the subject of this supplemental inspection, were as follows:

White PI

• Unexpected Dose Rate Alarm Received by an Operator in the Fuel Pool Cooling and Cleanup Heat Exchanger - NCV 0500440/2011002-01

• Unexpected Dose Rate Alarm Received during Reinsertion of Source Range Monitor C Detector - NCV 0500440/2011013-02

• Unexpected Dose Rate Alarm Received by Supplemental Worker during Replacement of Safety Relief Valves - NCV 0500440/2011004-02 White Finding

• High Radiation Levels Created during Withdrawal of Source Range Monitor C Detector - NOV 0500440/2011013-02 The inspectors reviewed the events that resulted in a failure to control access to locked high radiation areas (LHRAs) in May and June 2012. The inspectors reviewed the corrective action program and the supporting information related to the scaffolding, identified in May 2012 (NCV 05000440/2012003-02), in the turbine building 577 elevation catacomb area and the resin spill event in the radwaste building 574 elevation in June 2012 (NCV 05000440/2012009-02). These events were reviewed for understanding and to determine if there were similarities with the previously identified issues that were the subject of this supplemental inspection.

The inspectors also reviewed the licensees root cause evaluation (RCE) for each issue, in addition to other evaluations conducted in support of, and as a result of, the RCEs.

The inspectors reviewed the corrective actions taken or planned to address the identified causes. The inspectors also held discussions with the licensees staff to ensure that the root and contributing causes were understood and that corrective actions taken or planned were appropriate to address the causes and prevent recurrence. In addition, the inspectors performed an assessment of whether any safety culture components caused or significantly contributed to the issues.

The inspectors noted that the C source range monitor (SRM-C) event that was documented in the White finding was also one of four inputs to the White PI. For ease of documentation, the remainder of the inspection report parallels the inspection requirements of IP 95002. For clarity, documentation of each inspection requirement contains multiple subsections, one for the each of the events that resulted in the White PI, one for the White finding, and one for the common cause analysis performed by the licensee that covered all four events.

Definitions for some of the frequently used terms in this report include:

• RCE - an evaluation which determines the root causes (or basic reasons) for an event. Root causes for a problem are considered those issues which, if corrected, will prevent reoccurrence of that problem;

• Extent of Condition - the extent to which the actual condition exists with other plant processes, equipment, or human performance; and

• Extent of Cause - the extent to which the root causes of an identified problem have impacts to other plant processes, equipment, or human performance.

b. Inspection Results

• The inspectors concluded that the licensees root cause evaluations provided assurance that the root and contributing causes of risk-significant issues were understood.

• The inspectors did not determine whether the extent of condition and extent of cause of risk-significant issues were identified and did not complete an independent assessment of the extent of condition and extent of cause of individual and collective risk-significant issues. Inspection activities for this objective and the reasons this objective was not completed are discussed in more detail in this inspection report.

• The inspectors independently determined that there were safety culture components that caused or significantly contributed to the risk-significant issues.

• The inspectors identified significant weaknesses in the licensees ability to provide assurance that corrective actions for the White PI and White NOV were, or will be, sufficient to address the root and contributing causes and to preclude repetition.

This is supported by three similar events that occurred after the licensee initially implemented corrective actions for the White PI and White NOV.

Evaluation of the Inspection Requirements 02.01 Problem Identification The licensee used multiple methods to assess the condition and determine root and contributing causes. The methods used included Event and Causal Factors Charts, staff interviews, MORT, and TapRooT Root Cause Tree. Event and Causal Factors charts, TapRooT, and MORT are all specified as acceptable methods for performing a root cause analysis in procedure NOBP-LP-2011, FENOC Cause

Analysis.

a. As directed by IP 95002, the inspectors reviewed FENOCs evaluation of the issues to determine that it documented who identified the issues (i.e., licensee-identified, self-revealing, or NRC-identified) and the conditions under which the issues were identified.

White PI

.1 Unexpected Dose Rate Alarm Received by an Operator in the Fuel Pool Cooling and

Cleanup (FPCC) Heat Exchanger Room (Root Cause Evaluation 2011-1593A)

On November 19, 2010, an incident occurred involving an operator who received an unexpected dose rate alarm during the removal of a clearance order safety tag in the FPCC Heat Exchanger Room. This incident was evaluated by Condition Report (CR)-

10-86072, which was initially evaluated at a Limited Apparent (AL) cause level but was subsequently reinvestigated at the root cause level. The inspectors review of this incident determined that the licensees RCE (CR-2011-1593A, dated April 19, 2012),appropriately documented by whom the issue and conditions under which the issue was identified.

.2 Unexpected Dose Rate Alarm Received during Reinsertion of SRM-C Detector (Root

Cause Evaluation 2011-1593B)

On April 22, 2011, during an attempt to re-insert the SRM-C detector into the reactor, a worker encountered a much higher radiation field than planned. The worker received an unanticipated dose rate alarm while traveling to the designated work area. The dose rates in the travel path were known along with the fact that the dose rates quickly increased to more than 1000 REM/hour just beyond the travel path. This event was documented by the licensee in CR-2011-93300, which was initially closed without evaluation. Subsequently, the event was reinvestigated at the root cause level as CR 2011-1593B, dated April 19, 2012. The inspectors determined that the licensees RCE appropriately documented by whom and the conditions under which the issue was identified.

.3 Unexpected Dose Rate Alarm Received by Supplemental Worker during Replacement of

Safety Relief Valves (SRVs) (Root Cause Evaluation 2011-1593C)

On May 2, 2011, a worker performing an SRV replacement in the drywell received an unexpected dose rate alarm after the worker entered an area that was not included in the ALARA briefing. This event was evaluated by CR-2011-93976, which was classified as a Limited Apparent (AL) cause evaluation. Subsequently, the event was reinvestigated at the root cause level as CR-2011-1593C, dated April 19, 2012. The inspectors determined that the licensees RCE appropriately documented by whom and the conditions under which the issue was identified.

White Finding

.1 High Radiation Levels Created during Withdrawal of SRM-C Detector (Root Cause

Evaluation 2011-93247)

On April 21, 2011, the SRM-C detector was withdrawn from under the reactor vessel, exposing several radiation workers to very high radiation levels. After receiving unexpected dose rate alarms, the workers and the supporting radiation protection (RP)technicians promptly exited the undervessel area. This event was evaluated at the root cause level as CR-2011-93247, dated April 13, 2012. The inspectors determined that the licensees RCE appropriately documented by whom and the conditions under which the issue was identified.

.2 CCA of the White PI Occurrences and White NOV (Root Cause Evaluation 2011-1593C)

The licensee performed a CCA as CR-2011-1593, dated April 20, 2011, which reviewed all of the events that resulted in the White PI and the White NOV. In this CCA, the licensee reiterated the four examples of workers becoming exposed to unexpected radiological conditions without being made aware of the conditions prior to the work activities. The individual RCEs discussed how each issue was identified. Within this CCA, the licensee acknowledged that the placement of the plant in Column 3 of the NRCs Action Matrix caused them to perform this CCA. The collective volume of RCEs adequately documented the conditions under which the issues were identified.

b. As directed by IP 95002, the inspectors reviewed FENOCs evaluation of the issues to document how long the issues existed and prior opportunities for identification.

White PI

.1 Unexpected Dose Rate Alarm Received by an Operator in the Fuel Pool Cooling and

Cleanup (FPCC) Heat Exchanger Room (Root Cause Evaluation 2011-1593A)

An operator entered a dose field above the Radiation Work Permit (RWP) limits.

This occurred for brief periods when the operator was between the FPCC heat exchanger and the north wall of the FPCC Heat Exchanger room. As documented in CR 2011-1593A, the licensee identified that a different operator worked in a similar elevated dose field condition, which was outside the RWP limits, in March of 2010. The second operator received a dose rate alarm while working in a different area of the room. The licensee performed a search of their Corrective Action Program (CAP) for the preceding five years and identified 60 instances of unplanned dose rate alarms.

The licensee recognized that the number of alarms exceeded industry norms and that these alarms represented an opportunity to identify performance weaknesses. The licensee determined that they failed to use the CAP as an effective tool to prevent repeated Technical Specification (TS) violations as a root cause. The inspectors concluded that the licensee adequately documented the ineffective use of the CAP and prior opportunities to identify the condition.

.2 Unexpected Dose Rate Alarm Received during Reinsertion of SRM-C Detector (Root

Cause Evaluation 2011-1593B)

On April 22, 2011, an unexpected dose rate alarm event occurred when a worker entered the undervessel area and descended a ladder to reinsert the SRM-C detector cable. The worker felt a vibration from the remote indicating dosimetry during the ladder descent. Immediately following the ladder descent, the worker radioed the RP technician assigned oversight of the task to determine if the remote indicating dosimetry was an alarm. The worker was allowed to proceed due to an approximate 20 second delay in registering the dose rate alarm at the remote monitoring station. The worker proceeded to reinsert the cable. Additional work continued following re-insertion of the SRM-C cable without RP intervention after the remote monitoring station verified an alarm had occurred. The inspectors determined that the RCE adequately addressed and documented opportunities for prior identification and length of time that the issue existed.

.3 Unexpected Dose Rate Alarm Received by Supplemental Worker during Replacement of

Safety Relief Valves (SRVs) (Root Cause Evaluation 2011-1593C)

The May 2, 2011, unexpected dose rate alarm issue occurred when a worker entered an area that he was not briefed to enter. The issue was discovered immediately following entry into the area when the electronic dosimeter (ED), being worn by the worker, started alarming. The worker appropriately exited the area. Because this issue was discovered immediately, there was no reasonable prior opportunity for identification.

However, one of the root causes was related to inadequate implementation of the CAP to address prior, nearly identical, RP events. Specifically, the licensee had received four NRC violations for situations that involved unbriefed worker events in a two-year period.

The RCE documented how the prior events were evaluated and where those evaluations were inadequate. The inspectors determined that the RCE adequately addressed and documented opportunities for prior identification and length of time that the issue existed.

White Finding

.1 High Radiation Levels Created during Withdrawal of SRM-C Detector (Root Cause

Evaluation 2011-93247)

On April 21, 2011, workers were manually pulling the SRM-C cable in preparation for SRM-C detector replacement. The plant was in a refueling outage and the SRM had been stuck in the core during the prior operating cycle, which resulted in it being a highly activated component. When the workers removed more than the planned length of the cable, they unknowingly created a hazardous radiation dose field due to neutron activation of the cable. The workers ED alarmed upon ascending the ladder, which provided immediate indication of the High Radiation Area (HRA), and the workers exited the area. The level of risk associated with actual undervessel radiological conditions following the removal of SRM-C was not adequately considered or addressed by multiple site organizations during preparation for reinsertion of the SRM-C to the reactor.

The RCE established that planning by RP, the undervessel team, and the Outage Control Center (OCC) for the reinsertion work activity did not adequately consider and incorporate actual undervessel radiological conditions.

The licensee documented several onsite support organization issues associated with the SRM-C reinsertion evolution. These issues manifested in the licensee not planning the SRM-C reinsertion work commensurate with the radiological risks associated with the activity. These issues are relevant since they are related to, or occurred soon after, four unexpected dose rate alarms that were received during removal of the same stuck SRM just hours earlier. The RCE documented these event contributors. The inspectors determined that the RCE adequately documented and addressed the opportunities for prior identification and the length of time the issue existed.

.2 CCA of the White PI Occurrences and White NOV (Root Cause Evaluation 2011-1593C)

The CCA reiterated how long the issues existed and prior opportunities for identification for the four examples of TS violations for inadequate HRA radiological briefs. The CCA documented that these issues were not isolated occurrences. Despite the repetitive nature of these issues, none of the prior events were evaluated to identify the root, apparent, or contributing causes, such that corrective actions to correct the causes could have been developed. The inspectors determined that the RCE adequately documented and addressed the opportunities for prior identification and the length of time the issue existed.

c. As directed by IP 95002, the inspectors reviewed the licensees evaluation documents of plant-specific risk consequences, as applicable, and compliance concerns associated with the issues both individually and collectively.

White PI

.1 Unexpected Dose Rate Alarm Received by an Operator in the Fuel Pool Cooling and

Cleanup (FPCC) Heat Exchanger Room (Root Cause Evaluation 2011-1593A)

The licensee recognized that the failure to adequately inform individuals of radiological conditions could result in unexpected dose and potential overexposures. The licensee recognized that the issue represented a violation of TS 5.7.2. The licensee documented recognition of the hazards and regulatory issues associated with the performance deficiency in the RCE. Despite the licensees documentation in the RCE of the risk and regulatory impact, violations of the TS requirements persisted. These violations indicated that radiological risks were not fully appreciated by all plant workers. The performance deficiencies and associated NCV and Violation were documented in NRC Inspection Report No. 0500440/2011013.

.2 Unexpected Dose Rate Alarm Received during Reinsertion of SRM-C Detector (Root

Cause Evaluation 2011-1593B)

The licensee documented in the RCE the plant-specific risk consequences and compliance concerns associated with the issues, both individually and collectively.

The licensee acknowledged, that as a result of the undervessel activities on April 21, 2011, a violation of TS 5.7.1, that limited entry to HRA until after dose rates were established, had occurred. The RCE was conducted to develop to understanding of the cause of the events and establish appropriate corrective actions to prevent recurrence. The performance deficiencies and associated NCV and Violation were documented in NRC Inspection Report No. 0500440/2011013. These findings were reviewed in the RCE process.

.3 Unexpected Dose Rate Alarm Received by Supplemental Worker during Replacement of

Safety Relief Valves (SRVs) (Root Cause Evaluation 2011-1593C)

The May 2, 2011, unexpected dose rate alarm did not involve consequences to the physical plant but did involve potential consequences to the occupational safety of the employee involved. Section 2.2, Consequences, of the RCE and CCA briefly documents that the unplanned radiation exposure and entry into an area without knowledge of the radiological conditions was not consistent with plant and industry expectations for ensuring the radiation dose was kept As-Low-As-Is-Reasonably-Achievable (ALARA). The RCE and CCA further documented that the failure to adhere to TS 5.7.1 was a regulatory consequence. A collective assessment of the numerous RP issues was conducted in the CCA. The inspectors concluded the information in Section 2.2 of RCE 2011-1593C was adequate.

White Finding

.1 High Radiation Levels Created during Withdrawal of SRM-C Detector (Root Cause

Evaluation 2011-93247)

In the RCE, the licensee described and reviewed non-compliances with the regulations, the license TS and plant-specific procedures. The licensees RCE reviewed the following non-compliances:

1) Title 10 CFR 20.1501, the failure to properly make surveys that are necessary to comply with 10 CFR 20.1201, which limits occupational dose to individuals.

2) TS 5.7.1.b requires that entry into high and LHRAs be made after the dose rate levels in the area have been established and personnel are made aware of them.

The licensee permitted entry into a HRA without establishing the dose rate levels in the areas and informing personnel; and 3) Procedure HPI-C0015, Radiological Controls for Highly Radioactive and Irradiated Components or Materials, controls movement of highly radioactive objects and materials from the reactor vessel; and Procedure NOP-OP-4107, Radiation Work Permits, assures the ALARA plans are developed for high risk work.

The performance deficiencies and associated violations were documented in NRC Inspection Report No. 0500440/2011013. These findings were reviewed in the RCE.

.2 CCA of the White PI Occurrences and White NOV (Root Cause Evaluation 2011-1593C)

The CCA documented plant-specific risk consequences and compliance concerns associated with the issues, both individually and collectively. Specifically, personnel who entered HRAs for which they were unaware of the radiological conditions and risks created a potential for unplanned exposures and all four events involved a failure to comply with TSs for HRAs. The evaluation appropriately concluded that the failure to adequately inform individuals of the radiological conditions in an accessible area could result in unexpected doses and potential overexposures to radiation while performing work in the area.

d. Findings

No findings were identified.

02.02 Root Cause, Extent of Condition, and Extent of Cause Evaluation The inspection team determined that the licensee used systematic methodology to determine root and contributing causes. However, during the review of an event that occurred after May 2012 (resin spill event), the inspectors identified that a major contributor to this event was the licensees staff failure to implement existing plant procedures. A further review the events associated with the WHITE NOV and WHITE PI revealed that the failure of the licensee staff to implement existing plant procedure was also a significant contributor to why the events occurred. However, the failure to follow procedures was not identified by the licensee as a root cause, contributing cause, or common cause. Consequently, the licensee revised the common cause evaluation to highlight this deficiency and added appropriate corrective actions.

The inspectors noted that the licensee completed an extent of condition and extent of cause evaluations for each event associated with the WHITE NOV and the WHITE PI.

The inspectors also noted that the licensees extent of condition and cause evaluations relied heavily on a search of CAP and reviews of prior internal and external performance assessments. While that approach appears to be consistent with the licensees program, field walkdowns focusing on control programs may have provided additional valuable information to validate whether the full extent of condition and cause scope had been identified. By limiting the methodology to a search of the CAP, the extent of condition and cause review was only able to identify issues that were already known to the licensee and did not reveal previously unknown concerns or weaknesses.

a. As directed by IP 95002, the inspectors reviewed the licensees evaluations to determine whether the licensee used a systematic methodology to identify the root and contributing causes of the issues.

White PI

.1 Unexpected Dose Rate Alarm Received by an Operator in the FPCC Heat Exchanger

Room (Root Cause Evaluation 2011-1593A)

The licensee used multiple methods to assess the condition and determine root and contributing causes. The methods used included Event and Causal Factor Charts, Barrier Analysis and Management Oversight and Risk Tree (MORT) to evaluate this PI occurrence. Using these techniques, the licensee identified two root causes and three contributing causes:

• RC1: The Perry Radiological Control Program implementation does not accurately reflect industry best practices.

• RC2: The CAP implementation was ineffective in preventing repeated radiological TS violation events.

• CC1: Station work management assessment of radiological risk established for some LHRA activities were set inappropriately low.

• CC2: Inconsistent application of procedural requirements in the preparation, review, and approval of radiological survey maps.

• CC3: Less than adequate Management and Worker Accountability.

The inspectors concluded that RC1 (failure to use industry best practices) would be better characterized as the licensees failure to use basic radiological control practices and failure to follow established licensee procedures. During the event, an RP technician allowed workers to access an area that had not been surveyed. Although the survey map did not include hash marks to indicate the area had not been surveyed, which was common practice at Perry, the lack of dose rate data should have been sufficient to alert the RP technician and the radiation workers that additional survey information was needed. Basic radiological worker practices dictate that radiation workers do not enter an area without knowing the radiological conditions. In addition, licensee procedures required that for LHRAs, a radiological survey be completed once per shift or prior to entry. This LHRA had not been surveyed during the shift when the work was completed. This issue was documented in NRC IR 05000440/2011002 as an NCV. Although the licensee discussed the procedural non-compliance in the root cause, the licensee did not include the failure to use procedures as one of the root or contributing causes.

The inspectors concluded that the licensee used a systematic methodology to identify the root and contributing causes of the issues.

.2 Unexpected Dose Rate Alarm Received during Reinsertion of SRM-C Detector

(Root Cause Evaluation 2011-1593B)

The licensee used multiple methods to assess the condition and determine root and contributing causes. The methods used included MORT, Safety Culture Analysis, Event and Causal Factor Charts, and Barrier Analysis to evaluate this PI occurrence. The licensee identified one root cause and three contributing causes:

• RC1: The level of risk associated with actual undervessel radiological conditions following removal of SRM-C was not adequately considered or addressed by multiple organizations during preparation of reinsertion work activities.

• CC1: The Perry organization did not hold personnel accountable to high radiological standards.

• CC2: The use of applicable human error prevention tools to ensure implementation of standard radiological practices was less than adequate.

• CC3: The organization did not demonstrate a commitment to identifying and analyzing or resolving problems in accordance with the Corrective Action Program.

The licensee, as documented in CR-2011-1593B, concluded that the undervessel team and the licensees outage management organization did not adequately consider and incorporate actual undervessel conditions accessible to the worker. For example, the licensee did not change the work risk category or increased oversight assigned, and allowed personnel to return undervessel to reinsert the SRM using non-proceduralized work instructions even though a temporary area radiation monitor was saturated (reading off-scale high). The licensee concluded that these factors were relevant since they were related to, or occurred soon after, four unexpected dose rate alarms that were received during removal of the same stuck SRM, just hours earlier.

The inspectors concluded that the licensee used a systematic methodology to identify the root and contributing causes of the issues.

.3 Unexpected Dose Rate Alarm Received by Supplemental Worker during Replacement of

SRVs (Root Cause Evaluation 2011-1593C)

The licensee used multiple methods to assess the condition and determine root and contributing causes. The methods used included Event and Causal Factors Charts, staff interviews, MORT, and TapRooT Root Cause Tree. Event and Causal Factors charts, TapRooT, and MORT are all specified as acceptable methods for performing a RCA in procedure NOBP-LP-2011, FENOC Cause

Analysis.

The licensee identified two root causes and three contributing causes:

• RC1: Implementation of the CAP failed to correct multiple, nearly identical RP events that occurred at least two years.

• RC2: Less than adequate work preparation by supervisor and work crew.

• CC1: Less than adequate compliance with existing expectations, processes, and procedures.

• CC2: Less than adequate use of human error reduction tools.

• CC3: Less than adequate worker, supervisor and oversight accountability resulted in a worker entering a non-briefed radiological area and receiving a dose rate alarm.

The inspectors determined that the licensee used a systematic methodology to identify the root and contributing causes of the issues.

White Finding

.1 High Radiation Levels Created during Withdrawal of SRM-C Detector (Root

Cause Evaluation 2011-93247)

The licensee used multiple methods to assess the condition and determine root and contributing causes. The methods used included MORT, Safety Culture Analysis, Event and Causal Factor Charts, and Barrier

Analysis.

The licensee identified four root causes and three contributing causes:

• RC1: The site organization failed to address the significant radiological hazards associate with SRM-C removal.

• RC2: Less than adequate management of the RFO12 undervessel project, specifically, in preparation, review, approval, and implementation of the project plan.

• RC3: Less than adequate technical rigor was applied to the preparation, review, and approval of the ALARA plan, RWP and Order resulting from an inaccurate assessment of the potential radiological hazards involved.

• RC4: Less than adequate radiological controls established by RP Personnel to protect the under-vessel worker during the retraction of the source range monitor.

• CC1: There was less than adequate FENOC oversight of supplemental workers and enforcement of supplemental supervisor responsibilities in the undervessel project.

• CC2: Operating Experience information was available and should have been better utilized to establish effective radiological controls.

• CC3: The procedure for SRM removal did not include guidance for removing a detector that had been stuck in the core during power operations.

The licensees RCE established that the deficiencies in the work planning process and the management oversight of that process led to the failure to identify the potential hazards associated with the SRM-C removal. The RCE documented that the licensee did not fill positions listed in the Project Plan and failed to understand the responsibility of the owners representative in the project. The RCE documented that this created a missed opportunity to monitor and correct supplemental worker shortfalls. The licensees RCE identified procedural weaknesses, including the lack of specific guidance for removing the SRM-C detector in the ALARA Plan, RWP, and work order. The licensee concluded that this resulted in the failure to include radiological controls, hold points, or radiological stop work values for removing the SRM-C detector. The RCE established that RP personnel, in the course of assignment of shift duties and during briefing of duties, had opportunities to recognize the potential for high dose rates from the stuck SRM-C. The licensees evaluation concluded that, had the hazard been recognized, RP personnel could have directed discussion of specific controls on cable withdrawal rate, hold points, and contingency actions for the assigned work.

The inspectors concluded that the licensee used a systematic methodology to identify the root and contributing causes of the issues.

.2 CCA of the White PI Occurrences and White NOV (Root Cause Evaluation 2011-1593)

The licensee performed a CCA at the depth and rigor of a RCE to collectively evaluate similar RP events that were the subject of this inspection. Analysis techniques used to evaluate for common causes included Symptom Classification Technique, MORT, the Safety Culture supplement to MORT, Pareto Analysis, and Causal Linkage. The licensee identified five common causes:

• CCA1: Weaknesses with the implementation of the CAP allowed repeat events to occur in radiological control activities.

• CCA2: Preparation and management oversight processes, including supervisory practices, did not adequately assess radiological risks and inform personnel before allowing work activities to proceed.

• CCA3: Weaknesses in procedure compliance and ineffective application of human performance tools allowed people to not fully understand current radiological risks leading to non-conservative decisions and actions.

• CCA4: Opportunities have been missed to improve radiological control work processes, by not taking advantage of operating experience and industry best practices.

• CCA5: Without effective accountability and a commitment to excellence, the effectiveness of management controls and supervisory practices drifted to the point the allowed people to lose sight of safety as the overriding priority.

The CCA involved a review of the root causes, contributing causes, and safety culture aspects noted in each RCE. Similar root and common causes were combined into common themes using Symptom Classification Techniques. The licensee analyzed these common causes in the aggregate to determine the relationships between them; to evaluate cause and effect relationships to identify additional causal factors; and to provide insight for developing additional corrective actions to the common causes.

The inspectors concluded that the licensee used a systematic methodology to identify the root and contributing causes of the issues.

b. As directed by IP 95002, the inspectors reviewed FENOCs RCEs to determine whether they were conducted to a level of detail commensurate with the significance of the issue.

White PI

.1 Unexpected Dose Rate Alarm Received by an Operator in the FPCC Heat Exchanger

Room (Root Cause Evaluation 2011-1593A)

The licensee evaluated the condition several times, ultimately performing RCE 2011-1593A.

The licensee identified ineffective corrective actions as a root cause. In particular, in March 2010, a worker received an unexpected dose rate alarm in the same room. One of the corrective actions included briefing workers on the event. The root cause did not discuss the content of the brief and the licensee could not provide information as to the content of the brief. Although this detail was missing, the lack of information supported the licensees conclusion that the CAP had not been effective in addressing ongoing weaknesses in the RP program.

The inspectors concluded that the RCE was conducted to a level of detail commensurate with the significance of the problem.

.2 Unexpected Dose Rate Alarm Received during Reinsertion of SRM-C Detector

(Root Cause Evaluation 2011-1593B)

The licensee documented in the RCE that planning by RP, the undervessel team, and the OCC for SRM reinsertion did not adequately consider and incorporate potential or actual undervessel conditions, specifically, the determination of the radiological conditions accessible to the worker. The RCE appropriately examined the programmatic organizational and planning weaknesses.

The inspectors concluded that the RCE was conducted to a level of detail commensurate with the significance of the problem.

.3 Unexpected Dose Rate Alarm Received by Supplemental Worker during Replacement of

SRVs (Root Cause Evaluation 2011-1593C)

The licensee used a multi-disciplined team and independent consultants to evaluate the RCE for the May 2, 2011, unexpected dose rate alarm. The RCE was conducted to a level of detail commensurate with the significance of the issue. Two root causes were identified in RCE 2011-1593C:

• Implementation of the CAP failed to correct multiple, nearly identical RP events that occurred over at least two years.

• Less than adequate work preparation by supervisor and work crew.

Three contributing causes were also identified:

• Less than adequate compliance with existing expectations, processes, and procedures.

• Less than adequate use of human error reduction tools.

• Less than adequate worker, supervisor and oversight accountability resulted in a worker entering a non-briefed radiological area and receiving a dose rate alarm.

The inspectors concluded that RCE 2011-1593C was conducted to a level of detail commensurate with the significance of the problems.

White Finding

.1 High Radiation Levels Created during Withdrawal of SRM-C Detector (Root Cause

Evaluation 2011-93247)

The initial CR evaluation was revisited using the MORT RCE methodology. This methodology identified significant enhancements to the corrective actions. The licensee identified the Direct Cause (the technical reason for the equipment failure, or the human performance inappropriate action that immediately led to the event) as the undervessel workers used a flawed method of measurement that resulted in the removal of an excessive amount of SRM-C detector cable. Additionally, the licensee identified four root causes and three contributing causes.

Following the Unexpected Dose Rate Alarm Received during Reinsertion of Source Range Monitor C Detector, the licensee conducted three RCEs under CR-2011-01593 and an associated Common Cause for all four events reviewed in this inspection.

The inspectors concluded that RCE 2011-93247 was conducted to a level of detail commensurate with the significance of the problems.

.2 Common Cause Evaluation of the White Performance Indicator Occurrences and White

NOV (Root Cause Evaluation 2011-1593)

The licensee used a multi-disciplined team and independent consultants to perform the common cause evaluation.

The inspectors identified that the failure to implement existing plant procedures was a component of the events associated with the White NOV, the White PI, and the three events that occurred prior to this supplemental inspection. The inspectors noted that this procedure use and adherence issue was not identified by the licensee as a root cause, contributing cause, or common cause. The licensee stated that procedure use and adherence was adequately captured as part of the application of human performance tools common cause. However, the inspectors identified only one corrective action associated with this deficiency; to review procedure use and adherence results in two years. Consequently, the licensee revised the common cause evaluation on September 21, 2012, to highlight the failure to implement existing plant procedures as a common cause and created new corrective actions associated with this common cause.

This evaluation was conducted to a level of detail commensurate with the significance of the issue.

c. As directed by IP 95002, the inspectors reviewed FENOCs RCEs to determine whether they included a consideration of prior occurrences of the issues and knowledge of prior operating experience (OE).

White PI

.1 Unexpected Dose Rate Alarm Received by an Operator in the FPCC Heat Exchanger

Room (Root Cause Evaluation 2011-1593A)

The licensee identified prior occurrences and discussed inadequate use of OE and the CAP to prevent the condition in RCE 2012-1593C. The licensee included CAP implementation as one of the root causes, thereby demonstrating its recognition that prior occurrences of similar conditions and OE provided opportunities to prevent this event. The RCE included assessment of prior dose rate alarms by searching the CAP and binning prior occurrences by cause code. The search provided the licensee with the insight that prior corrective actions were not robust. The licensee recognized that the expenditure of a greater effort in understanding the cause of the prior events and incorporation of more robust corrective actions could have prevented this event.

The licensee also identified that prior similar occurrences resulted in weak corrective actions that were ultimately ineffective. The data revealed that these weak actions did not reduce the occurrences of unplanned dose rate alarms, which should have been noted by an effective trending program. The licensee recognized that previous evaluations focused on individuals but corrective actions focused on procedural changes and informing workers of events. The inspectors noted that in each of the events contributing to the degraded cornerstone, procedural compliance would have prevented, or significantly mitigated, the event and revising procedures without an understanding of the cause for procedure non-compliance may not prevent similar occurrences.

The inspectors determined that the operating experience review in RCE 2011-1593A was adequate.

.2 Unexpected Dose Rate Alarm Received during Reinsertion of SRM-C Detector

(Root Cause Evaluation 2011-1593B)

The licensee included a review of internal and external OE in RCE 2011-1593B and concluded that there was applicable OE that, if reviewed in the work planning stages, could have minimized the potential for issues during the SRM removal reinsertion. The inspectors determined that the review of OE performed by the RCE team was adequate to establish programmatic weaknesses in the radiological planning processes.

The inspectors determined that the operating experience review in RCE 2011-1593B was adequate.

.3 Unexpected Dose Rate Alarm Received by Supplemental Worker during Replacement of

SRVs (Root Cause Evaluation 2011-1593C)

The licensee included a review of internal and external operating experience in RCE 2011-1593C. The licensee identified prior similar events in both their internal and external operating experience reviews and evaluated applicability to the May 2, 2011, unexpected dose rate alarm. The licensees internal operating experience review revealed historical events that should have resulted in more effective corrective actions, which could have mitigated or prevented the unexpected dose rate alarm. This is related to Root Cause #1 and corrective actions have been developed. The licensees external operating experience review identified similar issues in the industry; however, the licensee concluded that the documentation was not of sufficient detail to develop thorough corrective actions that could have prevented the May 2, 2011, event. The inspectors determined that the operating experience review in RCE 2011-1593C was adequate.

White Finding

.1 High Radiation Levels Created during Withdrawal of SRM-C Detector

(Root Cause Evaluation 2011-93247)

The licensee included a review of internal and external OE in RCE 2011-93247 and identified applicable OE that could have provided valuable information for the planning and implantation of the SRM-C removal. The failure to adequately use available OE was identified as CC2 and was addressed in the corrective actions.

The inspectors determined that the operating experience review in RCE 2011-93247 was adequate.

.2 CCA of the White PI Occurrences and White NOV (Root Cause Evaluation 2011-1593)

The licensees consideration of prior occurrences of the problem and knowledge of prior OE was performed as part of the RCEs for each individual occurrence and in the CCA.

It should be noted that CCA4 is a common cause related to the use of OE.

The inspectors determined that the operating experience review was adequate.

d. As directed by IP 95002, the inspectors reviewed FENOCs RCEs to determine whether they addressed the extent of condition and extent of cause of the issues.

White PI In response to multiple inputs to the Occupational Radiation Safety PI, the licensee performed four RCEs and a CCA. The licensee also performed a RCE for the SRM-C withdrawal event that resulted in a White NOV. Each of these RCEs contained Extent of Condition and Cause evaluations.

In the evaluations associated with these events associated with the White PI, the licensee defined the condition to evaluate as less than adequate control in areas that have the potential to expose plant workers to unexpected hazards. The licensee considered eight areas: Security Access, Foreign Material Exclusion (FME) Zones, Shutdown Safety Equipment Rooms, Protected Equipment Areas, Industrial Safety Postings and Barriers, Heat Stress Areas, Radiological Areas, and the Clearance Program. Of the eight, the licensee concluded that the Extent of Condition did not apply to Security Access, FME Zones, Shutdown Safety Equipment Rooms, and Protected Equipment Areas because the plant worker was the hazard rather than being exposed to a hazard. The inspectors noted that a broader extent of condition review that evaluated the excluded areas may have revealed additional concerns with hazard barrier control programs.

For Industrial Safety Postings and Barriers, Heat Stress Areas, Radiation Areas, and Clearance Orders, the licensee performed a five-year review of the CAP database to determine whether incidents have occurred in any of these areas and whether they had been adequately corrected. In addition to these areas, the licensee performed a five year search for general inadequate controls to determine if other areas were affected.

The licensee identified that corrective actions to address previous issues in these areas were already in place and effectiveness reviews were scheduled to evaluate the corrective actions. These effectiveness reviews were not complete at the time of the inspection, thus were not evaluated by the inspectors.

The licensee performed a five year search of the CAP for other issues with inadequate controls. The results were subject to a Pareto Analysis, which found that the top contributors were control of radiological dose (14.3%), control of radiological contamination (9.1%); design configuration control (8%); control of FME/housekeeping (7.4%); and work orders/planning (6.9%). The licensee concluded that, since the Radiological Control Program made up approximately 23% of the results, the other areas were not significant contributors and could be excluded. The site determined that trends in the other areas had been previously identified in the CAP with actions planned or taken. However, no effectiveness reviews were created to determine the effectiveness of these actions.

The licensee concluded that the extent of condition existed in other plant areas, as discussed above, but determined that since the issues were already in CAP no new actions were necessary. The licensees assessment of the extent of each cause included the information in the extent of condition review as well as a review of internal self-assessments and external assessments.

The inspectors noted that the licensees extent of condition and cause evaluations relied heavily on a search of CAP and reviews of prior internal and external performance assessments. While that approach appears to be consistent with the licensees program, field walkdowns focusing on control programs, such as confined space entries, may have provided additional valuable information to validate whether the full extent of condition and cause scope had been identified.

White Finding

.1 High Radiation Levels Created during Withdrawal of SRM-C Detector (Root Cause

Evaluation 2011-93247)

An extent of condition review was performed to determine if the procedure/work instruction deficiencies existed in other procedures/work instructions. A review matrix with 93 procedure/work instruction types was assessed to determine whether each procedure/work instruction type contained instructions pertaining to activities that could cause a significant increase in work area dose rates. Eleven procedures types were identified. Each procedure/work instruction was reviewed to ensure it contained appropriate cautions or radiological hold points immediately prior to steps that could cause a significant increase in work area doses rates. Four unsatisfactory procedures/work instructions were identified and corrective actions were taken to prevent use of the procedures/work instructions prior to revision.

.2 CCA of the White PI Occurrences and White NOV (Root Cause Evaluation 2011-1593)

Based on the information reviewed, the licensee concluded that the extent of each of the five common causes in CCA 2011-1593 extended broadly beyond radiation protection:

• Common Cause 1 - Ineffective implementation of the Corrective Action Program is affecting the plants ability to improve performance and prevent repeat events. This CAP has broad applicability across the station, in multiple programs and processes beyond the Radiological Protection Program. Recent evaluations and assessments identified similar shortfalls in program content, implementation practices, and overall ineffectiveness in correcting internal, external, and self-revealing issues.

• Common Cause 2 - Risk management weaknesses extend across the organization and affect many areas beyond the Radiation Protection organization. These weaknesses have been identified by both internal and external sources. Preventive actions specified by recently completed root cause CRs 2011-02030 and 2011-03966 are intended to address the broad risk management weakness, but areas requiring more specific attention remain. Also, in three cases (2011-01593A, B, and C), workers initially stopped to clarify an unanticipated situation and contacted their supervisors. However, issues were resolved with a production mind set to accomplish the immediate task without appropriate consideration of the safety state of the situation. Corrective actions have been identified within all of the CRs reviewed in the above extent of cause evaluation, and to a large extent they achieve their intended function, but there still exists a gap on recognizing and addressing risk. There remains a need to:

a. Improve risk awareness in the field before starting or resuming physical work.

b. Provide a risk-assessment protocol for supervisors or individuals in a supervisory role during work when an unanticipated situation is encountered.

• Common Cause 3 - The extent of the human performance common cause, including procedure use and adherence, extends beyond the four events evaluated by this common cause. The extent of the human performance common cause has been well documented by internal analyses, INPO/WANO plant evaluations, and the NRC. These assessments consistently indicate that human performance shortfalls extend across all plant organizations and vertically from plant employees to plant management.

• Common Cause 4 - Cause strategy performed by CR 11-93247, Unexpected Radiation Levels Encountered during Removal of SRM C Detector, the Extent of Cause review performed by CR 11-93247 evaluated the use of OE broadly beyond the Radiological Control work processes impacted by this common cause. CR 11-02030, Concern with Inability to Close Human Performance Substantive Cross-Cutting Issue for Eight NRC Assessment Periods, identified OE usage as a contributing cause and further addresses the extent of the OE cause. Additionally, CR 11-07364, 2011 Annual Safety Culture Assessment, Measure 7c.1, Effectiveness in use of Operating Experience, was rated Yellow, provides further evidence of inadequate OE usage affecting the plants safety culture. Collectively, these recently performed evaluations address the OE extent of cause. Weakness in the use of OE has been identified as affecting plant performance beyond Radiological Control work processes. The corrective actions to address Radiological Control OE usage are appropriately specified in the individual root cause reports to address those identified issues. Additional corrective actions are needed to address the extended issues to effectively strengthen OE performance.

• Common Cause 5 - Collectively, the Perry management team along with its programs, processes, and business practices did not promote full ownership necessary to achieve desired results. The events reviewed in this common cause analysis reveal several below-the-line behaviors (relative to the FENOC accountability model) by the management team and their management system that tend to inhibit follow-through, learning, conservative decision-making, and continuous improvement. Managers tend to assume that current processes, programs, and plans will meet their expectations to provide the desired level of protection and safety. Weaknesses with accountability broadly manifest itself not only with individual performance in radiological controls but across the organization.

A reactive approach to accountability contributed to an ineffective corrective action program, inferior risk awareness, weak radiological protection and human performance practices, and poor incorporation of lessons learned from operating experience. Weak accountability influenced the behaviors, practices, norms, and rigor of performance required to obtain desired results, whether for production purposes or for safety. Accountability has traditionally been exercised post-event, without sufficient focus on what can be done proactively to achieve desired results, while averting at-risk behaviors and practices and accompanying events. The four radiological events as well as the Extent of Cause evaluations provide evidence that ineffective accountability has a systemic effect on overall station performance.

Collectively, these common causes have contributed to the occurrence of significant events beyond the common cause radiological events.

b. Findings

No findings were identified.

02.03 Corrective Actions Although many of the corrective actions had been completed and closed, the corrective actions in general appeared to be ineffective. Consequently, the inspectors concluded that significant weaknesses existed as evidenced by the three similar events that occurred after the licensee implemented its initial corrective actions:

• Failure to control a LHRA in the Main Turbine catacombs;

• Failure to control LHRA that resulted from a spill of resin; and

• Failure to control a LHRA associated with dry fuel storage (DFS).

a. As directed by IP 95002, the inspectors reviewed FENOCs RCEs to determine whether:

(1) FENOC specified appropriate corrective actions for each root and/or contributing cause, or

(2) an evaluation that states no actions are necessary was adequate.

White PI

.1 Unexpected Dose Rate Alarm Received by an Operator in the FPCC Heat Exchanger

Room (Root Cause Evaluation 2011-1593A)

The licensee identified corrective actions for each root and contributing cause. Each root cause included actions to preclude recurrence, with one exception. Specifically, the inspectors identified a general weakness in the failure to implement existing site procedures and noted that some of the corrective actions may not be effective without improving this area. For example, the licensee created actions to add requirements to procedures for access to radiologically controlled areas, which were not consistently implemented.

.2 Unexpected Dose Rate Alarm Received during Reinsertion of SRM-C Detector;

(Root Cause Evaluation 2011-1593B)

The licensee identified corrective actions for each root and contributing cause. Each root cause included actions to preclude recurrence. The inspectors concluded that the licensees corrective actions were reasonable. Specific actions to prevent recurrence included revisions to NOP-OP-4101, Access Controls for Radiologically Controlled Areas, to incorporate specific actions based on the radiological risk (color) of activities.

Additionally, NOP-OP-4102, Radiological Postings, Labeling, and Markings, and WNOP-WM-1001, Order Planning Process, were revised to incorporate changes related to the weaknesses identified in the RCE. Specific corrective actions were also assigned and implemented for the contributing causes identified in the RCE.

.3 Unexpected Dose Rate Alarm Received by Supplemental Worker during Replacement of

SRVs (Root Cause Evaluation 2011-1593C)

The licensee concluded that the May 2, 2011, unexpected dose rate alarm was caused by ineffective CAP implementation and less than adequate work preparation by supervisors and the work crew. To address the root cause of ineffective implementation of the CAP, the licensee developed several corrective actions to prevent recurrence including incorporating the results of industry benchmarking for trending best practices into the licensees trending procedures and establishment of a pre-screening process for inputs to the CAP. The inspectors reviewed procedures for, and observed implementation of, the pre-screening process for inputs into the CAP. Based on observations of the process and interviews with individuals involved in the process, the inspectors concluded that the pre-screening process appeared to be serving the intended purpose.

To address the root cause of less than adequate work preparation by supervisors and the work crew, the licensee developed several corrective actions to prevent recurrence, including assigning a radiological risk to activities; developing specific requirements for various radiological risk levels; and enhancing procedural requirements regarding the use of service air. Additional corrective actions included adding service air, electrical receptacle, and water connection locations to drywell survey maps and increasing the level of detail used in radiological access briefings.

Three contributing causes were also identified by the licensee. The inspectors reviewed the assigned corrective actions for the contributing causes and found them to be appropriate with one exception. Specifically, the inspectors noted that the corrective actions focused on enhancing procedures and processes but did not include measures to ensure procedural adherence and application of human performance tools. As documented in a previous NRC inspection report, at the time of the event, the work crew including the supervisor failed to contact RP as required by the licensees procedure when the work scope changed.

White Finding

.1 High Radiation Levels Created during Withdrawal of SRM-C Detector (Root Cause

Evaluation 2011-93247)

The first root cause was identified as the site organization failed to address the significant radiological hazards associate with SRM-C removal. The deficiencies in the work planning process and the management oversight of that process led to a failure to identify the potential hazards associated with the SRM-C removal. The licensee took specific actions to prevent recurrence, which included revising procedure NOP-OP-007, Risk Management, to better incorporate radiological risk considerations. Additionally, high radiological risk projects were directed to have stronger challenge from department managers. Finally, the lessons learned from this event were presented as a case study to managers, directors, and ALARA committee members, and as continuing education to the RP department staff. The inspectors reviewed several of the completed and in-progress corrective actions to monitor the progress of implementation. The inspectors determined that the corrective actions were adequate.

The second root cause was identified as less than adequate management of the RFO12 undervessel project. The licensees assessment noted that contract personnel executed preparation, review, approval, and implementation of the project plan. Management reviews of the project missed the risk significance of removing an SRM detector irradiated in the core during the run cycle. Additionally, failure to provide sufficient oversight, including not staffing positions listed in the Project Plan and failure to understand the responsibility of the owners representative in the project, created a missed opportunity to monitor and correct supplemental worker shortfalls. The actions taken to prevent recurrence were to strengthen the project challenge meetings by amending the project preparation process. Lessons learned were incorporated into initial training for supplemental/contract personnel and prior to the next refueling outage a snapshot assessment of the undervessel project will be performed to ensure these changes are implemented. The inspectors reviewed several of the completed and in-progress corrective actions to monitor the progress of implementation. The inspectors determined that the corrective actions were adequate.

The third root cause was identified as less than adequate technical rigor applied to the preparation, review and approval of the ALARA plan, RWP and Work Order resulting from an inaccurate assessment of the potential radiological hazards involved. The RCE identified procedural weakness, including a lack of specific guidance for removing the SRM in the ALARA Plan, RWP and Work Order. The weaknesses resulted in the failure to include radiological controls, hold points, or other radiological stop work values in the work instructions for removal of SRM-C. Actions taken to prevent recurrence included revision of the RWP and Work Order planning processes to include specific guidance for removing in-core detectors. Additionally, a case study of this event was created and presented as part of RP continuing training, and quarterly ALARA Committee and Subcommittee meetings were observed to verify that radiological risk aspects of high-risk radiological work was being discussed and evaluated. The inspectors reviewed several of the completed and in-progress corrective actions to monitor the progress of implementation. The inspectors determined that the corrective actions were adequate.

The fourth root cause was identified as less than adequate radiological controls established by RP personnel to protect the undervessel worker during retraction of the SRM. The RCE established that RP personnel had opportunities to recognize the potential for high dose rates from the stuck SRM-C. Discussion of specific controls on cable withdrawal rate, hold points, and contingency actions for the assigned work could have been provided by RP personnel had the hazard been recognized. Corrective actions to prevent recurrence included revision of the RWP procedure to strengthen actions related to removing in-core detectors; strengthening supervisor engagement in high risk work; and enforcement of the expectation that RP personnel attend work group pre-job briefs for high radiological risk work. Additionally, the licensee created a case study of the event and presented it in RP initial and continuing training and training for ALARA planners. The inspectors reviewed several of the completed and in-progress corrective actions to monitor the progress of implementation. The inspectors determined that the corrective actions were adequate.

.2 CCA of the White PI Occurrences and White NOV (Root Cause Evaluation 2011-1593)

The inspectors review of the RCEs in this inspection revealed weaknesses in procedural compliance that did not appear to be sufficiently addressed in the corrective action plan.

Based on this feedback, the licensee developed nine additional corrective action assignments (CAs 109-117) in the corrective action plan for the associated RCEs and CCA that were focused on enhancing and reinforcing procedural compliance. With the addition of corrective actions focused on procedural compliance the inspectors concluded that the overall corrective action plan, if adequately implemented, was appropriate.

b. As directed by IP 95002, the inspectors reviewed FENOCs RCEs to determine whether they prioritized corrective actions with consideration of risk significance and regulatory compliance.

.1 White PI and White NOV

The inspectors concluded the priorities used by the licensee to develop the initial schedule appeared to provide reasonable deadlines for the completion of corrective actions. However, it became evident after subsequent similar events occurred that weaknesses were present. Although many of the corrective actions had been completed and closed, the corrective actions in general appeared to be ineffective. For example, the inspectors identified the following actions that should have prevented or mitigated the delayed response to the June resin spill event:

• Brief all workers of all radiological conditions where they have access prior to entering a HRA.

• Improve use of VSDS (survey mapping program); consolidate survey data on a single survey map.

• Brief entries from one comprehensive survey map.

The inspectors determined that these actions would have likely caused the licensee to recognize the radiological hazards associated with the resin spill had they been effectively implemented. All of these action were referenced in licensee procedure NOP-OP-4101 Access Control for Radiologically Control Areas, dated March 10, 2012. The inspectors noted that workers that were briefed for the area should have understood that radiological data was missing from the surveys and insisted that the licensee obtain the missing data prior to entering the work area.

.2 CCA of the White PI Occurrences

The inspectors concluded that the schedule established in the CAP demonstrated appropriate prioritization with respect to risk significance and regulatory compliance.

However, weaknesses in implementation adversely affected the effectiveness of corrective actions that were otherwise implemented with proper prioritization. The RCE for the inadequate response to the June resin spill event indicated that actions with proper implementation were effective whereas several actions that were not well implemented were not effective.

The inspectors concluded that the corrective actions were generally appropriately prioritized and any weaknesses were more a result of implementation quality.

Specifically, the corrective actions were procedure changes designed to improve performance in this area; however, as discussed earlier in a number of events associated with the White PI the licensee staff failed to implement established procedures.

c. As directed by IP 95002, the inspectors reviewed FENOCs RCEs to determine whether they had established a schedule for implementing and completing the corrective actions.

White PI

.1 Unexpected Dose Rate Alarm Received by an Operator in the Fuel Pool Cooling and

Cleanup (FPCC) Heat Exchanger Room (Root Cause Evaluation 2011-1593A)

The licensee established a schedule for completion of the corrective actions. The licensee completed the first action in January 2012 and scheduled all actions for completion by the end of August 2012.

.2 Unexpected Dose Rate Alarm Received during Reinsertion of SRM-C Detector (Root

Cause Evaluation 2011-1593B)

The licensee established a schedule for completion of the corrective actions and documented them in the RCE. The RCE documented the causes with a code and described the specific corrective action, the group responsible and the due date for completion. The licensee completed the first action in February 2012 and scheduled all actions for completion by the end of August 2012.

.3 Unexpected Dose Rate Alarm Received by Supplemental Worker during Replacement of

Safety Relief Valves (SRVs) (Root Cause Evaluation 2011-1593C)

The licensee established a schedule for completion of the corrective actions. The licensee completed the first action in January 2012 and scheduled all actions for completion by the end of August 2012.

White Finding

.1 High Radiation Levels Created during Withdrawal of SRM-C Detector (Root Cause

Evaluation 2011-93247)

The licensee established a schedule for completion of the corrective actions and documented them in the RCE. The RCE documented the causes with a code and described the specific corrective action, the group responsible and the due date for completion. The licensee completed the first action in first action in May 2011 and scheduled all actions for completion by the end of June 2013.

.2 CCA of the White PI Occurrences

The licensee established a schedule for completion of the corrective actions and documented them in the RCE. The RCE documented the causes with a code and described the specific corrective action, the group responsible and the due date for completion. The licensee revised the CCA on September 14, 2012, and created additional actions to address the inspectors observations regarding procedure use and adherence issues. All actions are scheduled to be completed by December 31, 2012.

d. As directed by IP 95002, the inspectors reviewed FENOCs RCEs to determine whether they had developed quantitative and/or qualitative measures of success for determining the effectiveness of the corrective actions to preclude repetition.

White PI

.1 Unexpected Dose Rate Alarm Received by an Operator in the Fuel Pool Cooling and

Cleanup (FPCC) Heat Exchanger Room (Root Cause Evaluation 2011-1593A)

The licensee established effectiveness assessments of the corrective actions following Corrective Action Review Board (CARB) approval of the root cause. The effectiveness review consisted of assessments of the corrective actions. The review plan focused on the processes changed as part of the corrective action process and did not appear to determine if the corrective actions resulted in improved outcomes - for example, by reducing unplanned dose rate alarms. Given the licensees acknowledged weaknesses in reducing unplanned dose rate alarms through the CAP, validation that the licensees corrective action have resulted in a reduction of unplanned dose rate alarms is essential to understanding corrective action effectiveness. Although not described or formally included in an effectiveness review (ER), the licensee currently reviewed unplanned dose rate alarms on a (quarterly) basis as part of normal assessments of plant performance.

The licensee established ERs of the corrective actions following CARB approval of the RCE. The review plan focused on whether the processes changed as a result of the corrective actions and does not appear to determine if the corrective actions improved outcomes. Given the weaknesses in reducing unplanned dose rate alarms and the weaknesses in CAP effectiveness, validation that the corrective actions have resulted in an actual reduction of unplanned dose rate alarms was essential to understanding corrective action effectiveness. The licensee currently reviewed unplanned dose rate alarms on a quarterly basis as part of normal assessments of plant performance.

.2 Unexpected Dose Rate Alarm Received during Reinsertion of SRM-C Detector (Root

Cause Evaluation 2011-1593B)

The licensee developed five ERs to evaluate the effectiveness of implemented corrective actions. All of the ERs included quantitative or qualitative measures of success to evaluate against. The inspectors reviewed selected completed corrective actions to verify they had been effectively implemented. The inspectors determined that the licensee had established adequate measures to determine the effectiveness of their corrective actions.

.3 Unexpected Dose Rate Alarm Received by Supplemental Worker during Replacement of

Safety Relief Valves (SRVs) (Root Cause Evaluation 2011-1593C)

The licensee developed 13 ERs to evaluate the effectiveness of implemented corrective actions. All of the ERs included quantitative or qualitative measures of success to evaluate against. The inspectors reviewed completed ER 2011-1593-4, which concluded a corrective action to prevent recurrence had not been effectively implemented. The ER description indicated that prevent recurrence action 2011-1593-7, which was assigned to implement trending best practices identified through benchmarking into the licensees trending procedures, had not been completed. The ER concluded that no industry benchmarking of trending practices was completed; thus, the incorporation of benchmarking results was not completed.

Many of the ER assignments had not yet been completed at the time of the inspection; however, they were scheduled for completion in a reasonable timeframe.

White Finding

.1 High Radiation Levels Created during Withdrawal of SRM-C Detector (Root Cause

Evaluation 2011-93247)

The licensee developed 16 ERs to evaluate the effectiveness of implemented corrective actions prior to the next refueling outage, scheduled for spring 2013. Additionally, an ER assignment was planned to be accomplished during the next refueling outage and two ER assignments were planned to be accomplished following the refueling outage, to assess effectiveness of the corrective actions on precluding outage-related events and conditions. All of the ERs included quantitative or qualitative measures of success to evaluate against. The inspectors reviewed selected completed corrective actions to verify they had been effectively implemented. The inspectors determined that the licensee had established adequate measures to determine the effectiveness of their corrective actions.

.2 CCA of the White PI Occurrences

The licensee developed a total of 12 ERs to evaluate the effectiveness of implemented corrective actions. Ten were developed as part of the CCA documented in CR-2011-1593. Because of the similarity of the Radioactive Waste Building resin spill event to the previous radiological events that were the subject of this inspection, some of the ERs being conducted for CR-2011-1593 actions were revised to also evaluate CR-2012-09447 actions.

For example, ER 2011-1593-13 was revised to perform an ER of certain actions from CRs 2012-09447 and 2012-07583 in conjunction with ER 2011-1593-11 since the weaknesses and corrective actions for the events are similar.

e. As directed by IP 95002, the inspectors reviewed the RCEs to determine whether FENOCs corrective actions, planned or taken, adequately addressed a NOV that was the basis for the supplemental inspection, if applicable.

White PI

.1 Unexpected Dose Rate Alarm Received by an Operator in the Fuel Pool Cooling and

Cleanup (FPCC) Heat Exchanger Room (Root Cause Evaluation 2011-1593A)

This event did not result in a NOV.

Although the event addressed in this root cause did not result in a NOV, the inspectors compared the corrective actions to the NCV that documented this event. In 05000440/2011002-01, the NRC documented that the licensee failed to meet the requirements of TS 5.7.2 in that the licensee allowed a worker to enter a LHRA without being aware of the radiological conditions. Upon receipt of the alarm, the worker returned to the low dose area and informed the RP technician and his coworker. The technician performed a quick survey which validated the elevated dose rates and then informed RP supervision. The inspectors concluded that these actions restored compliance with the TS in that workers were no longer in an area with unknown dose rates. The licensee developed a Corrective Action Plan to address recurrence of the violation.

.2 Unexpected Dose Rate Alarm Received during Reinsertion of SRM-C Detector (Root

Cause Evaluation 2011-1593B)

This event was associated with EA-11-148, Subject: Significance Determination of White Finding with Assessment Follow-up and Notice of Violation: NRC Inspection Report No. 05000440/2011014 Perry Nuclear Power Plant, issued by the NRC on August 25, 2011. The inspectors reviewed the RCEs to determine whether the licensees corrective actions, planned or taken, adequately addressed the NOV that was the part of the basis for the supplemental inspection. The inspectors determined that the recent radiological events that occurred after May 2012, shared similar causes as the event that resulted in the NOV indicating that the previous corrective action were not adequate. Specifically, the shared similar root and contributing causes included:

• 11-93247 RC1: The Site Organization failed to address the significant radiological hazards (associated with Source Range Monitor Detector C removal).

• 11-93247 RC2: Less than adequate management of the (RF013 Undervessel)

Project; specifically, in the preparation, review, approval, and implementation of the (RF013 Undervessel Project) Plan.

• 11-93247 RC3: Less than adequate technical rigor was applied to the preparation, review and approval of the ALARA Plan, RWP, and Order resulting from an inaccurate assessment of the potential radiological hazards involved.

• 11-93247 RC4: Less than adequate radiological controls established by RP personnel to protect the (undervessel) workers (during the retraction of the source range monitor).

• 11-93247 CC2: Operating Experience (OE) information was available and should have been better utilized to establish effective radiological controls.

The inspectors determined that the NOV could not be closed for these reasons.

.3 Unexpected Dose Rate Alarm Received by Supplemental Worker during Replacement of

Safety Relief Valves (SRVs) (Root Cause Evaluation 2011-1593C)

This event did not result in a NOV.

Although the event addressed in this root cause did not result in a NOV, the inspectors compared the corrective actions to the NCV that documented this event. In NRC Inspection Report No. 05000440/2011004, the NRC documented that the licensee failed to meet the requirements of TS 5.7.1.b in that the licensee allowed workers to enter a LHRA without being aware of the radiological conditions. Upon receipt of the alarm, the worker returned to the low dose area and informed the RP technician and his co-worker.

The technician performed a quick survey which validated the elevated dose rates and then informed RP supervision. The inspectors concluded that these actions restored compliance with the TS in that workers were no longer in an area with unknown dose rates. As discussed in this report, the licensee developed a corrective action plan to address recurrence of the violation.

White Finding

.1 High Radiation Levels Created during Withdrawal of SRM-C Detector (Root Cause

Evaluation 2011-93247)

This event was associated with EA-11-148, Subject: Significance Determination of White Finding with Assessment Follow-up and Notice of Violation: NRC Inspection Report No. 05000440/2011014 Perry Nuclear Power Plant, issued by the NRC on August 25, 2011. The inspectors reviewed the RCEs to determine whether the licensees corrective actions, planned or taken, adequately addressed the NOV that was part of the basis for this supplemental inspection. As indicated above, the inspectors determined that the NOV could not be closed since the recent radiological events that occurred after May 2012, shared similar causes as the event that resulted in the NOV.

The repetition of these causal factors indicated that the corrective actions established to address event were not be effective.

.2 CCA of the White PI Occurrences

The CCA did not evaluate any events that were not previously evaluated. All events covered by the CCA were the subject of individual RCEs. The corrective actions to address any NOVs are discussed in the individual RCE sections.

f. Findings

(.1) Parallel White PI Inspection Finding

Introduction:

The NRC identified a parallel PI inspection finding of low to moderate safety significance (White) for the failure to implement corrective actions sufficient to address the root and contributing causes and prevent recurrence of events that resulted in a White Occupational Exposure Control Effectiveness PI.

Description:

The inspection team identified significant weaknesses in the licensees failure to provide assurance that the corrective actions for performance issues associated with the Occupational Exposure Control Effectiveness PI were sufficient to address the root and contributing causes and prevent recurrence. The inspectors determined there was a strong causal link between the performance issues listed below and the events that were the subject of this supplemental inspection. Specifically, three events that demonstrated that the corrective actions developed to address the causes of the White PI were not effective. These events were:

• Failure to control a LHRA in the Main Turbine catacombs. In May 2012, NRC inspectors performed a walkdown of the condenser area at Perry also known as the catacombs. The licensee had historically considered this area to be a LHRA.

In November 2011, the licensee concluded that the area could be down posted.

During a walkdown, NRC inspectors identified a scaffold configuration along with inadequate administrative controls that created a situation where the scaffolding could be used as a functional ladder that would provide access to a LHRA. The licensee concurred with the inspectors assessment that the scaffold afforded access to a LHRA. The licensee subsequently identified additional areas within the catacombs where functional ladders could have provided access to LHRAs.

• Failure to control LHRA that resulted from a spill of resin. On June 3, 2012, a resin spill occurred in the radioactive waste building at Perry. The spill involved approximately 2,000 gallons of radioactive water and resin. Despite the quantity an activity of the material, the licensee did not recognize for five days that the spill created a LHRA in accessible areas on the 574 elevation of the radioactive waste building. During this time, the licensee had multiple opportunities to recognize the radiological consequences of the spill. This event is the subject of an FAQ (FAQ 12-4) to determine the number of PI occurrences represented by the event.

• Failure to control a LHRA associated with dry fuel storage (DFS).

On September 22, 2012, the licensee identified that the area at the top of the scaffold for the DFS multi-purpose canister in the fuel handling building met the criteria for a LHRA. The licensee performed a survey as part of the work activities to verify appropriate LHRA controls were in place. However, on September 25, 2012, NRC inspectors walked down the area and identified the presence of a fully functional and easily assessable person-lift vehicle and the presence of functional ladders that could be used to circumvent the established LHRA controls.

Analysis:

In accordance with NRC Inspection Manual Chapter 0305, "Operating Reactor Assessment Program," the inspectors identified a parallel PI inspection finding because the licensee failed to implement adequate corrective actions to address the root and contributing causes and to prevent recurrence of the Occupational Exposure Control Effectiveness PI. The parallel PI finding is assigned the same safety significance as the initiating PI. Since the initiating PI was White, this inspection finding has been assigned a low to moderate safety significance (White). This parallel PI inspection finding provides for additional NRC review of the licensee's actions to address the weaknesses identified in this report and to demonstrate appropriate progress in reversing the adverse trend in Occupational Exposure Control Effectiveness performance as evidenced by the White PI.

This finding was not assessed for cross-cutting aspects.

Enforcement:

No violation of regulatory requirements is associated with this finding.

This parallel inspection finding shall take effect in the 4th quarter of 2011, which is the quarter the White PI was no longer considered an Action Matrix input in accordance with Section 11.02.b of IMC 0305, Operating Reactor Assessment Program. The finding will be removed from consideration of future agency action (per the Action Matrix) in the quarter following the successful completion of the follow-up supplemental inspection.

The parallel PI inspection finding will not be double-counted with the PI with which it is associated. (FIN 05000440/2012009-01, Parallel White PI Finding)

(.2) Failure to Implement Existing Plant Procedures

Introduction:

The inspectors identified multiple examples of a finding of very low safety significance and an associated NCV of TS 5.4 for failure to establish and implement procedures recommended by Regulatory Guide (RG) 1.33. Specifically, the licensee did not implement existing site instructions for responding to a spill of radioactive material that resulted in an unknown LHRA.

Discussion: Material condition issues have occurred with the Perry radioactive waste building floor drain system (FDS) for a long period of time. On May 29, 2012, licensee personnel received a high level alarm from a floor drain sump in the radioactive waste building on the 574 elevation. The non-licensed operator who responded to the alarm discovered that both FDS sump pumps had tripped on overload and 1-2 inches of standing water was in the area. The licensee concluded that the pumps had tripped due to the buildup of resin in the floor drains. A temporary sump pump was installed, which drained the area and cleared the high level alarm.

At approximately 12:55 a.m., on June 2, 2012, the temporary sump pump also became clogged with resin which resulted in 1-3 inches of water accumulating on the floor and subsequently flowing into a stairwell. The licensee secured water inputs into the radioactive waste system, which terminated additional water flow into the area, but did not investigate the cause of the water on the floor. At 2:50 a.m., on June 3, 2012, a RP technician entered this area to obtain a routine air sample and discovered a significant amount of accumulated water and resin on the hallway floor. This accumulation was at a greater volume than typical floor drain backups. At approximately 3:37 a.m., on June 3, 2012, another RP technician and a non-licensed operator entered the area to observe operation of the temporary sump pump. The individuals observed water and resin mixture near the east stairwell access point. Conditions in the east-west stairwell were not observed.

At approximately 4:00 a.m., on June 3, 2012, the Radioactive Waste Supervising Operator (RWSO) noted a larger than expected decrease in the A Condensate Backwash Storage Tank (CBST) level. The CBST is an input to the radioactive waste system. The RWSO suspected, based on prior experience, a failed A CBST pump seal. Access to the radioactive waste building 574 elevation was restricted by a RP technician but was not performed via an established formal process or entered into logs. Radioactive waste water input from the A CBST was stopped and the OCC organization, which was staffed for another site project, was briefed of the conditions in the radioactive waste building 574 elevation.

By this point, plant staff had written several condition reports documenting the various issues in the radioactive waste building 574 elevation (CRs 2012-08841, 2012-09092, 2012-09120, 2012-09154, 2012-09160, and 2012-09161). The inspectors review determined that at this point the site organizations assumed that the identified conditions were either a result of ongoing problems, bounded by previous events, or contained within existing plant barriers. However, on June 7, 2012, RP technicians entered the area to perform a full survey and discovered dose rates that met the criteria for a locked high radiation area. The licensee then implemented the measures necessary to prevent the unauthorized entry to the LHRA. The regulatory aspect of the failure to adequately control the LHRA will be discussed in NRC inspection report 05000440/2012005.

Based on the numerous CRs that had been written about the radioactive waste building 574 elevation, the inspectors questioned whether site procedures for responding to radioactive spills existed and were used by the site. The inspectors found multiple existing station procedures that were not implemented.

RPI-0506, "Response to Area Radiation Monitor Alarms, Airborne Radiation Monitor Alarms, and Radioactive Spills" The inspectors identified that an administrative instruction existed for responding to radioactive spills, RPI-0506, Response to Area Radiation Monitor Alarms, Airborne Radiation Monitor Alarms, and Radioactive Spills, Revision 4. Section 1.0 of instruction RPI-0506, stated, in part, that the purpose of the procedure is to provide Radiation Protection Section personnel guidance for prompt and proper response to radioactive spills to ensure the protection of Perry Nuclear Power Plant workers. The initial actions to be taken upon notification of a radiological spill, as specified in Section 6.6 of RPI-0506, included determining the extent of the spread of contamination, notifying the control room, properly posting the area, and documenting actions taken in the health physics log.

The inspectors review of the circumstances surrounding the event and interviews with personnel involved in the event revealed that instruction RPI-0506 was never entered.

Additionally, many of the initial actions prescribed by RPI-0506 in response to a radiological spill were not taken for several days. As a result, adequate containment, control, and cleanup of the June 2, 2012, resin spill in the radioactive waste building 574 elevation did not occur until June 7, 2012. Between June 2 and 7, 2012, workers were not adequately protected from potential radiological hazards due to the unknown elevated dose rates in the area. The inspectors determined that the unexpected decrease in A CBST level combined with prior information of the conditions in the radioactive waste building 574 elevation represented a missed opportunity to enter RPI-0506, Revision 4.

NOP-OP-1002, "Conduct of Operations" Licensee procedure NOP-OP-1002, Conduct of Operations, contains the licensees requirements for log taking and shift turnover. Although the RWSO recognized the loss of 2,000 gallons of spent radioactive resin and water, this information was not documented in a condition report, log entry, nor included in verbal communications with RP personnel. When the RWSO notified the RP technician that a CBST seal may have failed, the technician informally restricted access to the radioactive waste building 574 elevation. However, the technician did not log the restriction or inform the relieving technician of the restriction and the basis of the restriction. Additionally, on the following shift, at 9:23 a.m., a non-licensed operator attempted to enter the radioactive waste building 574 elevation for routine rounds but stopped at the door due to the presence of water and resin on the floor. The non-licensed operator contacted both the RWSO and Field Supervisor regarding this condition. However, no log entries were made to communicate the conditions noted by the non-licensed operator. Specific examples of non-compliance with NOP-OP-1002 include:

Shift Turnover Briefs - A Shift Turnover Briefing is performed at the beginning of the shift to ensure all members of the operating team understand the plant condition and priorities. Contrary to this requirement, on June 3, 2012, the oncoming shift was not briefed on the 2,000 gallon spill of spent radioactive resin.

Review of Unit Status - Review each Units status emphasizing nuclear safety. Topics shall include planned reactivity changes, shift priorities, evolutions in progress, activities with risk impacts, Operations Decision Making Instruction Trigger Points, and any problems with plant equipment. The inspectors determined that problems with plant equipment, as identified by the loss of resin, were not reviewed.

Turnover - Perform accurate and detailed shift turnovers to ensure oncoming operators are aware of all ongoing issues and activities. Contrary to this requirement, the turnover to the RWSO was not detailed or accurate enough to include the inventory lost in radioactive waste system.

Log Keeping - Maintain accurate and detailed logs to provide a history of plant changes and to allow reconstruction of events. Log changes in system status to help ensure others understand the changes in plant conditions over time. Contrary to this requirement, logs taken by the RWSO were not detailed enough to allow an understanding of system status or the change in plant conditions.

Responsibilities - Maintain broad awareness of plant conditions through all members of the crew. Communicate clearly and regularly to share important information and clarify priorities. Communicate the status of parameters to the operating crew when needed by describing the parameter, value, and trend, including any action taken or needed.

Contrary to this requirement, neither the RWSO, nor the Field Supervisor made the rest of the crew aware of the conditions in the radioactive waste building 574 elevation.

Additional Guidance The OCC was staffed for unrelated work activities on site, but received a report through the Assistant Shift Outage Director (ASOD) that the radioactive waste building 574 elevation had water on the floor. The ASOD assumed that the report was an update of a previously ongoing back-up of the radioactive waste building floor drain system.

Although some members of the OCC staff had information regarding spills in the radioactive waste building 574 elevation, the information was not captured in OCC logs, further pursued within the OCC organization, or included in turnovers between OCC members. Although the OCC organization is not required by regulation, the licensee developed procedures for OCC operation. The licensees guidelines for OCC operation procedure state:

• All members of the OCC have the responsibility of reinforcing Industrial, Nuclear, Radiological and Environmental Safety for all team members.

• The OCC is constructed to ensure that appropriate decisions are made for the outage; get disposition of outage issues and problem resolution in the shortest amount of time.

• For the OCC RP manager, the manager assists work groups to investigate and provide communication on radiological issues (contamination, dose exposures, etc.).

Analysis:

The inspectors concluded that the failure to follow existing station procedures in response to a radioactive spill was an issue of concern not related to a potentially willful violation, and the inspectors screened the issue in accordance with IMC 0612, Appendix B, Issue Screening. The inspectors concluded there were no traditional enforcement aspects of this issue of concern. Because the failure to use an existing site procedure to respond to a radioactive spill was contrary to a standard (RG 1.33) and was reasonably within the licensees ability to foresee and correct, the inspectors concluded the issue of concern was a performance deficiency. The inspectors determined the issue was more than minor because it could reasonably be viewed as a precursor to a significant event (lack of proper protection of workers from potential exposures), was related to the Programs and Process attribute of the Occupational Radiation Safety Cornerstone, and adversely affected the cornerstone objective to ensure the adequate protection of worker health and safety from exposure to radiation from radioactive material during routine civilian nuclear reactor operation.

As a result, the inspectors performed a significance review using IMC 0609, Appendix C, "Occupational Radiation Safety Significance Determination Process. In accordance with IMC 0609, Appendix C, the inspectors determined that the finding had very low safety significance (Green) because the performance deficiency did not involve ALARA or work controls deficiency that resulted in unplanned or unintended collective dose to workers; there was no overexposure to radiation; there was no substantial potential for an overexposure to radiation; and the licensees ability to assess doses to individuals was not compromised.

This finding is associated with a cross-cutting aspect in the decision-making component of the human performance cross-cutting area. Specifically, the licensee repeatedly failed to use conservative assumptions in their decisions affecting response to a radiological spill, which resulted in failure to adequately control the area for several days (H.1(b)).

Enforcement:

Technical Specification 5.4.1 requires, in part, that the licensee shall establish, implement, and maintain applicable procedures recommended in RG 1.33, Revision 2, Appendix A. Section 1 of Appendix A of RG 1.33 recommends, in part, administrative procedures for authorities and responsibilities for safe operation, for shift and relief turnover, and for log entries, and Section 7.e.4 of Appendix A of RG 1.33 recommends RP procedures for contamination control.

Procedure NOP-OP-1002, Conduct of Operations, Revision 6, addresses authorities and responsibilities for safe operation, shift and relief turnover, and log entries. This procedure requires, in part, that staff review each Units status emphasizing nuclear safety; perform accurate and detailed shift turnovers to ensure oncoming operators are aware of all ongoing issues and activities; maintain accurate and detailed logs to provide a history of plant changes and to allow reconstruction of events; and communicate the status of parameters to the operating crew when needed by describing the parameter, value, and trend, including any action taken or needed.

Procedure RPI-0506, Response to Area Radiation Monitor Alarms, Airborne Radiation Monitor Alarms, and Radioactive Spills, Revision 4, addresses contamination control and requires, in part, determining the extent of the spread of contamination, notifying the control room, properly posting the area, and documenting actions taken in the health physics log.

Contrary to the above, on June 2, 2012, the licensee failed to implement the requirements contained in procedures NOP-OP-1002 and RPI-0506 in responding to a spill of radioactive material that resulted in an unknown LHRA in the radioactive waste building 574 elevation and the potential to overexpose workers. Specifically, the oncoming shift was not briefed on the 2,000 gallon spill of spent radioactive resin; the turnover to the RWSO was not detailed or accurate enough to include the inventory lost in radioactive waste system; logs taken by the RWSO were not detailed enough to allow an understanding of system status or the change in plant condition; and neither the RWSO, nor the Field Supervisor made the rest of the crew aware of the conditions in the radioactive waste building 574 elevation, as required by procedure NOP-OP-1002. In addition, the licensee failed to determine the extent of the spread of contamination, to notify the control room, and to document actions taken in the health physics log, as required by procedure RPI-0506.

The licensee entered the finding into the CAP as CR-2012-09447. Because the violation is of very low safety significance and was entered in the licensees CAP, this violation is being treated as an NCV consistent with Section 2.3.2 of the NRC Enforcement Policy (NCV 05000440/20121009-02, Failure to Implement Existing Plant Procedures).

(.3) Failure to Control Access to Locked High Radiation Area

Introduction:

The inspectors identified a finding of very low safety significance and an associated NCV of TS 5.7.2 for the failure to properly control access to a locked high radiation area (LHRA). Specifically, on September 25, 2012, while inspecting access controls in the fuel handling building dry cask storage loading area, the inspectors identified inadequacies in the methods used by licensee to control an area that was previously determined to be a LHRA.

Description:

In the early morning hours of September 23, 2012, RP staff identified a LHRA on top of the loaded dry fuel storage cask during a routine radiological survey in the fuel handling building. The newly identified LHRA was walked down by the RP Supervisor (RPS), who identified the following vulnerabilities to controlling access to the LHRA at the top of the cask:

• four ladders that provided access to the scaffolding to the top of the cask;

• two person-lifts in the area; and

• horizontal cross members on the scaffolding itself that could provide access to the LHRA via a functional ladder.

The RPS and RP staff controlled the area using RP personnel as access control guards (ACGs) for about eight hours until six foot ladder locks were placed on the scaffold ladders to prevent access. Additionally, work in the area was suspended and work crews were removed from the fuel handling building after placing work in a safe condition. Due to scheduling and work hour limitations, the licensee dismissed the work groups for two days. The licensee indicated that with limited personnel in the fuel handling building the ACG could see anyone that entered the building from either of the two entrances and sufficiently prevent unauthorized access to the LHRA.

The inspectors acknowledged that a single individual located on the south side of the dry fuel storage cask could provide adequate visual coverage when only a few individuals were approaching the area, as was the case during the weekend. However, on September 25, 2012, when the physical work for dry cast storage resumed, many workers entered the area and not all were authorized for entries into the LHRA. An NRC inspector entered the area with the dry fuel cask project personnel after being briefed by RP. The work group proceeded past the guard to the north side of the dry fuel cask.

The inspector noted the person-lift and returned to the ACG to ask questions about LHRA controls. The briefing provided to the ACG had not identified the vulnerabilities in the area or the actions needed to prevent unauthorized access to LHRA conditions.

The ACG confirmed that they were unable to control access to a large group of personnel working on both sides of the dry fuel storage cask.

The person-lift was positioned on the north side of the dry fuel cask out of site of the ACG, who was stationed on the south side of the cask. The person-lift control panel had a three way key position that allowed operation from the control panel, the lift basket, and an OFF position. The as-found key-switch position was in the lift basket position and the key was removed. The inspectors verified that the person-lift was able to be operated from the basket without additional controls; no key was required. The person-lift activated a beeper when moved, which was audible at the ACG location with limited activity in the area. However, if multiple work activities were underway and the person-lift was being used, the beep would be more difficult to hear due to other noise in the area. The person-lift was capable of delivering a person to the lower and upper levels of the scaffolding and could swing within the LHRA portion of the top of the dry fuel storage cask. Additionally, the lower levels of the scaffolding were constructed such that in areas on the north side of the dry fuel storage cask as they could create a functional ladder to the lower scaffold decks, approximately 8 feet high. The person-lift and functional ladder represent methods for personnel, who thought they had the authority to access the area for whatever reason, to circumvent the established barriers and would have unencumbered access to the locked high radiation areas of the upper dry fuel storage cask.

The inspectors interviewed members of the RP staff and determined that the inspector observations were similar to the results of the initial vulnerability assessment performed by the night shift RPS on September 23, 2012. These interviews also identified that this assessment was not shared with other members of the RP staff and that controls were changed to a less conservative position without further evaluation. The inspectors determined that this poor communication of expectations and direction to the staff was similar to the resin spill event that occurred between June 2, 2012 and June 7, 2012, where initial assessment and actions were not communicated to the staff on subsequent shifts.

The inspectors noted that the RPM and dayshift RPS were on site later in the day, September 23, 2012, but did not walkdown the new LHRA. The RPM did not walk down the area until September 28, 2012.

The licensee controlled access to the LHRA through a combination of administrative and physical controls. Personnel entering the fuel handling building for dry cask storage activities were given a LHRA brief that explained the location of the elevated dose rate areas and reviewed the general area dose rates.

Administrative Controls:

• completion of scaffold user training;

• notification to RP when climbing above six feet; and

• the use of scaffold access ladders when climbing.

Physical Controls:

• The lower sections of the scaffold ladders were properly posted and controlled via ladder locks that prevented physical access to the lower six feet of the scaffold ladder; and

• An ACG was posted in the area to assure plant personnel did not access the upper portion of the dry fuel storage cask by unauthorized circumvention of the these barriers. However, the role of the ACG changed over the subsequent shifts, in fact, the dayshift RPS concluded that the ACG was not required.

The licensee documented this issue in their corrective action program as CR-2012-14884. Corrective actions included posting an additional ACG on the north side of the dry fuel storage cask, documenting RPM Standing Orders for control of the area, controlling keys to operate the person-lift by RP staff and providing additional physical barriers to the lower areas of the scaffolding to prevent use of functional ladders.

Analysis:

The inspectors determined that the failure to appropriately barricade areas on the top of the dry fuel storage cask that were accessible to personnel with radiation levels such that a major portion of the whole body could receive in 1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br />, a dose greater than or equal to 1000 mRem, in accordance with station TS 5.7.2, was a performance deficiency.

The inspectors reviewed Example 6.g of IMC 0612 Appendix E, Examples of Minor Issues, and determined that the performance deficiency was a finding of more than minor safety significance because actual LHRA conditions existed. The finding was not subject to traditional enforcement since the incident did not have a significant safety consequence, did not impact the NRCs ability to perform its regulatory function, and did not involve willful aspects.

In accordance with IMC 0609, Appendix C, Occupational Radiation Safety Significance Determination Process, the inspectors determined that the finding had very low safety significance (Green) because the finding was not an ALARA planning issue, there was no overexposure or potential for overexposure, and the licensees ability to assess dose was not compromised.

As described above, this event was similar to events at Perry within 2012. Therefore, this finding was associated with a cross-cutting aspect in the operating experience component of the problem identification and resolution cross-cutting area. Specifically, the licensee failed to implement and institutionalize operating experience through changes to station processes, procedures, equipment and training programs (P.2 (b)).

Enforcement:

Title 10 CFR 20.1601 requires control for access to HRAs and subpart (c)allows a licensee to apply to the Commission for approval of alternative methods for controlling access to HRAs.

Technical Specification 5.7.2 which implements an NRC-approved alternate method for controlling access to HRAs, states, in part, that areas accessible to personnel with radiation levels such that a major portion of the whole body could receive in 1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br /> a dose greater than or equal to 1000 mRem shall be provided with locked or continuously guarded doors to prevent unauthorized entry.

Contrary to the above, on September 25, 2012, the inspectors identified that the fuel handling building dry cask storage loading area with dose rates greater than 1000mRem/hr, was not adequately controlled such that established controls would not have prevented unauthorized entry.

Because this violation is of very low safety significance and it was entered into the licensees CAP as CR-2012-14884, this violation is being treated as an NCV consistent with Section 2.3.2 of the NRC Enforcement Policy. (NCV 05000440/2012009-03, Failure to Appropriately Control Access to a Locked High Radiation Area.)

02.04 Independent Assessment of Extent of Condition and Extent of Cause The inspectors did not complete an independent determination of the extent of condition or extent of cause of the events associated with the supplemental inspection discussed in Section 02.03.f.2 of this Inspection Report. The inspectors identified a condition considered a recurrence of the performance issues that were the subject of this inspection. As a result of the recurrence, the licensee will need to validate whether the identified causes and the previously established corrective actions were appropriate and whether causes were missed.

As part of the independent extent of condition and cause review, the inspectors reviewed the FENOC Company Nuclear Review Board (CNRB) meeting minutes for July 13, 2012. The CNRB noted that Perry continues to experience problems in work management potentially related to weaknesses in cross-functional accountability. The CNRB also noted that the site needs to reinforce standards of accountability.

The inspectors also reviewed the FENOC Fleet Oversight summary for the first trimester of 2012. Fleet Oversight noted most areas at Perry were marginally effective with declining trends in maintenance, work management, and outage management.

Interviews with Fleet and Site Oversight personnel revealed concerns with the work management process not being implemented to required standards. The inspectors noted that this was closely related to the causes and conditions that resulted in the White NOV and White PI.

The inspectors noted that the licensees extent of condition and cause evaluations relied heavily on a search of the CAP and on reviews of prior internal and external performance assessments. While that approach appears to be consistent with the licensees program, field walkdowns focusing on control programs would have provided additional valuable information to validate whether the full extent of condition and cause scope had been identified.

Additionally, the inspectors requested CAP trend reports for identified causal factors for conditions adverse to quality (CAQs) over the preceding one, two, and three years. The trend reports revealed that procedure use and adherence was a significant contributor to CAQs for both RP and the site as a whole. Therefore, the inspectors concluded this causal factor applied across the Perry organization. This causal factor was initially characterized by the licensee as a subset of general human performance tools. As a result, a comprehensive extent of condition and cause review for procedure use and adherence was not assessed by the licensee individually but rather as part of human performance in general. In response to the inspectors conclusions that procedure use and adherence had not been adequately addressed in the RCEs and CCA, the licensee enhanced the discussion of procedure use and adherence in the CCA and revised or added corrective actions to better focus on aspects of procedure use and adherence.

The independent extent of condition and cause review will be fully performed during the follow-up inspection for these issues. The lack of a completed independent assessment of the extent of condition and cause did not in any way contribute to the White Finding and White PI remaining open.

02.05 Safety Culture Consideration The NRC inspection staff independently confirmed that a number of safety culture components, which contributed to the issues, were identified in the CCA. These additional safety culture components included weaknesses in the CAP and resources.

For each of the identified prevalent and contributing safety culture components, the inspection staff confirmed that the licensee established corrective actions to address the issues.

a. Inspection Scope

As directed by IP 95002, the inspectors performed a focused inspection to independently determine that FENOCs RCE appropriately considered whether any safety culture component caused or significantly contributed to any risk significant issue.

Inspection Procedure 95002 requires that the inspection staff perform a focused inspection to independently determine that the licensees RCEs and CCA appropriately considered whether any safety culture component caused or significantly contributed to any risk significant issue.

The inspection staff reviewed condition reports and procedures to determine if the licensee properly considered whether any safety culture component caused or contributed to the issue. During the inspection period from August 27 to August 30, 2012, inspectors conducted interviews with licensee staff to evaluate independently the Safety Culture. A random sample of 35 non-supervisory and eight supervisory personnel from various departments, including Chemistry (6); Operations (4); Work Management/Outage Management (8); and Radiation Protection (17), were assembled in four groups, called focus groups. The inspection staff interviewed each focus group.

b. Findings and Observations

As part of the CCA, the licensee evaluated the identified root and contributing causes against the safety culture components that could have contributed to the issues. The licensees RCEs included a discussion of the 13 safety culture components described in Regulatory Issue Summary 2006-013, Information on the Changes Made to the Reactor Oversight Process to More Fully Address Safety Culture, (ADAMS Accession No.

ML061880341) as they applied to the violations and findings. In addition, the licensee determined that weaknesses in management oversight of supplemental workers, decision making, work practices, and the CAP were the most prevalent safety culture attributes. The licensee also included the results of 2010 and 2011 safety culture surveys and a 2012 independent assessment of the RP Department.

The NRC inspection staff independently confirmed that a number of other safety culture components, which contributed to the issue(s) were also identified in the CCA. These additional safety culture components included weaknesses in the CAP and resources.

For each of the identified prevalent and contributing safety culture components, the inspection staff confirmed that the licensee established corrective actions to address the issues. During the course of interviews with licensee personnel, the inspectors asked interviewees questions related to Safety Culture Work Environment (SCWE) to determine if the licensees staff were reluctant to raise safety concerns or if retaliation existed for raising safety concerns. The inspectors did not identify concerns related to SCWE during this limited scope review.

During the conduct of the focus groups, participants expressed a common theme that they were satisfied with the site managements current focus on safety. Participants stated recent personnel changes in senior management positions and the licensees implementation of changes in programs and processes demonstrate a commitment to prioritizing safety over productivity.

Focus Group participants provided information about management practices that have been implemented as tools for improving the sites focus on radiological safety. For example, site management promotes supervisory and management staff presence in the field; conducts site walk downs to identify risks; and frequently conducts field observations of work performance. Additionally, as a result of the radiological issues, site management oversight practices have changed. Previously they did not effectively use OE to enhance site operational safety, but management has recognized this issue and now incorporates OE in work planning. While focus group participants did feel that management encourages industry benchmarking, they stated the site does not do as much benchmarking as it should.

Corrective Action Program (CAP)

Participants in the focus groups stated they are comfortable raising concerns through the use of the CAP; they are encouraged to submit CRs; and they are familiar with the process for submitting CRs. The new CAP database system, DevonWay, is easy to use for submitting CRs and provides the initiator for the CR direct feedback on the closure of a CR. However, participants stated DevonWay is not user friendly for performing searches of the CAP database.

Environment for Raising Concerns Employee Concerns Program (ECP)

All of the Focus Group participants were aware of the purpose of the ECP and could identify the present ECP Manager and the previous ECP Manager. Focus Group participants, outside of members of the RP Department, stated they would be comfortable raising concerns by using the ECP. Some individuals stated they have used ECP, and, while they did not agree with the results of the ECP investigations evaluation, they were satisfied with the overall process. Focus Group participants from the RP Department expressed a general lack of trust for the ECP. Individuals stated they were not comfortable with raising concerns through the use of the ECP, specifically stating it was ineffective or that they believed their anonymity would not be maintained.

Raising Concerns through Management Participants conveyed a general theme that they would be comfortable raising concerns through the management chain without fear of retaliation. This theme was common across all departments, including RP since the recent change in the RPM. Individuals assigned to the RP Department did express that prior to the RPM change they did fear retaliation for raising issues or concerns.

There is a legacy issue within the RP Department associated with the level of trust and confidence RP technicians have for their supervisors. RP technicians expressed a concern that the present supervisors, as direct reports to the previous RPM, were aligned with the previous manager and developed their supervisory traits under his oversight. Presently, the staff is concerned that this style of leadership could continue unless it is addressed by senior management.

Department Staffing All departments identified the need for the licensee to increase staffing to provide the number of RP technicians needed to meet site production demands. This is a legacy issue resulting from a decline in staffing that has occurred over the past several years.

Site Specific Programs Observations/Leader in the Field Licensee programs have been implemented to promote management and supervisory oversight and observation of employees in the performance of their duties. Additionally, these programs provide opportunities for personal interaction and encourage communication and feedback. During the conduct of the Focus Groups, the inspectors identified that supervisors have the perception that the focus of these observations is to identify areas for improvement and are not designed to recognize positive performance.

In fact, many supervisors will not submit the documentation for a completed observation if they cannot identify any areas for improvement. Licensee management needs to be aware of the potential adverse impact this program can have on interpersonal relationships between workers and management, resulting from an employees perception that the focus of these observations is to identify negative performances or practices.

02.06 Evaluation of IMC 0305 Criteria for Treatment of Old Design Issues

a. Inspection Scope

This inspection requirement was not applicable as the events did not involve the self-identification of an old design issue.

b. Findings

No findings were identified.

4OA6 Management Meetings

.1 Exit Meeting Summary

The inspectors presented the inspection results to Mr. V. Kaminskas and other members of licensee management on November 16, 2012. The licensee representatives acknowledged the findings presented. The inspectors asked licensee management whether any materials examined during the inspection should be considered proprietary.

They did identify several documents provided to the NRC inspectors that contained proprietary information. None of this proprietary information is included in this inspection report.

ATTACHMENT:

SUPPLEMENTAL INFORMATION

KEY POINTS OF CONTACT

Licensee

Vito Kaminskas, Site Vice President

Stan Baker, Radiation Protection Manager

Eric Blood, Nuclear Compliance Engineer

Robert Coad, Performance Improvement

Mario Destefano, Fleet Employee Concerns Manager

John Grabnar, Plant General Manager

Harlan Hanson, Jr., Performance Improvement Director

Tom Lentz, Fleet Licensing Manager

Anthony Mueller, Jr., Training Manager

Paul Roney, Nuclear Supply System Engineer Supervisor

F. Rick Smith, Emergency Planning Manager

Jeff Tufts, Operations Manager

Tom Veitch, Regulatory Compliance Manager

Lloyd Zerr, Nuclear Compliance Supervisor

LIST OF ITEMS

Opened

05000440/2012009-01 FIN Parallel White PI Finding (Section 4OA4.02.03.f(1))

05000440/2012009-02 NCV Failure to Implement Existing Plant Procedures)

(Section 4OA4.02.03.f(2))

05000440/2012009-03 NCV Failure to Appropriately Control Access to a Locked High Radiation Area (Section 4OA4.02.03.f(3))

Closed

05000440/2012009-02 NCV Failure to Implement Existing Plant Procedures)

(Section 4OA4.02.03.f(2))

05000440/2012009-03 NCV Failure to Appropriately Control Access to a Locked High Radiation Area (Section 4OA4.02.03.f(3))

Discussed

05000440/2011014-01 VIO The Licensee Failed to Appropriately Identify and Assess the Radiological Hazards when Retracting a Source Range Monitor (Section 4OA4.02.03.e)

Attachment