ML080980289
| ML080980289 | |
| Person / Time | |
|---|---|
| Site: | Ginna  |
| Issue date: | 04/07/2008 |
| From: | David Lew Division Reactor Projects I |
| To: | John Carlin Public Service Enterprise Group |
| References | |
| EA 08-076 IR-08-502 | |
| Download: ML080980289 (25) | |
See also: IR 05000244/2008502
Text
UNITED STATES
NUCLEAR REGULATORY COMMISSION
REGION I
475 ALLENDALE ROAD
KING OF PRUSSIA, PA 19406-1415
April 7, 2008
EA 08-075
Mr. John T. Carlin
Vice President, R.E. Ginna Nuclear Power Plant
R.E. Ginna Nuclear Power Plant, LLC
1503 Lake Road
Ontario, New York 14519
SUBJECT: R.E. GINNA NUCLEAR POWER PLANT - NRC SUPPLEMENTAL INSPECTION
REPORT 05000244/2008502
Dear Mr. Carlin:
On February 22, 2008, the U.S. Nuclear Regulatory Commission (NRC) completed a
supplemental inspection at your R.E. Ginna Nuclear Power Plant. The enclosed report
documents the inspection results, which were discussed on February 22, 2008 with
Mr. David Holm and other members of your staff.
The purpose of this supplemental inspection, performed in accordance with Inspection
Procedure 95002, was to examine your problem identification, root cause evaluation,
extent-of-condition and extent-of-cause reviews, and corrective actions associated with the
issues that led to a Yellow Emergency Preparedness (EP) performance indicator (PI) that
placed Ginna in the Degraded Cornerstone column of the NRC Reactor Oversight Process
Action Matrix for the first quarter of 2007. Specifically, the Emergency Response Organization
(ERO) Drill Participation PI crossed the Yellow threshold during the first quarter of 2007, when
Ginna staff identified that control room communicators, a key ERO position, did not receive the
required drill or exercise opportunity after qualification. This inspection also included an
independent NRC review of the extent-of-condition and extent-of-cause for the issues
associated with the Yellow PI and an assessment of whether any safety culture component
caused or significantly contributed to the issues. The inspection examined activities conducted
under your license as they relate to safety and compliance with the Commissions rules and
regulations and with the conditions of your license. The inspectors reviewed selected
procedures and records, observed activities, and interviewed personnel.
The inspectors determined that Constellation identified the broad organizational issues that led
to the Yellow EP PI, appropriately identified root and contributing causes of the issues, and had
taken or planned actions to address the identified causes and prevent recurrence of the issues.
The inspectors determined that your extent of condition and extent of cause evaluations did not
systematically determine whether similar conditions actually existed or whether similar causes
had actually impacted other plant programs. However, the NRC independent extent of condition
and cause review did not identify any significant performance issues or plant impact that
Constellation had not already recognized. Based on the actions taken and planned to address
J. Carlin 2
the EP program issues and broader organizational issues, the inspectors determined that
agency follow-up beyond the baseline inspection program was not warranted for the EP and
ERO issues.
Based on the results of this inspection, one violation was identified involving changes made to
the Ginna Emergency Plan between 1996 and 2001. The violation has been considered for
escalated enforcement action in accordance with the NRC Enforcement Policy. The current
Enforcement Policy is included on the NRCs web site at http://www.nrc.gov/about-
nrc/regulatory/enforcement/enforce-pol.html. During your assessment of the Ginna EP
organization following the Yellow PI for ERO drill participation, you identified a violation of NRC
requirements for maintaining the Emergency Plan. The violation involved failure to obtain NRC
approval for changes made to the Emergency Plan which decreased the effectiveness of the
plan, contrary to 10 CFR 50.54(q). The changes involved revisions to the NRC-approved
Emergency Action Levels (EALs). Six of the changes were determined to have resulted in a
decrease in effectiveness of the emergency plan, in that the changes could have caused
incorrect event classification, or could have delayed the classification such that required
notifications to offsite emergency response organizations may not have been timely. The
violation is considered safety significant due to the potential for an incorrect event classification
or an untimely notification to offsite authorities during an event such as a Site Area Emergency
(SAE). The failure to obtain approval for the EAL changes had the potential to impact the
NRCs ability to perform its regulatory function; therefore, the violation was considered under
traditional enforcement.
The circumstances surrounding this violation, the significance of the issue, and the need for
lasting and effective corrective action were discussed with members of your staff at the
inspection exit meeting on February 22, 2008, and are described in section 03.b of the enclosed
inspection report. On March 13, 2008, in discussion with Mr. Glenn Dentel of my staff, you
declined the opportunity to respond in writing or attend a predecisional enforcement conference
regarding this issue. As a result, it was not necessary to conduct a predecisional enforcement
conference in order to enable the NRC to make an enforcement decision. You were advised by
separate correspondence, dated April 7, 2008, of the results of our deliberations on this matter.
In accordance with 10 CFR 2.390 of the NRCs Rules of Practice, a copy of this letter and its
enclosure, and your response (if any) will be available electronically for public inspection in the
NRC Public Document Room or from the Publicly Available Records (PARS) component of the
J. Carlin 3
NRCs document system (ADAMS). ADAMS is accessible from the NRC Web Site at
http://www.nrc.gov/reading-rm/adams.html (the Public Electronic Reading Room).
Sincerely,
/RA/
David C. Lew, Director
Division of Reactor Projects
Docket No. 50-244
License No. DPR-18
Enclosure: Inspection Report No. 05000244/2008502
w/ Attachments: 1. Supplemental Information
2. Table 1: Ginna EAL Decreases in Effectiveness
cc w/encl:
M. J. Wallace, President, Constellation Energy Nuclear Group, LLC
J. M. Heffley, Senior Vice President and Chief Nuclear Officer
P. Eddy, Electric Division, NYS Department of Public Service
C. Donaldson, Esquire, Assistant Attorney General, New York Department of Law
C. W. Fleming, Esquire, Senior Counsel, Constellation Energy Group, Inc.
B. Weaver, Director, Licensing, Constellation Energy Nuclear Group, LLC
P. Tonko, President and CEO, New York State Energy Research and Development Authority
J. Spath, Program Director, New York State Energy Research and Development Authority
G. Bastedo, Director, Wayne County Emergency Management Office
M. Meisenzahl, Administrator, Monroe County, Office of Emergency Preparedness
T. Judson, Central New York Citizens Awareness Network
J. Carlin 3
NRCs document system (ADAMS). ADAMS is accessible from the NRC Web Site at
http://www.nrc.gov/reading-rm/adams.html (the Public Electronic Reading Room).
Sincerely,
/RA/
David C. Lew, Director
Division of Reactor Projects
Docket No. 50-244
License No. DPR-18
Enclosure: Inspection Report No. 05000244/2008502
w/ Attachments: 1. Supplemental Information
2. Table 1: Ginna EAL Decreases in Effectiveness
cc w/encl:
M. J. Wallace, President, Constellation Energy Nuclear Group, LLC
J. M. Heffley, Senior Vice President and Chief Nuclear Officer
P. Eddy, Electric Division, NYS Department of Public Service
C. Donaldson, Esquire, Assistant Attorney General, New York Department of Law
C. W. Fleming, Esquire, Senior Counsel, Constellation Energy Group, Inc.
B. Weaver, Director, Licensing, Constellation Energy Nuclear Group, LLC
P. Tonko, President and CEO, New York State Energy Research and Development Authority
J. Spath, Program Director, New York State Energy Research and Development Authority
G. Bastedo, Director, Wayne County Emergency Management Office
M. Meisenzahl, Administrator, Monroe County, Office of Emergency Preparedness
T. Judson, Central New York Citizens Awareness Network
Distribution w/encl: K. Kolaczyk, DRP, Senior Resident Inspector
S. Collins, RA M. Marshfield, DRP, Resident Inspector
M. Dapas, DRA M. Rose, DRP, Resident OA
S. Williams, RI OEDO (Acting) J. Trapp, DRS
J. Lubinski, NRR D. Holody, ORA
D. Pickett, PM, NRR T. Walker, DRP
B. Vaidya, PM, NRR B. Bickett, DRP
G. Dentel, DRP Region I Docket Room (with concurrences)
ROPreports@nrc.gov
SUNSI Review Complete: TEW (Reviewers Initials)
DOCUMENT NAME: T:\DRP\BRANCH1\Ginna 95002\95002 report.rev2.doc
After declaring this document An Official Agency Record it will be released to the Public.
To receive a copy of this document, indicate in the box: "C" = Copy without attachment/enclosure "E" = Copy with
attachment/enclosure "N" = No copy ML080980289
OFFICE RI/DRP RI/DRP RI/DRS RI/ORA RI/DRP
NAME TWalker/TEW GDentel/GTD JTrapp/JMT DHolody/AEP FOR DLew/DCL
DATE 03/26/08 04/ 02/08 03/28/08 03/28/08 04/07/08
OFFICIAL RECORD COPY
1
U.S. NUCLEAR REGULATORY COMMISSION
REGION I
Docket No.: 50-244
License No.: DPR-18
Report No.: 05000244/2008502
Licensee: R.E. Ginna Nuclear Power Plant, LLC
Facility: R.E. Ginna Nuclear Power Plant
Location: Ontario, New York
Dates: January 28 - February 1 and February 19 - 22, 2008
Inspectors: T. Walker, Senior Project Engineer (Team Lead)
B. Bickett, Senior Project Engineer
S. Barr, Senior Emergency Preparedness Inspector
Approved by: Glenn T. Dentel, Chief
Projects Branch 1
Division of Reactor Projects
Enclosure
2
SUMMARY OF FINDINGS
IR 05000244/2008502; 1/28/2008 - 2/22/2008; R.E. Ginna Nuclear Power Plant, Supplemental
Inspection IP 95002 for Degraded Emergency Preparedness Cornerstone.
The inspection was conducted by three region-based inspectors. One violation was identified
during the inspection. This violation has been considered for escalated enforcement action in
accordance with the NRCs Enforcement Policy. The significance of most findings is identified
by the color (Green, White, Yellow, Red) using IMC 0609, Significance Determination Process
(SDP). Findings for which the SDP does not apply may be Green or be assigned a severity
level after NRC management review. The NRCs program for overseeing the safe operation of
commercial nuclear power reactors is described in NUREG-1649, Reactor Oversight Process,
Revision 4, dated December 2006.
Cornerstone: Emergency Preparedness
The NRC performed this supplemental inspection to assess Constellations evaluation
associated with the performance indicator (PI) for Emergency Response Organization (ERO)
drill participation which crossed the Yellow threshold in the first quarter of 2007 when control
room communicators did not receive the required drill or exercise opportunity after qualification.
The inspectors determined that Constellation identified the broad organizational issues that led
to the Yellow PI, appropriately identified root and contributing causes of the issues, and had
taken or planned actions to address the identified causes and prevent recurrence of the issues.
However, the inspectors determined that Constellation was slow to recognize the extent of the
organizational issues with the EP organization and ERO. Compensatory actions were taken,
but implementation of broader corrective actions was delayed as a result of the time taken to
complete the root cause evaluation.
The inspectors determined that Constellations extent of condition and extent of cause
evaluations identified potential areas where similar problems might exist, but did not
systematically determine whether similar conditions actually existed or whether similar causes
had actually impacted other plant programs and processes. Additionally, Constellation did not
clearly ensure that actions were in place or planned to specifically address any similar
organizational issues outside of the EP and ERO programs. Although Constellation did not
systematically evaluate the extent of organizational weaknesses, the NRC independent extent
of condition and cause review did not identify any significant performance issues or plant impact
that Constellation had not already recognized. The inspectors confirmed that the organizational
issues that extended beyond the EP and ERO programs were being addressed through existing
corrective action and improvement plans.
Based on the actions taken and planned to address the EP program issues and broader
organizational issues, the inspectors determined that agency follow-up beyond the baseline
inspection program was not warranted.
Enclosure
3
A. Findings
(TBD) A violation of 10 CFR 50.54(q) was identified involving changes made to the
NRC-approved emergency plan emergency action level (EAL) scheme between 1996
and 2001. The EAL changes involved a decrease in effectiveness of the emergency
plan and were made without prior Commission approval. Specifically, the licensee made
six changes to its EALs which limited the conditions under which the EAL applied. As a
result, some initiating conditions that had been assumed in the NRC-approved EALs
would not have resulted in emergency classification at the appropriate level. In
November 2007, Constellation restored the Ginna EALs to the original configuration and
conducted training for the staff.
The failure to obtain NRC approval for the changes to the EALs had the potential for
impacting the NRCs ability to perform its regulatory function; therefore, this violation was
considered under traditional enforcement. The violation was safety significant due to the
potential for an incorrect event classification or an untimely notification to offsite
authorities during an event such as a site area emergency. The revised EALs could
have adversely impacted Ginnas ability to assess and classify an event. The disposition
of this violation, in accordance with the Enforcement Policy, is addressed in a separate
letter dated April 7, 2008. (Section 03.b)
B. Licensee-Identified Violations
None.
Enclosure
4
REPORT DETAILS
01 INSPECTION SCOPE
The NRC conducted this supplemental inspection in accordance with Inspection Procedure (IP) 95002, Inspection for One Degraded Cornerstone or Any Three White Inputs in a Strategic
Performance Area, to assess Constellations evaluation associated with a degraded
Emergency Preparedness (EP) cornerstone due to a Yellow performance indicator (PI) in the
first quarter 2007. During the fourth quarter of 2006 and the first quarter of 2007, Constellation
added 59 maintenance technicians to the Emergency Response Organization (ERO) as control
room communicators, a key ERO position, yet none of the new communicators participated in a
drill during the first quarter of 2007. ERO Drill Participation is based on the number of key ERO
members who have participated in an EP drill within the previous eight quarters compared to the
total number of key ERO members. Addition of the communicators who had not participated in
a drill to the ERO caused the PI to cross the Yellow threshold (60 percent).
The specific inspection objectives were to:
- provide assurance that root and contributing causes were understood for the risk
significant performance issues;
- independently assess the extent of conditions and the extent of causes for the
performance issues;
- independently determine if safety culture components caused or significantly
contributed to the risk significant performance issues; and
- provide assurance that corrective actions taken and planned are sufficient to address
the root causes and contributing causes, and to prevent recurrence.
Constellation performed a root cause analysis (RCA) to identify weaknesses that existed in the
EP organization that allowed for a degraded ROP cornerstone and to determine the
organizational attributes that resulted in the Yellow PI for ERO drill participation. The inspectors
reviewed that evaluation, reviewed additional evaluations conducted in support of or as a result
of the RCA, and confirmed that corrective actions were taken or planned to address the
identified causes. The inspectors also held discussions with Constellation personnel to ensure
that the root and contributing causes were understood, including the contribution of safety
culture components, and corrective actions taken or planned were appropriate to address the
causes and prevent recurrence. The inspectors also independently assessed the extent of
condition and extent of cause of the identified issues. A more detailed discussion of the
activities associated with the independent review of extent of condition and cause is provided in
section 02.04. The documents reviewed are listed in Attachment 1.
Enclosure
5
02 EVALUATION OF INSPECTION REQUIREMENTS
02.01 Problem Identification
a. Determination of who identified the issue and under what conditions
While preparing the first-quarter 2007 EP PIs for submittal to the NRC, Constellation
identified that the data for the ERO Drill Participation PI had crossed the Yellow
threshold. The licensee informed the NRC resident inspector of the PI changing color
and reported the PI data to the NRC in April 2007. During evaluation of the issue,
Constellation determined that incorrect PI data had been reported for the fourth quarter
of 2006. Based on the corrected calculation, the ERO Drill Participation PI crossed the
White threshold in the fourth quarter of 2006.
The inspectors determined that Constellations analysis appropriately assessed the
circumstances surrounding identification of the issue.
b. Determination of how long the issue existed and prior opportunities for identification
Constellation began to add on-shift maintenance technicians to the Ginna ERO as
control room communicators in the fourth quarter of 2006 and continued to add
technicians to the ERO through the first quarter of 2007. The maintenance technicians
were added to the ERO as part of the transition to eliminate the contracted fire brigade.
The NRC had issued an answer to a frequently asked question (FAQ) concerning the
ERO Drill Participation PI in June 2006. This answer had provided clarity to the industry
by explaining that a drill used to qualify a person as a member of the ERO could not be
used as a drill participation in the calculation of the PI. Constellation had not taken this
FAQ answer into account and added technicians to the ERO without providing them a
drill within the first quarter of their being on the ERO.
The inspectors determined that Constellation appropriately identified missed
opportunities to identify the drill participation issue during transition from a contracted fire
brigade.
c. Determination of the plant-specific risk consequences and compliance concerns
associated with the issue
The EP drill program is implemented to train ERO members and to assess their
capability to respond to an emergency. The ERO Drill Participation PI is meant as an
indicator of the health of the licensees effort in these areas. The NRC identified a
Green finding in NRC Inspection report 05000244-2007002 for failure to fully train the
maintenance technicians on the ERO communicator responsibilities. These training
weaknesses could have been identified and addressed through performance of a drill
during the newly qualified communicators first quarter as members of the ERO.
Enclosure
6
02.02 Root Cause and Extent of Condition Evaluation
a. Evaluation of methods used to identify the root causes and contributing causes
Several different root cause methodologies were used by Constellation to evaluate the
cause of the issue. A Kepner-Tregoe/Stream Analysis/Why Staircase methodology was
used to evaluate the EP program weaknesses and identify one of the root causes. A
Barrier Analysis/Comparative Timeline/Why Staircase was used to assess the
organizational decision-making weaknesses associated with the addition of maintenance
technicians to the ERO and identify the second root cause.
The inspectors determined the evaluation methods used by the licensee to be
appropriate.
b. Level of detail of the root cause evaluation
Constellation revised the root cause analysis several times in evaluating the issues
associated with the ERO Drill Participation PI. On April 6, 2007, Constellation identified
that the PI had crossed the Yellow threshold and initiated an investigation. The first root
cause report was approved on May 21, 2007, and Revision 1 to the report was approved
on July 23, 2007. The final Revision 2 was signed by the Plant General Manager on
January 9, 2008. After Constellation produced the original root cause analysis and
again after the first revision, the licensee arranged for an independent review by outside
contractors. Both of these reviews determined that the licensee efforts had been too
narrowly focused. Specifically, the original root cause analysis examined the specific
event, but had not addressed potential EP organizational effectiveness gaps. Further,
although Revision 1 assessed EP programmatic performance, it did not adequately
consider the extent of cause and condition in other organizational performance areas at
Ginna. The third root cause analysis and report addressed the shortcomings of the first
two and identified two root causes.
1) Oversight by Corporate and station leadership was ineffective in monitoring program
improvement efforts. Emergency Preparedness leadership failed to establish
program expectations (clear roles and responsibilities), effectively address
performance gaps through the corrective action program, and execute a strategy to
achieve program improvements, resulting in a degraded NRC cornerstone.
2) The management failure to require formal change management practices with
respect to organizational changes resulted in flawed implementation of the change of
responsibilities for the control room communicator.
The final root cause report also identified a number of contributing causes related to the
EP organization, the stations appreciation of the ERO and EP-related issues, and the
stations use of performance indicators and performance improvement tools.
The inspectors concluded Constellation was slow to recognize the broader organization
issues associated with ERO drill participation issue, but ultimately conducted a thorough
evaluation of the issue. Constellation initiated CR 2008-001446 to address the delayed
Enclosure
7
recognition of the broader issues. The inspectors determined that Constellation
appropriately expanded their reviews as the broader causes were recognized. For
example, as part of the root cause analysis for the Yellow ERO Participation PI, a review
of the current Ginna EALs and their bases, and a comparison to NRC-approved EALs,
were conducted by consultants for Constellation. A violation of NRC requirements
related to changes to the EALs, which decreased the effectiveness of the emergency
plan, was identified as a result of this review as described in section 03.
c. Consideration of prior occurrences of the problem and knowledge of prior operating
experience
The final root cause effort identified a 2006 licensee investigation of problems related to
failures of the Emergency Response call-out tests. One of the root causes identified in
that investigation was management failure to establish sufficient oversight to recognize
fundamental weaknesses in the Emergency Response Organization. The root cause
analysis for the 2007 PI event determined that the corrective actions for the 2006 event
were not fully effective. The 2007 root cause analysis also examined previous EP self
assessments, and determined that the assessments and follow-through on associated
corrective actions had been weak. These findings from the 2007 root cause effort
resulted in some of the contributing causes cited in the final root cause report and the
associated corrective actions.
The inspectors concluded that Constellations final root cause analysis had properly
considered prior occurrences of events which had causal relations to the 2007 PI event.
d. Determination of the extent of condition and the extent of cause of the problem.
As indicated in section 02.02.b, the inspectors determined that Constellation
appropriately expanded their reviews as the broader organizational issues associated
with the ERO drill participation issue were recognized. The inspectors determined that
the additional reviews appropriately addressed the extent of condition and extent of
cause within the EP department and ERO.
For areas outside of the EP department and the ERO, Constellation primarily relied on
the knowledge transfer and retention (KT&R) process to determine the extent of
conditions and causes related to the organizational deficiencies identified in the stations
root cause analysis for the Yellow EP PI and associated degraded EP cornerstone.
Using the KT&R process, Constellation identified 37 programs or processes for
assessment in 2007 based on a higher potential for programmatic weaknesses similar to
those identified in the EP program. Constellation also credited the KT&R process for
assessing the vulnerability to events caused by organizational changes that did not have
a detailed change management plan.
The inspectors determined that the KT&R process, while valid for determining
organizational vulnerabilities similar to organizational shortcomings revealed as a result
of the Yellow PI, was not of sufficient scope and was not implemented with sufficient
rigor to determine all applicable aspects of the extent of condition and cause for the
associated root causes as identified in the root cause analysis. The following issues
Enclosure
8
highlight the inspectors observations with respect to the stations usage of the KT&R
process as the primary extent of condition and extent of cause assessment tool.
- The scope of the KT&R assessments was too narrowly focused in addressing key
causal factors in the areas of performance monitoring and program improvement.
While the KT&R assessments addressed most program and process issues,
including process documentation, roles and responsibilities and training, most of
the assessments did not consider factors that drive improvement of program
health, including corrective action program effectiveness and performance
improvement activities.
- The station criteria used in selecting the programs and processes for KT&R
assessments did not consider all applicable conditions and causal factors and
were not well documented. Specifically, causal factors associated with the EP
and ERO performance issues included weaknesses in addressing industry
operating experience (OE) and ineffective use of the Corrective Action Program
(CAP). However, based on the subjective criteria used by the station,
Constellation determined that neither the OE program nor CAP warranted a
KT&R assessment in 2007 and, as a result, failed to thoroughly capture these
specific programs in the extent of condition and cause evaluations.
- Although organizational changes were factored into the KT&R process rankings,
Constellation did not do a rigorous review to determine if similar conditions or
causal factors existed as a result of previous organizational changes,
implemented prior to the improved change management process. For example,
significant organizational changes, such as the restructuring of the performance
monitoring group, were not reviewed specifically to determine if weaknesses or
vulnerabilities similar to those associated with the ERO communicator and EP
program had been introduced due to ineffective change management.
Additionally, although the transfer of control room communicator responsibilities
due to disbanding the fire brigade was appropriately assessed in the root cause
analysis, no review was conducted to determine if other similar conditions or
causes might exist due to ineffective management of the change in fire brigade
staffing.
- The station did not perform a thorough review of the KT&R assessment results to
determine the actual extent of conditions and causes that existed at the station.
The station focused on trend codes resulting from the KT&R assessments.
Those trend codes addressed only aspects of the broader organizational issues
associated with documentation, staffing and training, but did not fully capture
aspects associated with performance monitoring and program improvement.
Additionally, the station did not correlate assessment results to determine the
actual extent of conditions and causes as defined in the root cause analysis. By
not correlating the KT&R assessment results, the KT&R output only gave the
station an indication of potential vulnerable areas where the organizational issues
existed.
- The inspectors determined that KT&R assessments performed in 2007 were not
Enclosure
9
of consistent quality. The station did not consistently adhere to fleet or site
processes for self-assessments to ensure actions to close gaps or improve
performance were identified, implemented and tracked. The inspectors
determined that there was less accountability for KT&R assessment actions and
due dates. Several of the assessments lacked documented CAs for some
identified deficiencies. Some assessment corrective actions and plans were
handled outside the CAP with less oversight and rigor than those handled within
the CAP.
The inspectors determined that Constellation appropriately performed a timely and
extensive review of all NRC PIs to consider immediate extent of condition issues
associated with NRC PI data. Constellations review, which included gap analyses and
challenge boards, appropriately identified issues that were not consistent with NRC
reporting requirements and station expectations.
Based on reviews of the root cause analysis for the Yellow PI and causal analyses for
significant performance issues identified by the station in several areas in 2006 and
2007, the inspectors determined that, programmatically, the Constellation has been
ineffective in performing and documenting thorough and rigorous extent of condition and
extent of cause evaluations. Specifically, the inspectors determined that significant
issues associated with Operations EOP usage, Operations Training performance issues,
and Flow Accelerated Program implementation were examples of extent of condition and
cause evaluations that did not fully capture the respective extent of issues. The
inspectors noted that, in response to previously identified CAP issues, corrective actions
and improvement plans were in progress that would address the issues.
Although Constellation did not systematically evaluate the extent of the organizational
weaknesses that led to the Yellow PI and degraded EP cornerstone, the inspectors did
not identify any significant performance issues or plant impact during their independent
extent of condition and cause review (discussed in section 02.04) that Constellation had
not recognized. Constellation initiated CR 2008-0638, 2008-1447, 2008-1449, 2008-
1450, 2008-1452, and 2008-1453 to address the weaknesses associated with extent of
condition and cause reviews identified during this inspection.
02.03 Corrective Actions
a. Appropriateness of corrective actions
The final root cause report identified corrective actions to address the identified root and
contributing causes for the Yellow PI and degraded EP cornerstone. Immediate
corrective actions taken by Constellation included: reporting the past inaccurate data and
the new PI data to the NRC; reviewing the training received by ERO communicators;
validating all other PI data at Ginna; and, replacing the maintenance technicians with
control room Shift Managers as the ERO communicator. Longer-term corrective actions
intended to prevent recurrence of this type event included: reorganization of the Ginna
EP program and staff, along with the review and revision of a large number of EP
procedures; development of EP health indicators and an EP Oversight Board;
implementation of a new change management process; and training of all supervisors
Enclosure
10
and managers in formal decision making and problem solving techniques.
The inspectors determined the corrective actions for the EP program and ERO issues
were well-developed, but identified two shortcomings in the implemented actions: the EP
health indicators intended to be presented to the EP Oversight Board did not have
specified targets or goals by which the indicators could be appropriately and consistently
assessed; and revisions to an EP training procedure did not include all of the intended
elements. Constellation initiated CRs 2007-000701 and 2007-000702 to address these
conditions.
Overall, the NRC determined the corrective actions specified in the final root cause
report were appropriate to address the broader organizational issues. In particular, the
inspectors observed that the new change management process was being rigorously
implemented for significant changes being made at the station.
b. Prioritization of corrective actions
As described above, Constellation took immediate corrective actions to rectify the ERO
drill participation issues and ensure that the ERO was staffed with qualified control room
communicators. Actions were taken in 2007 to reorganize the Ginna EP program, train
supervisors and managers, and implement a formal change management process.
Revised EP and ERO procedures were implemented during the first week of the
supplemental inspection.
The inspectors determined that the corrective actions were prioritized commensurate
with their significance. However, the several iterations of the root cause analysis for the
EP and ERO issues resulted in delayed implementation of the broader corrective actions.
Constellation captured this concern in CR 2008-001446. Although the broader actions
were delayed, the inspectors recognized that the additional time spent on fully evaluating
the issues allowed the licensee to identify the full scope of the issues that led to the
Yellow PI and degraded EP cornerstone.
c. Schedule for implementing and completing the corrective actions
At the time of this supplemental inspection, all of the licensees corrective actions had
either been implemented or scheduled. The immediate corrective actions to correct the
PI data and adequately staff the ERO Communicator position had been accomplished,
as had a number of the corrective actions related to the EP processes. The broader root
causes associated with station leadership and change management practices had been
identified in the final root cause report, which had corrective actions identified and
scheduled. All corrective actions to prevent recurrence, as well as all lower-tier
corrective and preventive actions, identified in the report had been completed by the time
of this inspection or had due dates required by the end of the first quarter of 2008.
The inspectors considered the schedule for completion of the remainder of the corrective
actions to be appropriate.
d. Measures of success for determining the effectiveness of the corrective actions to
Enclosure
11
prevent recurrence
Ten effectiveness reviews and self-assessments were planned through the second and
third quarters of 2008. These reviews are designed to provide further management
follow-up and assessment of the EP and ERO program changes made in response to the
ERO drill participation issues. Constellation planned to conduct effectiveness reviews in
2008 for the programs and processes that were assessed under the KT&R process in
2007 to assess the actions taken to address similar issues in other programs and
processes.
The inspectors determined that Constellations plans contained sufficient methods for
determining the effectiveness of the corrective actions associated with the EP program
and ERO. However, the inspectors noted, without appropriate rigor in scope and
conduct of the KT&R assessments, analysis of the results, and implementation of
corrective actions (described in section 02.02.d), there was no assurance that the KT&R
effectiveness reviews would address organizational issues of concern as identified in the
root cause analysis. Constellation captured this concern in CR 2008-001452.
02.04 Independent Assessment of Extent of Condition and Extent of Cause
a. Inspection Scope
The inspectors conducted an independent extent of condition and cause review of the
performance issues associated with the Yellow PI for ERO drill participation to assess
the validity of Constellations conclusions regarding the extent of condition and extent of
cause of the issues. The Yellow PI ultimately revealed significant and broad
organizational issues associated with the stations management, leadership and
performance monitoring of the EP and ERO organizations. The teams independent
review focused on the primary root causes associated with the Yellow PI described in
Section 02.02.b. Additionally, due to the broad nature of the root causes, the inspectors
independent review and assessment encompassed the stations identified contributing
causes that involved more specific aspects of the broader root causes.
The inspectors review approached the independent extent of condition and cause from
two distinct aspects. First, the team assessed whether Constellations extent of
condition and cause sufficiently identified and bounded all EP and ERO organizational
performance issues; and, second, the team assessed whether Constellations extent of
condition and cause sufficiently determined the actual extent of similar organizational
issues that potentially existed in other station departments, programs and processes.
In conducting this independent review, the team interviewed station management and
personnel, reviewed program and process documentation, and reviewed existing station
program monitoring and improvement efforts, including review of corrective action
documents. Based on the root and contributing causes identified by Constellation, the
inspectors focused their review on the following attributes of the programs and
processes:
Enclosure
12
- Program and process expectations that clearly delineated station management and
personnel roles and responsibilities;
- Program and process performance monitoring efforts that included performance gap
analyses;
- Program and process improvement efforts that included effective use of the CAP and
existing station improvement plans; and
- Change management implementation for past program and process changes
including organizational and staffing restructuring completed at the station.
b. Findings and Assessment
Overall, the inspectors did not identify any substantive extent of condition and cause
issues that the station was not aware of and had not already identified with corrective
action plans in place. However, the teams independent extent of condition and cause
review did determine existing organizational weaknesses that extended beyond EP and
ERO issues and should have been captured in the stations extent of condition and
cause reviews for the Yellow PI. These weaknesses were further described and
documented in Section 02.02.d of this report. Based upon those weaknesses identified
by the team, the scope of the teams independent review was expanded to provide
further assurance that the station had adequately identified the extent of organizational
issues that potentially were present in existing station programs and processes.
The teams review and assessment of the extent of organizational issues determined
that the following station programs and processes exhibited organizational and change
management weaknesses similar to those identified by the station in the root cause
analysis for the Yellow PI and degraded EP cornerstone:
- The inspectors determined that the Operations Training department has had
similar challenges in the last three years with respect to organizational oversight
and program improvement efforts. The Operations Training group has had
significant challenges with oversight of the instructor training program. These
challenges included ineffective management oversight evidenced by
administrative shortcomings with instructor qualifications and recent audit exam
performance issues in 2007. Additionally, the group has been challenged by high
staff turnover. The inspectors concluded that these issues should have been
identified and captured by the stations extent of condition and cause review.
Based on independent review, the inspectors confirmed that the site had
sufficient existing corrective actions planned or implemented to address these
performance issues.
- The inspectors determined that the Operations department has had similar
organizational challenges since early 2001 with respect to management oversight
and establishing program expectations and standards. The Operations group
has not effectively resolved emergency operating procedure usage issues that
have existed at the site since early 2000 and program improvement efforts,
Enclosure
13
including the CAP, have not been fully effective in resolving the issues. The
inspectors confirmed that the station had sufficient existing corrective actions
planned or implemented to address these issues.
- The inspectors noted several recent issues that have occurred, at least in part,
due to ineffective change management of previous organizational changes. For
example, in October 2007, Constellation identified that the calibration for a
temporary flow meter for cooling water to an emergency diesel generator had
expired. Although an alternate, more conservative method for monitoring cooling
water flow was available, use of this method ultimately led to an unplanned entry
into a Technical Specification (TS) Limiting Condition for Operation (LCO) for the
emergency diesel generator. Previously, the dedicated performance monitoring
group had been responsible for ensuring that the temporary flow meters were
calibrated. When this group was disbanded, there was no formal change
management plan. As a result, clear responsibility for calibration of the flow
meters was not established. Although none of the identified issues had a
significant adverse impact, the inspectors determined that issues associated with
the restructuring of the performance monitoring group, work management, and
security Instrumentation and Control (I&C) group were indicative of less than
effective change management prior to implementation of the new change
management process. Through interviews and existing documentation, the
inspectors confirmed that appropriate actions were implemented or planned to
address these areas.
- The inspectors determined that the Operating Experience (OE) program had
weaknesses related to procedural guidance and performance improvement
monitoring tools. Specifically, the OE procedural guidance had a single person
vulnerability in that, potentially significant and valuable OE items relied on one
individual to determine station applicability. Additionally, the OE program did not
have sufficient performance monitoring tools to clearly monitor the effectiveness
of program implementation. While the stations extent of condition and cause
review did not evaluate and capture this issue, inspectors determined that
existing condition reports had identified corrective actions to address the
concerns.
02.05 Safety Culture Considerations
As part of the root cause evaluation for the Yellow PI and degraded EP cornerstone,
Constellation evaluated the identified root and contributing causes against the safety
culture components that could have contributed to the performance issues.
Constellation determined that weaknesses in Decision Making, Continuous Learning
Environment, and Organizational Change Management were the most prevalent safety
culture attributes, and that Corrective Action Program and Accountability issues also
contributed to the event. Constellation also considered the results of a safety culture
assessment and safety conscious work environment (SCWE) survey, conducted in 2007,
in the consideration of safety culture components. For each of the identified contributing
components, Constellation confirmed that corrective actions were established to address
the issues.
Enclosure
14
The inspectors determined that Constellation appropriately considered whether
weaknesses in safety culture components were root or contributing causes for the
performance issues. The identified root and contributing causes were broad and,
therefore, encompassed the applicable safety culture attributes. The inspectors did not
identify any safety culture component that could reasonably have been a root cause or
significant contributing cause that had not been addressed in the root cause evaluation.
O3 OTHER ACTIVITIES
a. Inspection Scope
As part of the root cause analysis for the Yellow ERO Drill Participation PI, a review of
the current Ginna EALs and their bases, and a comparison to NRC-approved EALs, was
conducted by consultants for Constellation. This review identified nineteen EALs that
had been revised, six of which were determined to have resulted in a non-conservative
change to the EAL. These six changes were also determined to have resulted in a
decrease in effectiveness to the Ginna Emergency Plan. During the conduct of this
supplemental inspection, the inspectors reviewed the root cause evaluation for the EAL
changes, interviewed site operators and staff, and assessed the corrective actions taken
and planned to address the issues associated with the EAL changes.
b. Findings
Introduction: A violation of 10 CFR 50.54(q) was identified involving changes made to
the NRC-approved EALs between 1996 and 2001. The EAL changes involved a
decrease in effectiveness of the Emergency Plan and were made without prior
Commission approval. The failure to obtain NRC approval for the EAL changes had the
potential for impacting the NRCs ability to perform its regulatory function; therefore, this
violation was considered under traditional enforcement.
Description: 10 CFR 50.47(b) requires that the on-site emergency response plans for
nuclear power reactors meet each of 16 planning standards, of which, Planning
Standard 4 requires, in part, a standard emergency classification and action level
scheme. 10 CFR 50, Appendix E, Section IV.B requires, in part, that the means to be
used for determining the magnitude of and for continually assessing the impact of the
release of radioactive materials be described, including emergency action levels that are
to be used as criteria for determining the need for notification and participation of local
and State agencies. In accordance with 10 CFR 50.54(q), proposed changes that
decrease the effectiveness of the approved emergency plans may not be implemented
without application to and approval by the NRC. The licensee must determine if the
change is a decrease in effectiveness and if it is, the licensee must obtain prior approval
from the NRC before implementing the change.
In June 2007, as part the assessment of the Ginna EP organization following the Yellow
PI event, an independent review identified that there were weaknesses in the Ginna
50.54(q) process. Subsequent follow-up by Constellation identified that, between 1996
Enclosure
15
and 2001, Ginna had made 19 changes to the original EAL documents that were
approved by the NRC in 1995 when Ginna implemented the NUMARC/NESP-007
Methodology for Development of EALs. The potential for a decrease in effectiveness
was not recognized at the time of the changes and therefore prior NRC approval was not
solicited as required by 10 CFR 50.54(q). Constellations analysis of the nineteen EAL
changes revealed that six of the changes had resulted in a decrease in effectiveness of
the Ginna Emergency Plan. These six EALs and the changes made to them are
summarized in Table 1 in Attachment 2.
The inspectors determined that Ginna failed to maintain the emergency plans scheme of
EALs such that all initiating conditions, which had been assumed in the approved EALs,
would result in emergency classifications at appropriate levels. For example, the EAL
for the Containment Integrity Status for a Site Area Emergency (CIS-SAE) was
previously approved for any conditions causing a rapid uncontrolled decrease in
containment pressure following initial increase. The revised EAL for CIS-SAE was
limited to conditions resulting from a loss of coolant accident. This limitation excluded
other events, such as a main steam line break, which could challenge containment
integrity. The changes to the EALs could have resulted in an incorrect or missed event
classification, or could have delayed the classification such that required notifications to
offsite emergency response organizations may not have been timely.
The inspectors concluded that the failure to obtain NRC approval for the changes to the
EALs, in accordance with 10 CFR 50.54(q), was a performance deficiency because the
licensee should have recognized that the changes decreased the effectiveness of the
Ginna Emergency Plan.
In November 2007, Constellation changed the Ginna EALs back to the original
configuration and conducted site training for licensed operators and the site ERO.
Additional corrective actions described in the final root cause report had been scheduled
into the second quarter of 2008, with an effectiveness review for those corrective actions
scheduled by the end of 2008.
Analysis: The violation for failure to obtain NRC approval for the changes to the EALs
was considered under traditional enforcement because the failure had the potential for
impacting the NRCs ability to perform its regulatory function. The violation was safety
significant due to the potential for an incorrect event classification or an untimely
notification to offsite authorities during an event such as an SAE. The revised EALs
could have adversely impacted Ginnas ability to assess and classify an event.
Enforcement: 10 CFR 50.54(q) requires, in part, that a licensee maintain in effect
emergency plans which meet the standards in 10 CFR 50.47(b) and the requirements in
Appendix E of 10 CFR 50. The licensee may make changes to these plans without
Commission approval only if the changes do not decrease the effectiveness of the plans.
Contrary to these requirements, between 1996 and 2001, the licensee made changes
without NRC approval to the EALs in the Ginna Emergency Plan, required by
10 CFR 50.47(b)(4), that decreased the effectiveness of the plan. Constellation entered
this issue into the CAP as CR 2007-006123. The disposition of this violation, in
accordance with the NRC Enforcement Policy, is addressed in a separate letter dated
Enclosure
16
April 7, 2008. (VIO 05000244/2008502-01: Failure to Obtain NRC Approval for EAL
Changes Which Decreased the Effectiveness of the Emergency Plan)
O4 MANAGEMENT MEETINGS
Exit Meeting Summary
The inspectors presented the results of the supplemental inspection to Mr. David Holm
and other members of Constellation staff on February 22, 2008. The team manager
discussed the conclusions regarding the EAL issue with Mr. John Carlin,
Site Vice President, on March 13, 2008. The inspectors confirmed that no proprietary
material was examined during the inspection.
ATTACHMENT: SUPPLEMENTAL INFORMATION
Enclosure
A-1
SUPPLEMENTAL INFORMATION
KEY POINTS OF CONTACT
Licensee Personnel
J. Carlin Vice President, Ginna
A. Allen Director, Performance Improvement
D. Blankenship General Supervisor, Radiation Protection
D. Dean Assistant Operations Manager (Shift)
M. Geckle Manager, Training and Performance Improvement
M. Giacini Manager, Integrated Work Management
E. Hedderman General Supervisor, Chemistry
D. Holm Plant Manager
J. Jones Emergency Preparedness Manager
D. Kieper General Supervisor, Technical Training
K. Knight Consultant, KT&R Project Manager
E. Larsen Manager, Maintenance
J. Neis Sr. Engineer, Licensing
J. Pacher Manager, Nuclear Engineering Services
B. Weaver Director, Licensing
J. Yoe Manager, Operations
LIST OF ITEMS OPENED, CLOSED, AND DISCUSSED
Opened
VIO 05000244/2008502-01 Failure to Obtain NRC Approval for EAL Changes
Which Decreased the Effectiveness of the
Attachment 1
A-2
LIST OF DOCUMENTS REVIEWED
Condition Reports
2005-3152 2006-1993 2006-2160 2006-5594 2006-7201 2007-0012
2007-0023 2007-0104 2007-0137 2007-0193 2007-0520 2007-1359
2007-1932 2007-2095 2007-2662 2007-2664 2007-2665 2007-2666
2007-2866 2007-2871 2007-2901 2007-2976 2007-3419 2007-3563
2007-3682 2007-3713 2007-3720 2007-3733 2007-3744 2007-3747
2007-3765 2007-3772 2007-3896 2007-4128 2007-4129 2007-4144
2007-4303 2007-4305 2007-4306 2007-4319 2007-4330 2007-4374
2007-4520 2007-4545 2007-4570 2007-4651 2007-4894 2007-4895
2007-5422 2007-5428 2007-5429 2007-5552 2007-5620 2007-5638
2007-5781 2007-6123 2007-6359 2007-6660 2007-6674 2007-6807
2007-6839 2007-6840 2007-6890 2007-6930 2007-6997 2007-6996
2007-7098 2007-7100 2007-7293 2007-7711 2007-8504 2007-8563
2007-8576 2007-8610 2007-8715 2007-8778 2007-8887 2008-0178
2008-0576 2008-0591 2008-0625* 2008-0638* 2008-0701* 2008-0702*
2008-0707* 2008-0711* 2008-0712* 2008-0743 2008-0744 2008-0746*
2008-1112 2008-1273 2008-1329* 2008-1334* 2008-1336 2008-1342
2008-1446* 2008-1447* 2008-1449* 2008-1450* 2008-1452* 2008-1453*
Procedures:
A-205.2, Emergency Plan Implementing Procedures, Rev. 25
CNG-AM-1.01-1017, Performance Monitoring Program, Rev. 0
CNG-CA-1.01-1004, Root Cause Analysis, Rev. 1
CNG-CA-1.01-1009, Change Management, Rev. 0
CNG-CA-1.01-1010, Use of Operating Experience, Rev. 0
CNG-TR-1.01-1001, Training Administration, Rev. 0
CNG-TR-1.01-1000, Conduct of Training, Rev. 0
CCNPP Causal Analysis Handbook, Rev. 9
Change Management Website and Toolbox, Rev. 1
EPG-5, Emergency Preparedness Training Program, Rev. 1
EPIP 5-11, Nuclear Emergency Response Plan Training Program, Rev. 1
IP-EPP-5, Emergency Response Organization Expectations and Responsibilities, Rev. 4
IP-EPP-8, Emergency Preparedness Program Responsibilities and Oversight, Rev. 0
IP-EPP-9, Emergency Response Organization Performance Indicators, Rev. 0
IP-MTE-1, Calibration and Control of Measuring and Test Equipment, Rev. 13
Root Cause Team Lead Toolbox, Rev. 0
Apparent Cause Evaluation Toolbox, Rev. 1
Assessments and Audits:
Audit MAI-07-01G, Maintenance, April 2007
QPA Assessment Report 2007-0009, Safety Conscious Work Environment Survey,
August 2007
QPA Assessment Report 2007-0026, Radiation Protection Training Program, September 2007
Attachment 1
A-3
QPA Assessment Report 2007-0072, Maintenance Supervisor Training, October 2007
QPA Assessment Report 2008-0001, Assessment of Ginna Emergency Preparedness
Against Selected NRC Requirements, January 2008
QPA Assessment Report, Operator Initial License Class Oversight, November 2007
QPA Quarterly Reports - 2007
R. E. Ginna Change Management Assessment Team Report of Site Evaluation,
June 18 - 22, 2007
SA-2006-0073, Mid-Cycle Evaluation of R.E. Ginna Nuclear Power Station, July 2006
SA-2007-0053, Outage Management Snapshot, April 2007
SA-2007-0055, Snapshot Assessment of the Human Performance Program as
Implemented in the Integrated Work Management Department, September 2007
SA-2007-0056, Instruments and Dosimetry Snapshot, April 2007
SA-2007-0057, Security Systems Maintenance Snapshot, April 2007
SA-2007-0061, Component Health Snapshot, June 2007
SA-2007-0065, Flow Accelerated Corrosion Snapshot, May 2007
SA-2007-0070, Engineering Setpoint Control Program Snapshot, June 2007
SA-2007-0071, Maintenance Rework Snapshot, June 2007
SA-2007-0083, Snapshot Assessment of Unplanned LCOs, July 2007
SA-2007-0084, Snubber Program Snapshot, July 2007
SA-2007-0088, Measurement and Test Equipment Snapshot, July 2007
SA-2007-0089, Valve Packing Snapshot, August 2007
SA-2007-0100, OE program, November 2007
SA-2007-0082, ISI Snapshot, July 2007
SA-2007-0131, Operations Training Snapshot, October 2007
SA-2007-0147, Licensed Operator Training Programs, November 2007
SA-2007-0113, Mid-Cycle Assessment of Technical Training, November 2007
SA-2007-0098, 2007 Fleet Instructor Training, August 2007
SA-2007-0027, Licensed Operator Requalification Examination Development and Administration,
February 2007
Safety Culture Assessment Report, Rev. 1, July 2007
TQS-06-01-G, Nuclear Training, April 2006
Miscellaneous
2007 Ginna Program Health Reports (Multiple)
2007 Ginna Tier 1 - 4 Performance Indicators (Multiple)
2007 Operations Instructor Schedule
Change Management Oversight Committee Team Charter
Change Management Updates dated 9/14/07 - 1/10/08
Flow Accelerated Corrosion Improvement Plan, Rev. 0
Ginna Organizational Charts - 2005, 2006, and 2007
I&C Five Year Training Plan, March 2006
Nuclear Training Department Qualification Matrix - 2007
Operations Training Excellence Plan, Current Version
Plant Change Record (PCR) 2005-0020, Install permanent SW flow indication to
D/G coolers, Rev. 0
Technical Staff Request (TSR) 2006-0185, Evaluate Hardware Changes to Enhance
EDG JW/LO Coolers Backflushing, dated 8/22/06
Attachment 1
A-4
LIST OF ACRONYMS
ADAMS Agency-Wide Documents Access and Management System
CAP Corrective Action Program
CFR Code of Federal Regulations
CIS-SAE Containment Integrity Status for a Site Area Emergency
CR condition report
EALS Emergency Action Levels
ERO Emergency Response Organization
FAQ frequently asked question
GINNA R.E. Ginna Nuclear Power Plant
KT&R knowledge transfer and retention
I&C instrumentation and control
IMC Inspection Manual Chapter
IP Inspection Procedure
LCO Limiting Condition for Operation
NEI Nuclear Energy Institute
NCV non-cited violation
NRC U.S. Nuclear Regulatory Commission
OE operating experience
PARS Publicly Available Records
PI performance indicator
RCA root cause analysis
SAE Site Area Emergency
SDP Significance Determination Process
TS Technical Specifications
UE Unusual Event
Attachment 1
A-5
Table 1
Ginna EAL Decreases in Effectiveness
EAL EAL EAL Approved by NRC (1995) EAL (EPIP 1-0, Rev. 39)
Level
2.2.1 UE Letdown line monitor Letdown line monitor
Failed Fuel R-9 > 2 R/hr R-9 > 2 R/hr and Tavg > 500
Detectors deg F
2.3.1 Alert Containment radiation monitor Containment radiation monitor
Containment R-29/R-30 reading > 10 R/hr R-29/R-30 reading > 10 R/hr
Radiation due to RCS leakage
3.2.1 UE Release of secondary side to Unisolable release of
Primary to atmosphere with primary to secondary side
Secondary secondary leakage > 0.1 gpm to atmosphere with primary to
Leakage per steam generator secondary leakage greater than
150 gpd in the affected S/G
4.1.1 UE/ Both doors open on Both doors open on
Containment Alert containment airlock containment airlock
Inability to close containment Inability to close containment
(Alert condition pressure relief or purge valves pressure relief or purge valves
for steam line which results in a radiological which results in a radiological
break release pathway to the release pathway to the
inappropriately environment environment
column) CI or CIV valve(s) not closed CI or CIV valve(s) not closed
when required which results in when required which results in
a radiological release pathway a radiological release pathway
to the environment to the environment
Rapid uncontrolled pressure
decrease following initial
increase due to steam line
break
4.1.2 SAE Rapid uncontrolled decrease in Rapid uncontrolled decrease in
Containment containment pressure following containment pressure following
Integrity Status initial increase initial increase due to a LOCA
Fire or Explosion Which affects safety system Loss of a safety system
operability as indicated by
degraded system performance
Attachment 2