ML081000567

Response to NRC Confirmatory Action Letter (CAL)-4-07-004, List of Specific Tasks, Due Dates, Measures and Metrics

ML081000567
Person / Time
Site:	Palo Verde
Issue date:	03/31/2008
From:	Edington R Arizona Public Service Co, Pinnacle West Capital Corp
To:	Collins E Region 4 Administrator
References
102-05837-RKE/DCM/REB/CJS, CAL-4-07-004
Download: ML081000567 (133)

Text

Confirmatory Action Letter - CAL-4-07-004 A LW A subsidiaryof Pinnacle West CapitalCorporation Randall K. Edington Mail Station 7602 Palo Verde Nuclear Executive Vice President Tel (623) 393-5148 PO Box 52034 Generating Station Chief Nuclear Officer Fax (623) 393-6077 Phoenix, Arizona 85072-2034 102-05837-RKE/DCM/REB/CJS March 31, 2008 Mr. E. E. Collins Jr.

Regional Administrator, Region IV U.S. Nuclear Regulatory Commission

'611 Ryan Plaza Drive, Suite 400 Arlington, TX 76011-4005

References:

1) Revised Confirmatory Action Letter CAL-4-07-004 dated February 15, 2008, from Elmo E. Collins, Region IV NRC, to Randall K. Edington (ADAMS ML080460653)

2) Arizona Public Service Company (APS) letter number 102-05789, dated December 31, 2007, Response to NRC Confirmatory Action Letter (CAL)

Action 5: Submittal of Portions of the Modified Improvement Plan

Subject:

Palo Verde Nuclear Generating Station (PVNGS)

Units 1, 2, and 3 Docket Nos. STN 50-528/529/530 Response to NRC Confirmatory Action Letter (CAL)-4-07-004, List of Specific Tasks, Due Dates, Measures and Metrics This letter responds to the revised CAL-4-07-004 (Reference 1), which requested that APS submit to the NRC a list of the specific tasks, including due dates, associated with the action plans and strategies for each of the twelve CAL key performance areas. This submittal also includes a description of measures and metrics for each PVNGS Site Integrated Improvement Plan (SLIP) Action Plan to aid in monitoring performance improvement, as requested. to this letter is the updated SLIP, which reflects ongoing APS enhancements, including the establishment of performance measures arnd metrics for each of the Action Plans. The revised SlIP contains key improvement actions that APS is taking to address the A member of the STARS (Strategic Teaming and Resource Sharing) Alliance Callaway 0 Comanche Peak El Diablo Canyon C Palo Verde C South Texas Project Cl Wolf Creek

NRC Region IV Confirmatory Action Letter 4-07-004 Response to NRC Confirmatory Action Letter (CAL)-4-07-004, List of Specific Tasks, Due Dates, Measures and Metrics Page 2 causes of the decline in performance at PVNGS. The SlIP actions are a subset of the overall Site Integrated Business Plan (SIBP).

The revised'CAL identified those Action Plans and strategies from the SlIP that the NRC has determined are necessary to address performance issues. For each of the identified strategies, Attachment1I providesthe specific SlIP task numbers that implement that strategy. APS considers these tasks to be regulatory commitments. Attachments 2 through 13 provide a detailed listing of the specific tasks and due dates for each of the 12 key performance areas identified in the revised CAL. Additional information has, in some cases, been provided in the task list in order for the committed actions to be understood in context.

This clarifying material, as well as any other actions to which these tasks may refer, are not part of the regulatory commitment.

The due dates noted in Attachments 2 through 13 are the dates by which APS intends to implement each task. Subsequent to implementation, these tasks will be subject to review by a Closure Review Board to confirm that they have been properly completed. These tasks will be ready for inspection upon completion of the Closure Review Board for each task.

As required in the CAL, APS will notify the NRC when APS has satisfactorily completed or demonstrated substantial and sustainable improvement in each of the twelve key performance areas itemized in the CAL. Substantial and sustainable performance improvement will be indicated by (1) progress in implementing the tasks in that area, and (2) positive performance results as indicated by the collective trend of metrics and other effectiveness reviews.

A number of actions and issues addressed in CAL-4-07-004 and in this response have been the subject of previous plans and correspondence between APS and the NRC. Please note that the actions, metrics, and effectiveness reviews described in this response supersede and replace previous plans and commitments. In particular, these actions, metrics and effectiveness reviews supersede and replace previously submitted plans and correspondence describing actions to address the Recirculation Actuation Signal (RAS) and K-1 Relay issues.

Performance measures and metrics have been developed for each of th e fifteen SlIP Action Plans. These measures and metrics consist of (1) quantitative metrics and (2) effectiveness reviews. The metrics and effectiveness reviews (typically some form of audit or assessment) for each SlIP Action Plan are identified in Attachment 1. Descriptions of each of the quantitative metrics are presented in Attachment 14.

The SlIP is not a static document. As implementation proceeds, APS will adjust specific actions, timetables, performance measures and metrics as warranted by circumstances or

NRC Region IV Confirmatory Action Lett4)r 4 07-004 Response to NRC Confir Mai Dry Action Letter (CAL)-4-07-004, List of Specific.Tasks, Due Dates, Measures and M(-trio S Page 3 effectiveness reviews, ar idWill keep the NRC informed during periodic updates as requested in the CAL.

Our goal is to achieve su bstAintial near-term improvement and to institutionalize the changes we make so that this per lance improvement is sustained. Through the SlIP and SIBP, we will return PVNGS to exc Bllent performance in support of our mission to safely and efficiently generate electi 1cp for the long term.

Ifyou have any question ý, p. ease contact me or Dwight Mims, Vice President Regulatory Affairs and Plant lmprov nt, at (623) 393-5403.

Sincerely, Palo Veirde Nuclear Generating Station Site Integrated Improvement Plan ,R ivision I Key Per rormance Area 1 - Recirculation Actuation Signal (RAS) Actions

- Lisi ting of Specific Tasks and Due Dates (Covers 10 Focus Areas) Key [ormance Area 2 - Unit 3 Emergency Diesel Generator (EDG)

K-1Il ty Actions - Listing of Specific Tasks and Due Dates Key Pet Formance Area 3 - Problem Identification and Resolution (PI&R)

Actic ns *Listing of Specific Tasks and Due Dates Key ýen ormance Area 4 - Human Performance Actions - Listing of Spec ific Tasks and Due Dates Key ýen ormance Area 5 - Engineering Programs Actions - Listing of Spel ific Tasks and Due Dates Key enormance Area 6 - Quality of Equipment Evaluations Actions -

Listii goCf Specific Tasks and Due Dates Key enormance Area 7 - Safety Culture Assessment Actions - Listing of Si ic Tasks and Due Dates Key er ormance Area 8 - Standards and Expectations for Performance and *untability Actions - Listing of Specific Tasks and Due Dates 0 Key Ccc ormance Area 9 - Change Management Process Actions -

Listii f Specific Tasks and Due Dates

NRC Region IV Confirmatory Action Letter 4-07-004 Response to NRC Confirmatory Action Letter (CAL)-4-07-004, List of Specific Tasks, Due Dates, Measures and Metrics Page 4 1 Key Performance Area 10 -- Emergency Preparedness Program Actions

- Listing of Specific Tasks and Due Dates 2 Key Performance Area 11 -- Longstanding Equipment Actions - Listing of Specific Tasks and Due Dates 3 Key Performance Area 12 -- Backlog Tracking and Prioritization Actions

- Listing of Specific Tasks and Due Dates 4 Descriptions of Metrics RKE/DCM/REB/CJS/gat cc: M. T. Markley NRC NRR Project Manager - (send electronic and paper)

R. I.Treadway NRC Senior Resident Inspector for PVNGS

Attachment 1 Palo Verde Nuclear Generating Station Site Integrated Improvement Plan Revision 1

PALO VERDE NUCLEAR GENERATING STATION SITE INTEGRATED IMPROVEMENT PLAN REVISION 1 1.0 PURPOSE The Site Integrated Improvement Plan (SlIP) contains actions to address the causes of the decline in Palo Verde Nuclear Generating Station (PVNGS) performance that impact the Reactor Safety Strategic Performance Area, including the issues that led to PVNGS being placed in the Multiple / Repetitive Degraded Cornerstone Column (Column IV)of the NRC Action Matrix (NRC Inspection Manual Chapter 0305, Operating Reactor Assessment Program, Exhibit 4). The SlIP also addresses the drivers of safety culture issues identified during independent safety culture assessments at PVNGS. The objective of the SlIP is to achieve substantial and sustainable improvement in performance.

The actions contained in the SlIP are a subset of the PVNGS Site Integrated Business Plan (SIBP).

2.0 DEVELOPMENT, SCOPE, AND STRUCTURE The SlIP has been developed based upon a series of evaluations that APS performed to identify the fundamental problems that led to the decline in PVNGS performance and the causes of those fundamental problems. The SlIP also contains actions to address causes of the violations that led to the NRC Inspection Procedure (IP) 95001 and 95002 inspections, causes of the Human Performance (HU) and Problem Identification &

Resolution (PI&R) substantive cross-cutting issues, and the drivers of the safety culture issues that were identified in the 2007 independent safety culture assessments conducted by Synergy, Inc. and an Independent Safety Culture Performance Evaluation Team composed of outside industry experts.

The assessments, reviews and causal analyses upon which the SlIP actions are based were performed under the auspices of the PVNGS Improved Performance and Cultural Transformation (ImPACT) Team and the PVNGS Corrective Action Program (CAP).

They included:

• A systematic review of site performance issues (dating back a minimum of 6 years in most areas).

" A collective evaluation of those site performance issues, resulting in the identification of twelve fundamental overall problems that had contributed to the decline in performance.

" Causal analyses and/or reviews to identify'the reasons for those fundamental overall problems.

" Performance of independent assessments that examined the PVNGS safety culture. These assessments included a survey and follow-up interviews of site personnel, as well as an evaluation of safety culture performance by a team of 1

outside industry experts. Stream analyses were performed to identify the drivers of safety culture issues identified by these assessments.

• Reviews and causal analyses of the Emergency Diesel Generator K-1 relay and Recirculation Actuation Signal (RAS) conditions, including reviews of actions taken in response to those conditions.

• Reviews and causal analyses of the issues associated with the HU and PI&R substantive cross-cutting areas.

In a few cases where other assessments, reviews, and causal analyses had been recently performed and were determined to be acceptable, the ImPACT Team relied upon those results to understand the nature and causes of problems and to serve as bases for development of corrective actions.

These reviews and analyses resulted in the development of fifteen (15) Action Plans grouped into five (5) Improvement Areas. These Action. Plans are designed to address the results of the causal analyses and assessments. The 15 Action Plans and their associated Improvement Areas are:

IMPROVEMENT AREAS ACTION PLANS

• Operational Focus (including Operations Fundamentals Operations and Operability Determinations)

• Equipment Reliability

• Engineering Technical Rigor Engineering

• DesignrControl/Configuration Management

• Engineering Programs (including Maintenance Rule, Equipment Qualification, and Fire Protection)

• Performance Improvement (including Corrective Action Program, Operating Experience, and Self Assessment/

Site Programs and Processes Benchmarking) e Managing Plant Workloads

• Emergency Preparedness

• Programs, Procedures and Work Instructions

• Organizational Effectiveness Organization and Human 9 Human Performance/Industrial Safety Performance e Safety Culture e Training and Qualification

• Emergency Diesel Generator K-1 Relay Event EDG K-1 Relay and RAS [Inspection Procedure (IP) 95001]

a Recirculation Actuation Signal Event (IP 95002)

The 15 Action Plans are presented in Section 6.0.

2

3.0 SELECTION OF ACTIONS TO BE INCLUDED IN THE SlIP The actions to address the causes and drivers of the problems in the areas identified above have been included in the PVNGS SIBP along with many other actions to improve PVNGS performance and support the mission to safely and efficiently generate electricity for the long term. APS has established an Implementation and Monitoring Team to oversee the SIBP and SLIP. To select items for inclusion in the SLIP, line management and Implementation and Monitoring Team members (including ImPACT Team members familiar with the causal analysis and other reviews performed by ImPACT) performed reviews to ensure that the SlIP contained actions to address the causes and/or drivers of the identified problems and to confirm that those actions are likely to address those causes and drivers successfully. In particular, within each SlIP Action Plan, the following types of actions have been included:

• Actions designed to prevent recurrence of root causes of issues for which a root cause analysis was performed

" Actions designed to address drivers of issues for which stream analyses were performed These types of actions form the backbone of the SLIP. Because these actions include the actions to prevent recurrence of root causes and actions to address drivers, there is confidence they will result in substantial and sustainable performance improvement.

In addition, during reviews of the SlIP by PVNGS management, there were instances in which management chose to modify or supplement these actions with additional actions designed to address the identified problems and their causes. The selection of these additional actions was based upon consideration of the following factors:

" Is the action likely to result in significant improvement in performance in the area being addressed?

• Is the action needed to promptly address an area in which no corrective action to prevent recurrence (CAPR) is scheduled to be completed in the near term?

• Is the action needed to address issues identified during the NRC IP 95003 inspection?

• Is the action necessary to address important operability, reliability, or safety issues?

• Given available resources and time, is the action achievable?

• Is the action defined with sufficient clarity such that implementation can be verified, measured and monitored?

• Will the action result in improvement within a reasonable time (1-2 years or sooner) commensurate with the level of need for immediate improvement?

• Collectively, do the selected actions address the causes of problems in the area and appear likely, if implemented, to result in substantial and sustainable performance in that area?

0 Collectively, can all of the selected actions be accomplished in a quality manner as described and scheduled?

3

In cases where an action to prevent recurrence resulting from a root cause analysis was modified, the change was reviewed by the PVNGS Corrective Action Review Board (CARB) pursuant to CAP requirements to ensure the revised actions appropriately addressed the identified causes.

4.0 IMPLEMENTATION, TRACKING, AND CLOSURE OF SlIP ACTIONS Closure of SlIP actions is subject to the requirements of a formal procedure, 01 DP-OAC06, Site Integrated Business Plan (SIBP)/ Site Integrated Improvement Plan (SLIP)

Process. Pursuant to this procedure:

• Closure of actions requires the sign off of the responsible leader.

• Closure is supported by a formal closure package providing evidence of the completion of the action.

" Closure packages are reviewed and maintained by the Implementation and Monitoring Team (IMT). The IMT provides feedback to the organization on the quality of the closure packages in order to raise standards in the corrective action program.

• Each action has been entered into the PVNGS CAP, and must meet the closure requirements of that program.

• Action closures are reviewed by a Closure Review Board that includes members of PVNGS management independent of the management responsible for implementation of the action.

These controls provide confidence that SlIP actions will be rigorously implemented.

Completion status of SlIP actions will be tracked and reported to PVNGS senior management on a periodic basis (approximately monthly).

5.0 EFFECTIVENESS REVIEW OF SlIP AREAS Effectiveness of the SlIP will be monitored by several means, including:

• Effectiveness measures and performance metrics for each SlIP Improvement Area

• Planned internal effectiveness reviews or self-assessments for each SlIP Improvement Area

• Periodic review of progress and effectiveness by the Implementation and Monitoring Team

• Periodic review of progress and effectiveness by PVNGS senior management

• Independent surveys or assessments (including an independent safety culture survey and performance evaluation) 4

The specific methods to be used for monitoring the effectiveness in achieving improvement in each SlIP area are presented in Section 6.0. The set of metrics for each SlIP Action Plan has been established and is reflected in the Action Plans.

6.0 ACTION PLANS For each Action Plan presented below, the following information is provided: (1) a problem statement describing the overall problem being addressed and its primary causes and/or drivers; (2) an Action Plan Strategy describing the actions being taken to address the problem and its primary causes and/or drivers; (3) the effectiveness reviews and metrics for each plan. Detailed implementing steps for actions contained in these Action Plans have been developed and are included in the SIBP. Cross-references to the appropriate SIBP/SIIP sections are provided.

5

4Jý ATTACHMENT I I Acdon Plan SbvAeff I

1. Develop and implement the Leadership/Management Model from the Organizational Effectiveness Root Cause. (SISPISIIP 2.1.D.5)

Palo Verde lacked an operationally focused 2. Create a site-wide awareness/focus on the plant and corresponding safety aspects by organization. As a result, long standing issues setting the expectation to open initial daily meetings with discussions on plant status and correlating safety aspects. (SIBP/SIIP 4.4.11) had been tolerated while reliable plant operation, the operability of systems important to safety, and 3. Complete an aggregate review of Installed temporary mods, degraded-nonconforming I Effectl"nms Raviiaws I Metrics; I nuclear safety had been challenged. work orders, control room deficiencies, installed jumpers, operability determinations, number of work orders on safety systems, longstanding permits, and operator-work-arounds that have been proceduralized to determine overall impact to operational Operational Focus Indicator Additionally, control room personnel have not nuclear safety of the plant. (SIBP/SIIP 4.1.G.1 through 4.1.G.3) 5 Operator Work Arounds Indicator consistently demonstrated the level of formality 4. Identify and review for aggregate Impact, imbedded operator-work-arounds and burdens Operator Burdens Indicator and rigor associated with the levels of that challenge nuclear safety and Institutionalize the process. (SIBP/SlIP 4.1.G.10 and  ;- Lit Annunciators Indicator professionalism expected of personnel in 4.1.G.11) Control Room Discrepancy Logs Indicator command and control of a nuclear power plant. 5. Establish a site-wide emphasis and alignment on core mission and on core fundamental Long.term Tag Outs Indicator focus areas including: Safely and efficiently generate electricity for the long term, and Fire System Component Condition Records core fundamental focus areas of Plant Equipment, People, Corrective Action Program, Indicator Safety, and Knowledge/Training. (SIBPISlIP 7.1.B.10)

Furthermore, the operability assessment process Temporary Modifications Indicator has not been consistently applied to ensure timely, 6. Develop and implement leadership training to address key nuclear fundamentals and Unplanned Entries into Limiting Conditions improve overall leadership. (SIBPISIIP 2.4.A.8) of Operation Indicator complete and properly prioritized evaluation of potentially degraded or non-conforming 7. Develop and implement a site-wide communication and meeting strategy to address site Site Corrective Maintenance Indicator conditions. alignment, operational focus, and site-wide penetration of messages (SIBPISIIP 7.1.B.1 Site Elective Maintenance Indicator and 7.1.B.5). ) Site Chemistry Effectiveness Indicator

8. Identify key Operations department attributes and behaviors of an operationally focused Forced Loss Rate Indicator organization from INPO 01-002, Conduct of Operations and Incorporate them into Unplanned Power Change (NRC Indicator) procedures and training. (SIBP/SIIP 4.1.G.4, 4.1.G.5, and 4.1.G.6) Unplanned Power Change (PVNGS Site

9. Develop and Implement a Palo Verde specific power plant fundamentals course for site Indicator) staff. (SIBP/SIIP 5.1.A.1 through 5.1.A.3) Operability Determination Quality Indicator Senior management failed to establish and enforce Engineering Systems Health Report Total

10. Develop and implement a strategy to expand operational knowledge and experience appropriate expectations for maintaining an across the organization. (SIBP/SIIP 2.4.C.6) Color Progress Indicator operationally focused organization led by Site Plant Performance Index (Annualized)

11. Develop and implement plans and training to ensure that Operations management Quarterly Reviews by a Management operations. defines, communicates, and reinforces Operations Fundamentals such as high professional standards, control board monitoring, communications, and ownership of Review Challenge Team (SIBPISIIP 4.1 .H.1 equipment problems. (SIBPISIIP 6.11.1 and 6.11.2) thru 4.1.H.8 and 4.1 .F.28)

12. Ensure potentially degraded or non-conforming conditions receive a timely, thorough 2008 Mid-cycle Assessment and appropriately prioritized Operability Determination and provide training for key (SIBP/SIIP 2.6.9) operations and engineering personnel. (SIBP/SIIP 4.1.F.9 through 4.1.F.27, and 4.1.F.34) 033108 Arizona Public Service Palo Verde Nuclear Generating Station

ATTACHMENT I

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1. Revise and implement the plan to complete the Reliability Centered Maintenance (RCM) project. (SIBPISIIP 1.2.C.11 and 1.2.C.12)

Critical equipment has not operated properly on demand and has not performed reliably through I ffetvnemRe~e IMW

2. Develop and implement a Long Range Planning process which the operating cycle. includes major repetitive activities, major modifications, major maintenance activities, appropriate approval processes, and - Operational Focus Indicator process metrics to measure its health. (SIBP/SIIP 19.1.1.c, 19.1.1.f, Operator Work Arounds Indicator 19.1.1 .h, and 19.1.14) Operator Burdens Indicator

)o Lit Annunciators Indicator

3. Revise the Equipment Root Cause of Failure Analysis (ERCFA) ) Control Room Discrepancy Logs Indicator program to require that ERCFA level I evaluations include ) Long-term Tag Outs Indicator consideration and documentation of corrective actions to Fire System Component Condition Records minimize the likelihood of recurrence including revisions to the PM Indicator Lack of ownership, accountability, and visibility Temporary Modifications Indicator resulted in the station being ineffective at Program. (SIBP/SIIP 1.2.D.2, 1.2.D.3, and 1.2.D.4)

Unplanned Entries into Limiting Conditions implementing the Reliability Centered of Operation Indicator

4. Transition the System Team Steering Committee to a Plant Health Maintenance (RCM) project within established Site Corrective Maintenance Indicator targets. Committee and revise the charter to be consistent with industry guidance and to reinforce rigor and ownership in eliminating o Site Elective Maintenance Indicator equipment reliability challenges. (SIBPISIIP 1.2.F.10, 1.3.A.2, and *- Site Chemistry Effectiveness Indicator The station does not have a site wide long range 1.3.A.3) Forced Loss Rate Indicator process to prioritize, budget, and integrate Unplanned Power Change (NRC Indicator) individual system long-term reliability plans for system and component health. 5. Develop and implement the LeadershiplManagement Model and Unplanned Power Change (PVNGS Site the Accountability Model from the Organizational Effectiveness Indicator)

Root Cause. (SIBP/SIIP 2.1.D.5 and 2.1.D.6) " Engineering Systems Health Report Total The equipment root cause process does not Color Progress Indicator consistently require consideration of actions to

6. Implement a minor modifications process to better address small " Engineering Program Health Report Total minimize recurrence for ERCFA I equipment equipment challenges. (SIBP/SIIP 1.4.2 and 1.4.6) Color Progress Indicator failure evaluations Quarterly reviews by a Management Review

7. Establish a site Top 10 process for identifying and prioritizing Challenge Team.

equipment issues and address specific long-standing issues (SIBPISIIP 1.5.1 thru 1.5.8) associated with known equipment deficiencies. (SIBP/SIIP 1.2.A.3, - 2008 Mid-cycle Assessment 11.3.1 through 11.3.7, and 11.3.15) (SIBP/SIIP 2.6.9) 033108 Arizona Public Service Palo Verde Nuclear Generating Station

ATTACHMENT I ZJýý Action Plan StnM*gy Aý/\

1. Develop and Implement the LeadershiplManagement Model and the Accountability Model from the Organizational Effectiveness Root Cause. (SIBP/SIIP 2.1.D.5 and 2.1.0.6)

2. Develop and train on a Conduct of Engineering procedure. The procedure should include Inconsistencies in some design output engineering principles and standards. Incorporate a requirement into the engineering documentation, important operability Training Program Description (TPD) to train on the Conduct of Engineering procedure in determinations input, and engineering initial training and continuing training. (SIBPISIIP 11.1.6 and 11.8.30) assumptions made during critical evaluations and 3. Implement an Engineering Operations Support team with a charter for Operations resolution of key issues created challenges to interface and support on the Operability Determination process. (SIBPISIIP 4.1.G.16) reliable plant operations and meeting regulatory

4. Develop and incorporate Operability Determination training into initial and continuing requirements. engineering training. (SIBP/SIIP 5.1.E.3 and 5.1.E.4)

Engineering Work Product Quality Indicator

5. Establish a process to ensure technical information used for key operations, - Operability Determination Quality Indicator maintenance and regulatory activities contains appropriate engineering review and approval requirements. (SIBP/SIIP 4.1.F.31, 4.1.F.32, 4.1.F.33, 11.4.15) Quarterly Reviews by a Management Review Challenge Team

6. Develop and provide training for problem solving and decision making techniques. (SIBPISIIP 11.11.1 thru 11.11.8)

(SIBPISIIP 11.8.20 and 11.8.21) 2008 Mid-cycle Assessment

7. Establish an Engineering Leader Observation Program that is incorporated within the site (SIBP/SIIP 2.6.9) observation program as a tool for monitoring and adjusting engineering products, practices and human performance standards and tools. (SIBPISIIP 11.4.1)

Engineering leadership has not maintained 8. Provide training for use of Engineering Department Guide EDG-01 Engineering Human accountability for enforcement of engineering Performance Tools and EDG-02 Engineering Human Performance Tools for Technical fundamentals and human performance standards. Task Risk/Rigor. (SIBP/SIIP 11.4.9)

9. Establish metrics for Engineering Human Performance. (SIBPISIIP 11.4.10)

Training has not been used effectively to improve engineering performance. 10. Implement an Engineering work management and scheduling department and issue for use Initial base load work schedules for Design, System, & Maintenance Engineering Department. (BIBPI5lIP 11.9.A.1 and 11.9.A.8)

Lack of engineering work management

11. Develop a procedure that describes the purpose, conduct, membership, criteria and (prioritizationldue dates) and resource allocation requirements for using an Engineering Quality Product Review Board.

(concurrent duties, responsibilities and loss of (SIBP/SIIP 11.4.17) expertise) has affected quality of products.

12. Establish an Engineering Training group and align it within the Engineering Performance Improvement Department to provide focus on the engineering training program.

(SIBPISIIP 11.10.3)

13. Review selected equipment causal analyses and PMs outside their grace period between January 1, 2002 and December 31, 2007 that could potentially affect plant safety to ensure that those determinations were appropriate from a safety perspective.

(SIBPISIIP 3.2.9.a and 3.2.9.b) 033108 Arizona Public Service Palo Verde Nuclear Generating Station

ATTACHMENT 1 Action Plan Strate&

1. Develop and implement the LeadershiplManagement Model and the Accountability Model from the Organizational Effectiveness Weaknesses in the Design Control & Configuration Root Cause. (SIBP/SIIP 2.1.D.5 and 2.1.D.6) evW. I Nkti],s Management processes and their implementation IEfetivrwW have resulted in some errors in design output

2. Improve configuration change processes, including control of Quality of the Resolution of Component documents, plant procedures and inappropriate temporary changes and train personnel on the improved Design Basis Review (CDBR) Related Actions operating conditions. This is demonstrated by processes. (SIBPISIIP 11.7.1, and 11.7.4 through 11.7.6) Indicator latent design issues that challenge operability, plant configuration change weaknesses, long ) Component Design Basis Review (CDBR)

3. Inventory engineering backlogs, complete significance reviews, Project Schedule Adherence Indicator standing temporary mods, and inadequate design products. and develop work-off plans. (SIBPISIIP 11.9.A.4 through 11.9.A.6 Engineering Condition Report Disposition and 11.9.A.18) Request/Condition Report Action Item (CRDR/CRAI) Reduction Indicator

4. Communicate and train the concept that Engineering is the Temporary Modifications Indicator "Design Authority" for the site. (SIBPISIIP 7.1.C.6, 11.7.18, and Engineering Work Product Quality Indicator 11.7.19) Quarterly reviews by a Management Review Challenge Team.

5. Implement the CDBR for high risk/low margin components in (SIBP/SIIP 11.13.1 thru 11.13.8) accordance with the project schedule. (SIBP/SIIP 11.6.1.a, 2008 Mid-cycle Assessment 11.6.1.b, 11.6.1.c, 11.6.7, and 11.6.13) (SIBP/SIIP 2.6.9)

6. Inventory, plan, and work off backlogs of temporary changes and degraded conditions. (SIBP/SIIP 4.1.G.1 through 4.1.G.3, 11.3.11, and 11.3.14)

Engineering has not taken full ownership and NOTE: For additional actions to address Engineering product quality accountability as the design authority. see SlIP ACTION PLAN 3 - Engineering Technical Rigor 033108 Arizona Public Service Palo Verde Nuclear Generating Station

ATTACHMENT 1

1. As an interim measure to determine full extent of condition, Engineering is to evaluate what existing programs need to be immediately assessed or assessed near term and complete the assessments. (SIBPISIIP 1.2.E.21, 1.2.E.22, and 1.2.E.35)

2. Establish owners for each one of the Engineering Programs, issue roles and Engineering Programs are not consistently aligned responsibilities, and ensure they are trained on expectations and standards. I EffechNwe" RevWws I MeMcs I with industry standards and practices or other (SIBPISIIP 1.2.E.1, 1.2.E.14, and 11.10.4 )

work processes. Resources are not adequate to

3. Develop and implement the Leadership/Management Model and Leadership meet both emerging daily priorities and address Training from the Organizational Effectiveness Root Cause. (SIBP/SIIP 2.1.D.5 and long-term programmatic issues. Learning Engineering Program Health Report Total 2.4.A.8) opportunities have been missed as self Color Progress Indicator assessment, benchmarking, corrective action and 4. Create and implement an Engineering work management and scheduling Forced Loss Rate Indicator department and issue initial base-load schedule to ensure appropriate allocation of operating experience has not been fully utilized to ) Unplanned Entries into Limiting resources. (SlBP/SlIP 11.9.A.1 and 11.9.A.14) improve Engineering Programs. Conditions of Operations Indicator

5. Engineering Management will ensure a "rollup" of the Engineering Program Chemistry Effectiveness Indicator Performance Indicators is presented for the first three quarters of 2008 at the quarterly Management Review Meeting. (SIBP/SIIP 1.2.E.7)

Unplanned Power Change (NRC Indicator)

Unplanned Power Change (PVNGS Site

6. Revise the engineering program health reporting procedure (73DP-OAP05) to Indicator) address self-assessment expectations, revise metrics using industry input, establish MRM program health indicator rollup presentations, require that program  ; Quarterly reviews by a Management documents are maintained current, and to use change management when Review Challenge Team.

modifying engineering programs. (SIBPISIIP 1.2.E.8, 1.2.E.13, and 1.2.E.16) (SIBPISIIP 11.12.1 thru 11.12.8)

7. Realign engineering to consolidate system engineer responsibilities for the 2008 Mid-cycle Assessment Maintenance Rule Program and establish a section leader responsible for (SIBP/SIIP 2.6.9) management oversight of the program. Complete a self-assessment of the Maintenance Rule Program using external expertise. (SIBP/SIIP 1.2.E.24 and 1.2.E.27)

Engineering leadership was not focused on Engineering fundamentals and did not place 8. Complete corrective actions from the evaluation of the U3R13 transient adequate oversight and ownership on Engineering combustible material procedure violations. Complete benchmarking of transient Programs. combustible material processes and organizational structures for Fire Protection program implementation. (SIBP/SIIP 1.2.E.29, 1.2.E.30, and 1.2.E.32)

Organizational structure and resource allocation 9. Enter actions from the 2007 Equipment Qualification Program Self-Assessment Into were not adequate to ensure long-term success of the corrective action program and benchmark the Equipment Qualification Program using the INPO Engineering Program Guide (EPG-02). (SIBP/SIIP 1.2.E.28 and Engineering Programs. 1.2.E.31)

10. Based on industry best practices, identify if there are other engineering processes that should be managed as an Engineering Program. (SIBPISIIP 1.2.E.15) 033108 Arizona Public Service Palo Verde Nuclear Generating Station

ATIACHMENT 1 N

mum pun mrst"Y

1. Develop and communicate Corrective Action Program (CAP) fundamentals for station personnel and for managers and supervisors. (SIBP/SIIP 3.3.3.j)

PVNGS continues to demonstrate weaknesses in

2. Increase visibility of CAP indicators and reinforce CAP behaviors through the effective implementation of the station management alignment and review meetings.

Corrective Action Program (CAP). CRDR quality is (SIBP/SIIP 3.2.7.i through 3.2.7.p) at an unacceptably low level.

3. Develop a process to conduct crosscutting reviews during Management Review Meetings (MRM). (SIBP/SIIP 8.4.4) Condition Report Disposition Request (CRDR) Inventory Indicator

4. Incorporate performance objectives for CAP timeliness and quality into the Corrective Action Program (CAP) Quality Performance Management Plans (PMPs) for each position.

Index (SIBP/SIIP 3.5.3.f)

Condition Report Disposition Request

5. Develop and implement the Leadership/Management Model and the (CRDR) Evaluation Age Indicator Accountability Model from the Organizational Effectiveness Root Cause. Average Age of Open Corrective Actions to (SIBP/SIIP 2.1.D.5 and 2.1.D.6) Prevent Recurrence Indicator Quarterly reviews by a Management Review

6. Improve quality and consistency of root and apparent cause evaluations.

(SIBP/SIIP 3.2.5, 3.3.2, and 3.3.3.b) Challenge Team.

(SIBPISIIP 3.5.5 thru 3.5.12)

7. Establish a process to provide training to Performance Advocates on their 2008 Mid-cycle Assessment responsibility for quality program implementation. (SIBP/SIIP 2.6.9)

The primary cause is inadequate personnel and (SIP/SIIP 3.3.3.d) organizational accountability. In addition contributing causes included: insufficient change 8. Develop and implement qualification requirements for ARRC and CARB members. (SIBP/SlIP 3.3.3.b and 3.3.3.c) management, weak CAP procedures, ineffective CAP program oversight, ineffective 9. Complete a job qualification and training for root cause investigators and communication of standards and expectations, investigation directors. (SIBP/SIIP 3.3.1.b, 3.3.1.c, and 3.3.2.c) ineffective performance indicators, and inadequate training and qualifications. 10. Implement process changes to include reinstitution of the adverse evaluation, improvement of CAP governing procedures , and improvement of trending processes. (SIBP/SIIP 3.4.7.a through 3.4.7.k, 3.4.2.b, 3.4.9.d, and 3.4.10.a through 3.4.10.j)

11. Institutionalize the use of a formal Change Management Process.

(SIBP/SlIP 6.10.1) 033108 Arizona Public Service Palo Verde Nuclear Generating Station

ATTACHMENT 1 Operating Experience (OE) - Lessons learned from 1. Revise 65DP-0QQ01, Industry Operating Experience Review, to include important industry and internal operating experience have conduct of operating experience elements from INPO 05-05 and 97-011, not been put into practice. including in the procedure, roles, responsibilities, and ownership expectations. (SIBP/SIIP 6.7.1) I ft~eaiiaR6*9M IMott" I In addition, the Self Assessment and Benchmarking Program (SAIBM) is ineffective in identifying and 2. Develop and implement an operating experience screening committee, resolving performance gaps include criteria, charter, roles/responsibilities for cross-disciplinary review of in-coming (external) operating experience. (SlBP/SIIP 6.7.16)

3. Evaluate the SOER select listing from INPO and re-evaluate the analysis Timeliness of Operating Experience and corrective actions taken by the station. Screening Indicator (SIBP/SIIP 6.7.17, 6.7.29 and 6.7.30)

The station has not embraced Operating Experience as a Quarterly reviews of Operating Experience learning tool and lessons learned. The degree of 4. Develop a process to add OE to work packages. (SIBP/SIIP 6.7.11) by a Management Review Challenge Team.

management oversight and engagement was not (SIBP/SIIP 6.7.20 thru 6.7.27) adequate. Periodic verification and validation of Quarterly reviews of SA/BM by a

5. Implement more usable OE search engine(s). (SIBP/SIIP 6.7.12) operating experience evaluation results has not been Management Review Challenge Team.

performed. The process for periodic effectiveness reviews has not been adequate. Key attributes and 6. Develop and implement controls to ensure corrective actions (SIBP/SIIP 15.1.17 thru 15.1.24) behaviors, integral to a successful operating experience implemented into procedures, processes, and training to address high- 2008 Mid-cycle Assessment program, were not evident in the current program or tier OE are not inadvertently deleted. (SIBP/SIIP 6.7.6) (SIBP/SIIP 2.6.9) implementation.

7. Evaluate and implement a robust self assessment and benchmarking The value of the Self Assessment process has not been process program aligned with industry best practices.

firmly anchored and management has not provided (SIBP/SIIP 15.1.2, 15.1.7, 15.1.10, and 15.2.1) adequate program oversight and ownership. Self-assessments were not consistently intrusive. 8. Conduct station quality review boards for reviewing and approving self Benchmarking was infrequent, lacked a disciplined assessment and benchmarking reports.

approach to planning, and was not constructively used (SIBP/SIIP 15.1.9) for station-wide improvement. Station management has not demonstrated adequate leadership to ensure the

9. Implement self assessment team leader and sponsor training prior to PVNGS program aligns with station standards, industry standards, and was effectively supported and conduct of cross-functional, mid-cycle, or comprehensive implemented. Program oversight and ownership was not assessments. (SIBP/SIIP 15.1.6) well established.

10. Implement a process to schedule overall station self assessments by department. (SIBP/SlIP 15.1.16) 033108 Arizona Public Service Palo Verde Nuclear Generating Station

ATTACHMENT1 A

I AcmPnSt-m I

1. Revise procedure 51DP-90M03, Site Scheduling, to incorporate Effective work management is an organizational industry best practices based upon industry benchmarking and =

process whereby individuals clearly understand INPO AP-928 including roles and responsibilities and conduct of and follow roles in order to ensure work is planned meeting expectations. (SIBPISIIP 14.4.16) and scheduled in accordance with established plans, schedules and procedures to ensure the 2. Revise procedure 51DP-90M09, Outage Planning and Execution, right work is performed on the right equipment at to incorporate industry best practices based upon industry the right time in order to improve plant safety, benchmarking and INPO 06-008 including roles and Operational Focus Indicator reliability and performance. Contrary to this, the responsibilities and conduct of meeting expectations. Online Schedule Adherence Indicator processes and procedures for Work Management (SIBPISIIP 17.3.17) Online Scope Stability T-5 thru T-1 Indicator and Outage Management have not been effectively Site Corrective Maintenance Indicator implemented at PVNGS in order to improve and 3. Develop a plan to implement INPO style High Performance Team Site Elective Maintenance Indicator maintain station equipment reliability. Building Training in the Work Management Area.

Total/Adverse Procedure Change Inventory (SIBPISIIP 14.4.10)

Indicator

4. Develop a charter and standard agenda for each T- minus Engineering Condition Report Disposition Request/Condition Report Action Item scheduling meeting. (SIBP/SIIP 14.4.13)

(CRDRICRAI) Reduction Indicator

5. Conduct Engineering work management and periodic alignment )- Condition Report Disposition Request meetings with Operations, Maintenance, Work Management & (CRDR) Inventory Indicator Engineering. (SIBP/SIIP 11.9.A.9 and 11.9.A.10) Quarterly reviews by a Management Review Site organizations have isolated themselves from Challenge Team.

the industry and themselves, resulting in a lack of 6. Improve Maintenance and Operations support of schedule (SIBP/SIIP 14.2.11 thru 14.2.18) alignment on the Work Management process. development including appropriate metrics to monitor > Assess Readiness for 2R14 and 1R14.

Department Managers have different perspectives performance. (SIBP/SIIP 14.1.8,14.5.2, and 14.5.3) (SIBP/SIIP 17.3.18) on how Work Management should be supported or > 2008 Mid-cycle Assessment.

improved. 7. Complete an assessment of the current tools and processes for (SIBP/SIIP 2.6.9) online and outage risk management against industry best Site personnel across the organization and up the practices to identify improvement opportunities.

management chain do not value the work (SIBPISIIP 14.1.15) management process due to little understanding about how the Work Management process is 8. Identify PVNGS work tracking system backlogs. Screen and supposed to work. perform significance reviews of items contained in the work tracking systems. (SIBP/SIIP 14.2.21, 14.2.22, and 14.2.23) 033108 Arizona Public Service Palo Verde Nuclear Generating Station

ATTACHMENT 1

/ I X

1. Revise policy guidance on Emergency Planning to incorporate revised roles and responsibilities. (SIBP/SIIP 9.1.A.1 and 9.1.A.5)

Weaknesses in the Emergency Preparedness (EP) 2. Develop and implement the Leadership/Management Model and the Program ownership and program implementation Accountability Model from the Organizational Effectiveness Root exist. Numerous deficiencies have been identified Cause. (SIBP/SIIP 2.1.D.5 and 2.1.D.6) showing an adverse trend in the timely and accurate emergency plan notifications, 3. Emergency Planning to institute alignment meetings between classifications, and Protective Action Emergency Response Organization's Emergency Coordinators (EC) and Emergency Response Organization (ERO)

Recommendations Emergency Operations Directors (EOD). (SIBP/SIIP 9.1.A.22)

Drill/Exercise Performance (NRC Indicator)

4. Enhance the training program and conduct training for EC's and EOD's Emergency Response Organization (ERO) on EAL's. (SIBP/SIIP 9.2.A.15, 9.2.A.16, and 9.2.A.22) Drill/Exercise Performance (PVNGS Site Indicator)

5. Create an EP Training Review Group as well as the appropriate number Emergency Drill Participation (NRC Indicator) of Training Advisory Committees and control EP training similar to Alert and Notification System (NRC Indicator) accredited training programs. (SIBP/SIIP 9.2.A.23, 9.2.A.31 and 9.1.A.33)

Quarterly Reviews by Management Challenge With respect to Emergency Preparedness, leaders 6. Develop and implement a strategy (posters, lanyard cards, etc) to Review Team have not established, communicated, and communicate Emergency Planning Program elements to the line (SIBP/SIIP 9.6.1 thru 9.6.8) reinforced high expectations for performance and organization. (SlBP/SIIP 9.1.A.6 and 9.1.A.21) held individuals accountable to those standards.

Shortfalls in meeting expectations are sometimes 7. Revise EOD Performance Management Plans to include an expectation not evaluated, understood and promptly addressed. that they are responsible for their team's performance commencing 2008. (SIBP/SIIP 9.1.A.4)

Emergency Preparedness Drill/Exercise Performance is in the 4th Quartile due to training 8. Develop and implement a multi-discipline E-Plan Steering Committee that will provide oversight of the Emergency Preparedness program.

designed to meet requirements vice operational (SIBP/SIIP 9.1.A.24) excellence.

9. Revise 21SP-OSKII to address implementation of EALs 7-1, 7-2, and 7-3 and provide applicable training. (SIBP/SIIP 9.5.5 and 9.5.6)

10. Implement Emergency Response Organization weekly turnover meetings. (SIBPISIIP 9.1.A.11 and 9.1.B.9)

11. Develop a plan for implementation of NEI 99-01 Rev.5 for EAL upgrade and present to Senior Management. (SIBP/SIIP 9.5.1 and 9.5.2) 033108 Arizona Public Service Palo Verde Nuclear Generating Station

ATTACHMENT I

1. Develop and implement the LeadershiplManagement Model and the Accountability Model from the Organizational Effectiveness Root Cause. (SIBPISIIP 2.1.D.5 and 2.1.D.6)

Palo Verde Nuclear Station, procedure, and policy guidance deficiencies have continued to result in 2. Establish an administrative review committee for management of ineffective program implementation and have program, procedure and process priorities. (SIBPISIIP 12.2.2) IEffecOveness ftWem I MQUUS I contributed to procedure adherence problems.

Previous attempts to resolve issues associated 3. Establish a Site Work Management System (SWMS) users board for with programs, procedures and processes have not review and prioritization of software change requests.

been successful in elimination of the overall issue. (SIBP/SIIP 16.2.A.1) *- Total/Adverse Procedure Change Inventory Indicator

4. Re-establish a procedures administrative control program and Quarterly Reviews by Management develop upper tier documents for implementation of vital processes Challenge Review Team and controls for procedural hierarchy. (SIBP/SIIP 12.3.10 thru 12.3.17)

(SIBPISIIP 12.2.8)

Conduct an effectiveness review of the

5. Identify major programs and processes vital to ensuring performance Administrative Review Committee at PVNGS is maintained. (SIBP/SIIP 12.2.7) (SIBPISIIP 12.2.3) 2008 Mid-cycle Assessment

6. Revise procedure 01DP-OAP01, Procedure Process, to improve (SIBPISIIP 2.6.9) usability. (SIBP/SIIP 10.2.7)

Inadequate procedure program / process controls 7. Complete Process mapping for development of a PV process inventory infrastructure. (SIBP/SIIP 12.3.2 and 12.3.3) have contributed to procedure quality issues.

8. Develop CAP and Work Management process simplification improvement plans. (SIBPISIIP 12.4.4, 12.4.5 and 12.4.6)

9. Reduce the number of procedure writer's guides to enhance procedure consistency. (SIBPISIIP 10.2.8)

10. Identify and develop SWMS usability improvements.

(SIBP/SIIP 16.2.A.4.b and 16.2.A.4.c)

11. Establish an organizational structure to focus on control and improvement of site processes with particular focus on CAP and Work Management. (SIBP/SIIP 4.4.20) 033108 Arizona Public Service Palo Verde Nuclear Generating Station

ATTACHMENT 1 A

1. Develop and implement a Management Review Meeting (MRM) process for Performance Indicators (PI) to include cross cutting reviews, deep dives, and an accountability process for improving performance. (SIBP/SIIP 8.4.1, 8.4.4, 8.4.5, 8.4.6, and 8.4.15)

Site efforts to internalize nuclear fundamentals have not been effective and have not improved 2. Create a site-wide awareness/focus on the plant and corresponding safety station performance. Shortcomings in nuclear aspects by setting the expectation to open initial daily meetings with fundamentals continue to exist, are tolerated by the discussions on plant status and correlating safety aspects. Operational Focus Indicator Palo Verde organization, and sometimes challenge (SIBP/SIIP 4.4.11)

Site Plant Performance Index (Annualized) long term safe and reliable operation. Site Clock Reset Indicator

3. Develop and implement a site-wide leadershiplmanagement model to establish standards of performance to be used as a basis for improving Consequential Human Error Rate Indicator individual behaviors and station performance. (SIBPISIIP 2.1.D.5) Site Chemistry Effectiveness Indicator

4. Develop and implement a site-wide accountability model. (SIBPISIIP 2.1.D.6) Forced Loss Rate Indicator Engineering Systems Health Report Total

5. Develop and implement a site-wide communication and meeting strategy to Color Progress Indicator address site alignment, operational focus, and site-wide penetration of  ;- Engineering Program Health Report Total messages. (SIBP/SIIP 7.1.B.1 and 7.1.B.5)

Leaders have not established, communicated, and Color Progress Indicator reinforced high standards and expectations for 6. Develop and implement leadership training to address key nuclear Condition Report Disposition Request performance and held individuals accountable to fundamentals and improve overall leadership training. (SIBP/SIIP 2.2.E.1.b (CRDR) Inventory Indicator those standards. Shortfalls in meeting and 2.4.A.8) Corrective Action Program (CAP) Quality expectations are sometimes not evaluated, Index understood and promptly addressed. 7. Develop and implement leader evaluations and a management succession plan to assure qualified and competent leadership for the long term. APSIPVNGS Industrial Safety Accident Rate (SIBP/SIIP 2.3.C.l.a and 2.4.B.4) (ISAR) Indicator Responsibility, accountability, and authority for ) Non-Utility Industrial Safety Accident Rate nuclear safety are not well defined, clearly 8. Improve the quality and assure the effectiveness of the employee (ISAR) Indicator understood, and effectively implemented. Some Performance Management Process. (SIBP/SIIP 2.3.A.3, 2.3.A.4, 2.3.A.8 and Quarterly reviews by a Management Review leaders are not leading advocates of nuclear safety 2.3.A.9)

Challenge Team.

and do not demonstrate their commitment both in

9. Implement a Safety Culture Team and a Recovery Team (Implementation (SIBP/SIIP 2.6.1 thru 2.6.8) word and deed. Individual behaviors that demonstrate nuclear safety principles are not and Monitoring Team) to assure continued focus on improving PVNGS 2008 Mid-cycle Assessment performance. (SIBP/SIIP 4.4.10 and 8.10.1) (SIBPISIIP 2.6.9) consistently applied to daily activities.

- 2008 Safety Culture Assessment

10. Institutionalize the use of a formal Change Management Process.

(SIBP/SIIP 6.10.1) (SIBPISIIP 4.4.8.b) 033108 Arizona Public Service Palo Verde Nuclear Generating Station

ATTACHMENT1 X-t-I. Revise and implement standards and expectations, including HU fundamentals. (SIBPISIIP 6.1.1 thru 6.1.3, 6.1.6, and 6.1.11)

Human Performance (HU) - Palo Verde has experienced an increase in human performance 2. Implement Observation Program, analyze data quarterly to errors over the last four years. Corrective actions determine areas for improvement, and identify corrective actions. IEffectiveness RiwvIews I Ustrics I have not addressed effectively the cross-cutting (SIBPISIIP 6.2.1.a, 6.5.2.a through 6.5.2.k) issues involving failing to implement standards and fundamentals, reinforcing behaviors, use of error- 3. Establish the advocate's role in trending process and provide prevention tools, and changing behaviors. These them training on how to analyze potential adverse trends. Site Clock Reset Indicator problems were identified across several (SIBP/SIIP 6.3.2) o Consequential Human Error Rate Indicator cornerstones and involved multiple groups within Quarterly reviews by Management the PV organization. Challenge Review Team

4. Developlimplement graded approach for HU tools for leaders and include in the Standards and Expectations Preventing Events (SIBP/SIIP 6.9.5 thru 6.9.12)

Handbook. (SIBP/SIIP 6.1.4.a) 2008 Mid-cycle Assessment (SIBPISIIP 2.6.9)

5. Complete human performance tools training utilizing HU Integrated Human Performance Self simulators and dynamic learning tools. (SIBP/SIIP 6.4.1) Assessment (SIBPISIIP 6.9.1)

6. Develop and implement training for coach-the-coach, including situations awareness, observations, and how to provide feedback Human Performance - The Palo Verde organization skills. (SIBPISIIP 6.2.4.b and 6.4.4.b) does not demonstrate ownership and leadership of the human performance culture. 7. Develop and implement the Accountability Model from the Organizational Effectiveness Root Cause. (SIBPISIIP 2.1.D.6)

In addition, a common cause analysis concluded that the leading causes of the department clock 8. Develop Integrated Issues Identification Team (lilT) to be used in reset issues were worker behaviors, organizational conjunction with coach-the-coach program. lilT should include factors, and job site conditions. cross-functional members, a charter, observation training, field time (physical walk downs), identification of issues. (SIBP/SIIP 6.2.10)

9. Inventory existing mock-up's and develop a strategy to use mock-ups for human performance training focused on behaviors in the field. (SIBPISIIP 6.2.11) Palo Verde Nuclear Generating Station 033108 Arizona Public Service

ATTACHMENT 1 AcUan Plan ShvbW

1. Evaluate and determine the staffing, structure, roles, responsibilities and qualifications of the Palo Verde Safety Department, including establishment of rotational safety Industrial Safety (IS) - The station has exhibited IEffecOvwwss Reviews I Metrics, I department personnel positions. (SIBPISIIP 4.2.3) I I poor implementation practices and weakness in correcting deficient conditions in the area of Industrial Safety that resulted in unacceptable

2. Develop and implement an Industrial Safety observation program Industrial Safety performance consisting of a core group of individuals for the purpose of providing a catalyst for Industrial Safety culture change. APS/PVNGS Industrial Safety Accident (SIBPISIIP 4.2.20) Rate (ISAR) Indicator Non-Utility Industrial Safety Accident Rate

3. Develop and provide formal behavioral based safety observation (ISAR) Indicator techniques training for the PV Leadership Team (SIBPISIIP 4.2.21)

• Industrial Safety Work Orders and Average Age Indicator

4. Develop and put into practice a reporting mechanism that is Quarterly reviews by Management capable of capturing the various industrial safety-related items in Challenge Review Team SWMS and establish performance indicator(s). (SIBPISIIP 4.2.22) (SIBP/SIIP 4.5.1 thru 4.5.8)

- 2008 Mid-cycle Assessment

5. Develop and implement a Palo Verde accountability and (SIBP/SIIP 2.6.9)

Industrial Safety has not been a high priority for all leadershiplmanagement model from the Organizational Station personnel due to lack of organizational Effectiveness Root Cause. (SIBPISIIP 2.1.D.5 and 2.1.D.6) alignment and accountability.

033108 Arizona Public Service Palo Verde Nuclear Generating Station

ATTACHMENT 1

1. Develop and implement the Leadership/Management Model and the Accountability Model to reinforce site standards and expectations.

(SIBP/SIIP 2.1.0.5, 2.1.D.6, and 4.4.14)

2. Develop and implement a Management Review Meeting (MRM) process for Performance Indicators (PI) to include cross cutting reviews, deep dives, and an accountability process for improving performance. (SIBPISIIP 8.4.1 and 8.4.4)

Results of independent safety culture surveys, interviews and assessment determined that Palo 3. Create a site-wide awareness of safety culture by setting the expectation to open Verde has several areas for improvement regarding initial daily meetings with discussions on plant status and corresponding safety culture. Performance in this area has nuclear, radiological, industrial, and cultural safety aspects. (SIBPISIIP 4.4.11) declined since a similar survey effort and action

4. Establish a Safety Culture Team to better focus the site on safety culture and plan was implemented in 2005. > Operational Focus Index implement a more formal process for periodic evaluation of PVNGS Safety Culture and SCWE. (SLIP 4.4.16 and 4.4.10) Corrective Action Program (CAP) Quality Index

5. Develop and implement a site-wide communication and meeting strategy to Condition Report Disposition Request address site alignment, operational focus, site-wide penetration of messages and to communicate Corrective Action Program (CAP) and Work Management (CRDR) Evaluation Age Indicator

> Operability Determination Quality Indicator I

(WM) improvements. (SIBPISIIP 7.1.B.1, 7.1.8.5, and 7.1.C.7)

> Online Schedule Adherence Indicator

6. Educate employees on behaviors which support a strong Safety Culture via small group meetings. (SIBP/SlIP 4.4.4)

Interim effectiveness reviews of Priority Groups

7. Develop and implement leadership training on nuclear fundamentals, including: 2008 Safety Culture Assessment (SIBPISIIP Nuclear Safety, Safety Culture, SCWE, Operations Focus, and CAP. Establish 4.4.8.b) and implement competencies (including Nuclear Safety, Safety Culture, and Drivers resulting from Safety Culture streaming SCWE behaviors) for key positions and implement a formal Management analysis include: Succession Plan. (SIBP/SIIP 2.3.C.l.a, 2.4.A.8, 2.4.B.4, and 4.4.17)

Individual Accountability and Ownership

- Clarity and Communication of Overall 8. Implement specific action plans, including targeted staffing strategies, for each Safety Culture priority group and follow up with other site groups to assure they Priorities and Strategy address safety culture weaknesses in their areas. (SBP/SIIP 2.2.B.1 through Quality of Leadership and Management 2.2.B.5, 2.2.B.8, 4.4.35, 4.4.36, and 20.2 through 20.14)

Receptivity to Employee Input

9. Establish a formal process for use of a change management tool and

>- Change Management communicate to site personnel the requirements for use of the tool. (SIBP/SIIP Site Programs and Processes 4.4.18, 6.10.1, and 6.10.5)

10. Perform evaluation of weaknesses and complexity in site processes, procedures, programs, and work instructions, and establish an organizational structure to focus on control and improvement of site processes with particular focus on CAP and Work Management. (SIBP/SIIP 4.4.19,4.4.20, and 4.4.32) 033108 Arizona Public Service Palo Verde Nuclear Generating Station

ATTACHMENT 1 Actilort Plan Sbatew NOTE: These actions are to address the training program issues.

The line and training organizations have not Specific knowledge deficiencies are addressed in their respective SlIP sufficiently engaged each other to improve the Action Plans.

station's performance and fundamental knowledge E Covens" Revi"s / metrics.

deficiencies. Additionally, a learning organizational 1. Train line managers associated with accredited programs on the culture has not been embraced. importance and value of using training as a strategic tool for improving performance. (SIBP/SIIP 5.3.A.6) Emergency Response Organization (ERO)

Drill/Exercise Performance (NRC Indicator)

2. Senior management established knowledge and training as one of Emergency Response Organization (ERO) five permanent building blocks within the site integrated Drill/Exercise Performance (PVNGS Site improvement plan. (SIBPISIIP 7.1 .B.1 0)

Indicator)

Training was not recognized or valued as a key

3. Establish guidance for and training on analysis of performance Corrective Action Program (CAP) Quality strategic tool for performance improvement.

data such as field observations, corrective actions, human Index performance clock resets and line performance indicators for Site Clock Reset Indicator Training management did not have the organizational presence to effectively reinforce possible training solutions. (SIBPISIIP 5.3.A.7 and 5.3.A.8) Consequential Human Error Rate Indicator station training culture. Quarterly Reviews by a Management Review

4. Provide Nuclear Training Department instructors and leaders Challenge Team The tools and guidance for gathering and analyzing continuing training on methods to determine and develop specific (SIBPISIIP 5.3.D.7 thru 5.3.D.14) plant performance data were insufficient to metrics and problem statements. (SIBPISIIP 5.3.C.7) 2008 Mid-cycle Assessment determine performance gaps and identify (SIBPISIIP 2.6.9) appropriate training solutions. 5. Enhance the existing guidelines on self assessment to establish a more comprehensive template for conducting accredited training Station management did not value self program self assessments. (SIBPISIIP 5.3.D.2 and 5.3.D.6) assessments as a tool to improve performance.

6. Operations to establish individual Shift Manager biennial Nuclear Training staff lacked knowledge andlor professional development plans for each shift manager using the skill to develop specific training intervention ACAD 97-004 as a guide. (SIBPISIIP 5.3.A.14) problem statements and metrics.

7. Implement orientation to key training oversight committee The site wide policy for performing self assessment members on their roles and responsibilities. (SIBPISIIP 5.3.C.10) is not an effective tool for identifying the site strategy or requirement for self assessments including comprehensive self assessments.

033108 Arizona Public Service Palo Verde Nuclear Generating Station

ATTACHMENT1 A

Acffon Plan Strafty Unit 3 emergency diesel generator (DG) "A" KI contactor latched

1. Straightened metal actuator arm in the Unit 3 Diesel Generator (DG) =pp closed during the September 4, 2006 shutdown, however, the normally open direct current (DC) coil switch contact did not close (A) K1 relay to restore sufficient contact compression. Inspected as expected. This caused DG A to be incapable of performing its and straightened 5 other DG's K-1 relay actuator arms as design function. The condition was not identified until September necessary. (SIBP/SIIP 3.6.49) IEffectiveness R&vW#m / Metrics I 22, 2006; therefore, DG 3A had been out of service for 18 days. This contactor had only been in service since July 26, 2006, having replaced a contactor that had failed with the same symptoms. 2. Updated vendor tech manual and Model Work Scope Library (WSL) 05000530/2006-12-01: 10 CFR Part 50, Appendix B, Criterion V, revised to ensure proper contactor set-up and DC coil switch "Instructions, Procedures, and Drawings," for the failure to Effectiveness Review of Corrective establish appropriate instructions for performing corrective cleaning instructions are provided. Actions to Prevent Recurrence (CAPRs) maintenance activities on an emergency diesel generator K-I (SIBP/SIIP 3.6.5, 3.6.47 and 3.6.48) (SIBPISIIP 3.6.79) relay.

,. 0500053012006-12-02: 10 CFR Part 50, Appendix B, Criterion XVI,

3. Reviewed Preventive Maintenance (PM) templates for the Diesel "Corrective Actions," for the failure to identify and correct the cause of erratic emergency diesel generator K-I relay operation Generator (DG) System to ensure that identified single point prior to Installation of the relay on July 26, 2006 vulnerabilities are effectively managed.

(SIBP/SIIP 3.6.57)

4. Reviewed similar relays in other safety related systems for extent of cause. (SIBPISIIP 3.6.59 through 3.6.65)

(Failure Mechanism): Insufficient contact compression introduced by stack-up of tolerances and a bent metal actuator arm permitted Inconsistent electrical operation of the DC coil switch, normally open 5. Implement 01DP-9ZZ01, Systematic Troubleshooting, as the Palo contact of the KI contactor. Verde troubleshooting and problem solving process and provide The Ki contactor was treated as a single reliable replaceable training to selected Operations, Maintenance, and Engineering component; therefore, subcomponents of the Ki contactor personnel. (SIBPISIIP 3.6.55, 3.6.72 and 11.8.21) mechanics were not fully understood. This lack of understanding, produced Ineffective preventive maintenance (PM) tasks for the emergency diesel generator field flash and de-excitation circuit.

6. Develop and provide training to ERCFA qualified personnel on failure modes considerations, use of OE, and accountability to Inadequate management expectation for use of a systematic assure quality investigations. (SIBPISIIP 3.6.7) problem solving methodology: (1) no clear site-wide expectation of a common process to be used when equipment fails; (2) the requirement to consider all possible failure modes and document 7. Replace the K1 relays in the EDG control cabinets XJDGA(B)B02 refuting evidence is not sufficiently clear in ERCFA procedure 70DP- for all six onsite Class 1 E EDGs. Implement mod in all three units.

0EE01; (3)troubleshooting game plans do not require multiple failure mode strategy and they tend to direct the action toward pre-(SIBPISIIP 3.6.11) determined probable causes; and (4) the correct failure modes were not identified In recent equipment problem solving efforts, such as the KI relay.

033108 Arizona Public Service Palo Verde Nuclear Generating Station

ATTACHMENT 1 SlIP Action Plan - 15 RAS Event Executive Sponsor: John Hesser SlIP Action Plan contains actions, metrics, and effectiveness A lack of some specific provisions in the design ws to address each of the 10 Focus Areas associated with the I Effoeftem" R"Iew and licensing bases, ineffective questioning event, including Focus Area Plans for:

attitude and technical rigor in reviewing design NoMeasures and metrics for monitoring performance documents and inadequate communications of s Area 1 - Procedures Did Not Contain Necessary Requirements improvement in each Focus Area are identified in each design and licensing information to the s Area 2 - Lack of Specific Provisions in the Licensing and Focus Area Plan.

appropriate groups resulted in a failure to fill Design Basis and maintain full ECCS suction lines from the s Area 3 - Part 1 - Lack of Questioning Attitude and Technical Recirculation Actuation Sump. Rigor of Individuals

- Part 2 - Lack of Questioning Attitude and Technical Rigor of Individuals - Operability Determinations s Area 4 - Inadequate Communication of Design Information s Area 5 - Inadequate Problem Identification and Resolution U~ s Area 6 - Limited or Weak Operating Experience Program s Area 7 - Limited Experience and Training s Area 8 - Limited Resources s Area 9 - Limited Nuclear Assurance Department Oversight Lack of Specific Provisions in the Design and s Area 10 - Limited Procedural Guidance (DBM Writer's Guide)

Licensing Basis. The design and licensing basis documents did not contain explicit e Focus Area Plans are presented on the following pages.

statements requiring the ECCS suction lines to be filled. The reasons for not explicitly stating these requirements was not positively ascertained.

Ineffective Questioning Attitude and Technical Rigor of individuals. Some PVNGS personnel had a narrow focus and an incorrect mindset (i.e., incorrect belief in self-venting theory) in reviewing information provided in various design documents that indicated the need to keep the ECCS suction line filled. There was a general ineffective use of a QV&V process.

Inadequate Communication of Design Information. The need to keep the ECCS suction lines filled was identified but not appropriately communicated. Follow-through for ensuring start-up procedures contained provisions for filling and venting the system was inadequate.

3/31/08 Arizona Public Service Palo Verde Nuclear Generating Station

ATTACHMENT 1 SlIP Action Plan 15 - RAS Focus Area I Procedures Did Not Contain Necessary Requirements I Acflon Plan StrateW I evised procedure "Recovery from Shutdown Cooling to Normal The design intent that the suction line be filled rating Lineup," 40OP-9SI02, to fill the RAS penetrations with borated Effectiven"s Reviews/Metflc*

with water was not translated into start-up r by keeping the sump full. (Completed during the investigation) procedures, surveillance procedures, and Io Perform a Focus Area Owner review of corrective action operating procedures. [As a consequence, the odifications have been completed to assure that vent and drain effectiveness in this Focus Area. (SIBP/SIIP 3.7.2.a) suction line was not kept full of water] ement supports keeping the line filled. (SIBP/SIIP 3.7.3.p and 3.d) eveloped test instruction "Containment Recirculation Sump Isolation e Leak Testing," 73TI-9ZZ21, to leak-test the inboard RAS etration CIV using air prior to filling with borated water. Incorporated irement to perform this leak test into procedure "Recovery from down Cooling to Normal Operating Lineup," 40OP-9SI02.

P/SlIP 3.7.2.e) evised surveillance test procedure "RAS Line Fill Check," 40ST-4 to verify the RAS penetrations are full of water on a monthly basis i M. the vent and drain modifications are completed. (SIBP/SIIP 3.7.2.b 3.7.2.c)

Direct Cause 1 - The design intent that the evised surveillance test procedure 40ST-9SI04 to include time suction line be filled with water was not ria for evaluating the amount of air escaping the vent valve and translated into start-up procedures, surveillance dering the venting steps to eliminate one possible path for drawing procedures, and operating procedures. ito the piping on the vent. (SIBP/SIIP 3.7.2.g) omplete Engineering Study 13-MS-A102 to determine venting tion and tolerable void size criteria for surveillance test procedure T-9SI04 that will ensure no adverse impact to pump operation.

P/SIIP 3.7.2.j) evise surveillance test procedure 40ST-9SI04 to align the edure acceptance criteria and contingency actions with the Its of Engineering Study 13-MS-A102. Also revise the procedure stimating void size. (SIBP/SIIP 3.7.2.k) 3/31/08 Arizona Public Service Palo Verde Nuclear Generating Station

ATTACHMENT 1 SlIP Action Plan 15 - RAS Focus Area 2 Lack of Specific Provisions in the Licensing and Design Basis Action Plan Stra A the original condition:

Licensing and Design Basis Information was afety Injection (SI) Design Basis Manual (DBM) has been incomplete and inaccurate, particularly with to document the requirement to fill ECCS suction lines Architect Engineer (AE) to NSSS provider interface ted during the investigation) ad UFSAR Section 6.3.2.6 to add a new paragraph to indicate l Quality of the Resolution of CDBR Related Actions documentation.

Indicator Ito have the ECCS lines (including the suction lines) filled to

• CDBR Project Schedule Adherence Indicator roper operation of the CS and HPSI pumps. Evaluations have DoPerform Focus Area Owner reviews of the CDBR rformed to determine the need for revisions to other affected project. (SIBP/SIIP 3.7.3.aa and 3.7.3.bb) of the UFSAR and other affected licensing documents.

lo An end of project effectiveness review for the CDBR IP 3.7.3.k and 3.7.3.1)

Project is planned. (SIBP/SIIP 3.7.5.d/11.6.12) echnical Requirements Manual has been revised to include a ient to periodically verify that the ECCS sump suction lines are BP/SIIP 3.7.3.m and 3.7.3.1)

RAS specific design and licensing requirements were changed to XCS suction line fill requirements clear, modifications have been ed to assure that vent and drain placement supports keeping the

_ line filled I. (SIBP/SIIP 3.7.3.p and 3.7.3.d) fy and resolve limitations of Design Basis Manuals:

unicated to engineering personnel regarding DBM limitations Action) (SIBP/SIIP 3.7.3.q)

Root Cause 1 - The design and licensing basis

• d initial Engineering Tech Staff training to address limitations documents did not contain explicit statements (SIBP/SIIP 3.7.3.o, 3.7.5.gg and 3.7.8.j) requiring the ECCS suction lines to be filled. The ote on DBM cover page on limitations of DBMs and direction to reasons for not explicitly stating these source documents (SIBP/SIIP 3.7.3.h and 3.7.11.a) requirements was not positively ascertained.

e the DBM Writer's Guide to provide guidance on addressing requirements and Operating Experience reviews.

Root Cause 4 - Personnel missed opportunities to IP 3.7.3.w) identify the unanalyzed condition involving the fy and resolve latent design and licensing basis issues:

unfilled suction lines because the design basis ete Component Design Bases Review (CDBR) for high risk documents did not contain an explicit statement ents (SIBP/SIIP 11.6.1.a, 11.6.1.b, 11.6.1.c and 11.6.13) that required the lines to be filled.

DBMs based upon CDBR results.

P 3.7.3.x and 3.7.3.y)

Contributing Cause 1 - The design of the ECCS suction lines at PVNGS was different than the addition to actions shown, Focus Area 4 contains actions for design at other CE plants, but the PVNGS design condition reviews related to pre-startup Independent Design did not account for the significance of those These reviews were performed to assure that the results of differences.

pendent Design Reviews were incorporated into design and Contributing Cause 7 - By design, the "100% documents and plant procedures.

validation" of the DBMs was comprehensive and focused on validation of the information in the DBMs but was not 100%.

3/31/08 Arizona Public Service Palo Verde Nuclear Generating Station

ATTACHMENT 1 SlIP Action Plan 15 - RAS Focus Area 3 - Part 1 Lack of Questioning Attitude and Technical Rigor of Individuals I Action Plan ftategy Cý

1. Defined and established site standards for questioning attitude and Ineffective use of error prevention tools and technical rigor and incorporated in Revision 3 of the Site Standards and -Efftcflven"s Iteview-a/Me management oversight is illustrated by errors Expectations document. (SIBP/SIIP 6.1.7, 6.1.8 and 3.7.4.gg) related to technical rigor, questioning attitude, lo Engineering Work Product Quality Indicator and decision making tools. 2. Implement training on questioning attitude and technical rigor, NoPerform Focus Area Owner reviews of corrective action including a systematic approach to decision making and add to effectiveness in this Focus Area. (SIBP/SIIP 3.7.4.u and employee indoctrination training program. (SIBP/SIIP 6.4.6 and 6.4.7) 3.7.4.v)

3. Established the Engineering Department Guidelines which include human performance tools relating to questioning attitude and technical rigor. (SIBP/SIIP 3.7.5.mm)

4. Develop and implement training on the Engineering Department Guidelines. (SIBP/SIIP 1.2.E.19)

5. Established formal Engineering Principles and Expectations including expectations for technical rigor, verification of assumptions, and alertness to situations that could impact compliance with design and licensing basis. (SIBP/SIIP 11.1.1)

Root Cause 2 - Some PVNGS personnel had a 6. Provided classroom training on Engineering Principles and narrow focus and an incorrect mindset (i.e., Expectations. (SIBP/SIIP 11.1.2) incorrect belief in self-venting theory) in reviewing information provided in various design 7. Incorporate Engineering Department Guidelines and Principles and documents that indicated the need to keep the Expectations into the Conduct of Engineering procedure. (SIBP/SIIP ECCS suction lines filled. There was a general 11.8.30) ineffective use of a QV&V process.

8. Implement an engineering leader observation and observation Root Cause 5 - Some PVNGS personnel had a analysis and trending program. (SIBP/SIIP 11.4.1) narrow focus and an incorrect mindset (i.e.,

incorrect belief in self-venting theory) in 9. Implement an Engineering Product Quality Review Board including reviewing various documents and information grading, feedback and metrics. (SIBP/SIIP 11.4.17) related to the ECCS suction lines. There was general ineffective use of a QV&V process. 10. Implemented the plant walkdown procedure and provided training on the procedure and use of questioning attitude during walkdowns.

Root Cause 8 - As a result of inadequate (SIBP/SIIP 3.7.4.1, 3.7.4.m, 3.7.4.n and 3.7.4.q) technical reviews, PVNGS personnel overlooked information regarding the need to fill 11. Strengthened the use of technical reviews of high tier Operating the ECCS suction lines or did not review Experience. (see also RAS Focus Area 6). (SIBP/SIIP 3.7.4.f) identified issues that could have led to identification of the unanalyzed condition involving the suction lines.

3/31/08 Arizona Public Service Palo Verde Nuclear Generating Station

ATTACHMENT 1 SlIP Action Plan 15 - RAS Focus Area 3 - Part 2 Lack of Questioning Attitude and Technical Rigor of Individuals - Operability Determinations I , ý , -AoMwi Pian Stra" E=

1. Interim actions:

Inadequate implementation of the operability - Assigned a dedicated advisor to drive rigor and consistency in Operability determination process has led to issues with Determinations (OD) (SIBP/SIIP 4.1.F.9) identification of issues requiring IODs/PODs - Instituted Plant Manager Daily Challenge Board review of Immediate OD Quality Indicator Operability Determinations (IOD) and Prompt Operability Determinations (POD) D Perform Focus Area Owner reviews of corrective action and the quality of IODs/IPODs.

(SIBP/SIIP 4.1 .F.22) effectiveness in this Focus Area. (SIBP/SIIP 3.7.4.y and

- Issued revised expectations for system engineering for monitoring and trending system performance. (SIBP/SIIP 1.2.F.1) 3.7.4.z)

2. Training and qualification of personnel on the OD and Functional Assessment process:

- Develop OD process lesson plan and incorporate into initial License Training that uses actual events for exercises (SIBP/SIIP 4.1.F.16)

- Provide OD training to Engineering FIN (E-FIN) and SROs/STAs on OD changes, the standard for technical rigor including critical thinking, and the use of design basis information in support of PODs (SIBP/SIIP 4.1 .F.21)

(CRDR 3130598 Common Cause Analysis) - Establish a formal qualification requirement and dedicated E-FIN for POD 1: Management and ownership of OD process is preparation (SIBP/SIIP 4.1.F.23 and 4.1.F.19) lacking across organizational boundaries, with no - All SROs/STAs will be trained in the IOD process. (SIBP/SIIP 4.1 .F.14) clear leadership for the process. In addition, at times, 3. Improved entry into the OD process:

entry into performance of ODs is being driven by the - OD procedure changed to require a documented Operability/Functionality NRC or other outside organization, instead of by Assessment for any PVAR on T.S. or T.S. support SSCs (SIBP/SIIP 4.1.F.10)

PVNGS. 4. Improvements in OD process:

2: Knowledge weakness exist across organizational - Revised OD procedure to support PVAR process (SIBP/SIIP 3.7.4.i) boundaries, including operations, engineering, -Added an IOD checklist to OD procedure to aid SROs (SIBP/SIIP 4.1.F.1 1) maintenance, chemistry, work control, and within the - Revised OD Procedure to have Operations make an initial extent of management team. This is demonstrated by a clear condition determination or coordinate with appropriate departments to obtain lack of understanding potential impacts to operability the information (SIBP/SIIP 4.1.F.12) with other systems and/or process and when to - Revised OD procedure to include the requirements for "Engineering implement the OD process. Technical Rigor" (SIBP/SIIP 4.1 .F.32) 3: OD program is incomplete to support the process. - Revised OD procedure to document any unverified assumptions and require It does not adequately incorporate questioning a corrective action to validate the assumptions. (SIBP/SIIP 4.1.F.18) attitude and QV&V behaviors. It does not require a 5. Improved OD metrics and OD review processes:

documented assessment of minor conditions adverse - Developed OD quality improvement plan & metrics (SIBP/SIIP 4.1.F.30) to quality related to TS or TS support SSCs. Links to - Established updated metrics for OD performance. (SIBP/SIIP 4.1.F.27)

CAP to ensure extent of condition is determined did 6. Improve site's sensitivity to Nuclear Safety and Operability through Spray not exist and were sometimes missed. Pond training, OD training, trending improvements, and daily plant status and 4: Metrics, indicators, and the trending programs are [safety meetings. (SIBP/SIIP 11.8.22, 4.4.1, 4.4.11, and 1.2.F.4) inadequate to properly identify potential operability [7. Review PODs approved prior to April 1, 2008 and currently in effect, and impacts issues in a timely manner. Furthermore, due !initiate necessary corrective actions to bring those determinations into to lack of management oversight and ownership, compliance with current standards. (SIBP/SIIP 4.1.F.33) indicators are not being used to drive and identify performance improvement opportunities.

3/31/08 Arizona Public Service Palo Verde Nuclear Generating Station

ATTACHMENT 1 A

SlIP Action Plan 15 - RAS Focus Area 4 Inadequate Communication of Design Information

1. Establish a process to formally provide technical information by the Inadequate internal and external engineering staff. This process will apply to key operation, maintenance communications resulted in incomplete and regulatory activities and shall not circumvent the Corrective Action technical information provided from engineering Program (e.g., CRDRs, DFWOs). The process will contain appropriate Po Operability Determination Quality Indicator or vendors to functional groups. engineering review and approval requirements based on type of request.

op Engineering Work Product Quality Indicator (SIBP/SIIP 3.7.5.hh and 11.4.15) li Perform Focus Area Owner reviews of corrective action

2. Expectations regarding communication of technical information were effectiveness in this Focus Area. (SIBP/SIIP 3.7.5.c and communicated to personnel through guidelines, expectations 3.7.5.jj) documents, and briefings:

- A RAS event case study was developed and provided to engineering, operations, nuclear assurance, and regulatory affairs personnel regarding the need for proper communication of information. Use of this case study has been embedded into pre-job briefs for self-assessments, significant investigations, and high-tier operating experience reviews.

(SIBP/SIIP 3.7.5.dd and 3.7.7.b).

- Human performance tools, including tools to ensure strong communication of technical information, were included in new Engineering Department Guidelines and the Conduct of Engineering procedure. (SIBP/SIIP 3.7.5.mm and 11.8.30)

Root Cause 3 - The need to keep the ECCS

3. Established additional procedural guidance for addressing suction lines filled was identified but not vendor correspondence to assure that appropriate, cognizant appropriately communicated. Follow-through personnel determine distribution of this correspondence.

for ensuring start-up procedures contained (SIBP/SIIP 3.7.5.kk) provisions for filling and venting the system was

4. Reviewed the nine Independent Design Reviews (IDRs) performed inadequate.

prior to plant startup to ensure that design intent has been incorporated into the design and licensing bases. (SIBP/SIIP 3.7.5.e, Root Cause 6 - The need to keep the ECCS 3.7.5.f, 3.7.5.g, 3.7.5.i, 3.7.5.1, 3.7.5.v, 3.7.5.p, 3.7.5.q, 3.7.5.u, 3.7.5.r, suction lines filled was identified but not 3.7.5.s, 3.7.5.t, 3.7.5.nn, 3.7.5.a, 3.7.3.a, 3.7.5.m, 3.7.5.n, 3.7.5.o and appropriately communicated.

3.7.5.00)

5. Strengthen the engineering to operations interface by providing the Operability Determinations Discovery Evaluation Checklist to assist in identifying degraded/nonconforming conditions requiring immediate control room contact. (SIBP/SIIP 3.7.5.k)

6. Develop and conduct training of engineering (non-administrative) personnel on the station vendor documentation procedure.

(SIBP/SIIP 3.7.5.11)

NOTE: Other actions to identify potential, latent issues resulting from inadequate communication of design information are described in Focus Area 2 (i.e., CDBR).

3/31/08 Arizona Public Service Palo Verde Nuclear Generating Station

ATTACHMENT 1 A

SlIP Action Plan 15 - RAS Focus Area 5 Inadequate Problem Identification and Resolution nd: Some of the failures to document the voided suction pipe Inadequate implementation of the Corrective urred in the late 1980s and early 1990s. Between that time and I EffecOveness RevlewsNetri Action Program (CAP) resulted in inconsistent he issue was again identified in 2004, two changes were made problem identification, narrowly focused that issues are reviewed under the Corrective Action Program 0- CAP Quality Index Indicator evaluations, and ineffective and untimely issue ) In 1994, 90AC-01P04, "Condition Reporting," was issued, 0- Perform a Focus Area Owner review of corrective action resolution. 'anded the use of Condition Reports/Disposition Requests effectiveness in this Focus Area. (SIBP/SIIP 3.7.6.d) to include requests for technical clarifications and evaluations Note: Multiple processes/programs could be captured under the Engineering Evaluation Request (EER) used to document questions and provide and (b) In 1997, the Instruction Change Request (ICR) process guidance outside the CAP. Problem ntinued as a process for requesting information and instead identification and resolution has not always re generated and controlled through the Site Work been fully effective. ent System (SWMS).

n, in December 2006, the Palo Verde Action Request (PVAR) mented as a "single entry" form for documentation of any is change ensures that issues are not missed due to the use of

)rms/processes for documenting issues. Communications and ere provided to site personnel on use of the PVAR to U mt', issues.

al Actions:

ed PVNGS programs and processes to identify processes Root Cause 7 - Issues related to the e CAP that may be used for identification of items needing acceptability of the unfilled ECCS suction lines action. As necessary, revise processes to ensure that any were not documented on CRDRs due to unclear ding corrective action are addressed through the CAP.

procedural guidance. P 3.4.4.c) shed the Action Request Review Committee (ARRC) to review nd ensure that condition statements, risk assessments, and ons are appropriate. Established qualification requirements on NRC and INPO guidance for ARRC members.

P 3.2.1.d and 3.3.3.b) shed the Condition Review Group (CRG) to ensure on and buy-in of responsible management in the disposition and definition of corrective actions. (SIBP/SIIP 3.2.4) ed Corrective Action Review Board (CARB) review of root and cause evaluations under the CAP and provision for feedback B reviews to applicable leaders and trending of CARB review

)evelop and implement job familiarization requirements for mbers, including appropriate training on cause evaluation and (SIBP/SIIP 3.2.3, 3.2.5.f and 3.3.3.c) d additional and ongoing training and familiarization regarding process and CAP fundamentals to PVNGS personnel.

P 3.3.3.i and 3.3.3.j) 3/31/08 Arizona Public Service Palo Verde Nuclear Generating Station

ATTACHMENT 1 SlIP Action Plan 15 - RAS Focus Area 6 Limited or Weak Operating Experience Program I Action Plan Strategy ng experience (OE) usage has been/is being integrated into station PVNGS did not effectively use Operating ments, procedures, and expectations to ensure day-to-day usage: I Effeefiveness ReviewsNe Experience to enhance safety. sto be developed to add OE to work packages (SIBP/SIIP 6.7.11) ined RAS event case study and embedded in pre-job briefs for self-Io Timeliness of Operating Experience Screening Indicator nt, significant CRDR, and high-tier OE evaluations (SIBP/SIIP 3.7.3.j) 0o Quarterly reviews of OE by Management Review ed and institutionalized the OE books emphasizing OE use (SIBP/SIIP 16.1.15)

Challenge Team. (SIBP/SIIP 6.7.20 thru 6.7.27) of selected leaders on the use of OE in day-to-day activities, program roles and responsibilities. (SIBP/SIIP 3.7.7.p and 3.7.7.q) ersonnel on use of Operating Experience search tools:

pa database for the retrieval and knowledge management of experience and train target population on its use (SIBP/SIIP 6.7.10) and train operating experience points of contact in departments and Performance Improvement staff members on the use of external INPO IIBP/SIIP 6.7.5) gnificant and ACE CRDR evaluators on OE use and evaluation (SIBP/SIIP 6.7.8) ed a 95/95 sample of past high-tier OE to identify any potential

-*oeablt concerns that were not appropriately addressed. (SIBP/SIIP 3.7.7.i) ng Experience Process Improvements:

he process of reviewing high-tier OE to require independent d review, a checklist to assure broad analysis, roles and Root Cause 9 - The PVNGS Operating lities, and other process improvements 3.7.4.f, 3.7.7.c, 3.7.4.g, 3.7.7.f, 3.7.7.1, 3.7.7.o, 6.7.16 and 6.7.1)

Experience Program did not require reviews of ance Improvement Department will perform or coordinate review of all some types of operating experience reports

'E (SIBP/SIIP 3.7.7.d) related to the ECCS suction lines. and controls to be developed to assure procedure changes result of OE reviews cannot be eliminated without appropriate Contributing Cause 4 - The Operating BP/SIIP 6.7.6)

Experience Program had little guidance ed and implemented improved metrics for station OE Program.

applicable to the review of the IOE reports 6.7.7) related to the ECCS suction lines and gave low active SOERs for adequate disposition and sustainability of actions.

priority to the reviews, resulting in a narrow 6.7.17) focus to the reviews and a lack of review by the selected Engineering, Operations, Regulatory Affairs and Nuclear personnel on RAS event and importance of fully addressing Nuclear Assurance Department.

E. (SIBP/SIIP 3.7.5.dd) d Nuclear Regulatory Affairs Procedure technical rigor requirements ng NRC documents. (SIBP/SIIP 3.7.4.h and 3.7.7.k) d past OE Digests (previously titled Tracking Trends) and Topical r adequate evaluation. (SIBP/SIIP 3.7.7.g) 3/31/08 Arizona Public Service Palo Verde Nuclear Generating Station

ATTACHMENT 1 SlIP Action Plan 15 - RAS Focus Area 7 Limited Experience and Training F--

1. For System Engineers, developed a design and licensing bases Gaps in engineering technical knowledge knowledge assessment and turnover process for assigned systems. F-Eff ectivenimm RwAw**ftAeWCS___]

assessment, design basis, and SSC knowledge Completed incumbent analysis of system engineers per the system contributed to incorrect technical decisions and engineering handbook work authorization checklist and identified gaps in

• Engineering Product Quality Indicator errors in design information. knowledge. (SIBP/SIIP 3.7.8.h and 3.7.8.1) D Operability Determination Quality Indicator 0 Perform Focus Area Owner reviews of corrective action

2. Perform remediation of system engineering derived from incumbent effectiveness in this Focus Area. (SIBP/SIIP 3.7.8.aa and analysis gaps. (SIBP/SIIP 3.7.8.i and 3.7.8.b) 3.7.8.bb)

3. Developed and implemented a procedure to identify design and licensing basis knowledge gaps among incumbent engineering personnel. (SIBP/SIIP 3.7.8.m, 3.7.8.n and 3.7.8.0)

4. For Design and Component engineers, perform incumbent analyses to identify training and knowledge weaknesses. (SIBP/SIIP 11.8.8 and 11.8.7)

5. Perform remediation for design and component engineering derived from incumbent analysis gaps. (SIBP/SIIP 3.7.8.v, 3.7.8.c and 3.7.8.d)

Contributing Cause 2 - PVNGS personnel with 6. Develop and implement Computer Based Training for methods and responsibility for start-up did not have adequate critical aspects of understanding of the design and licensing bases of system design or licensing basis training or interfacing systems. (SIBP/SIIP 3.7.8.u, 3.7.8.w, 3.7.8.x and 3.7.8.y) experience to be able to detect the need for filling of the suction lines. 7. Develop and implement improved initial training for engineering personnel on design and licensing basis. (SIBP/SIIP 11.8.4)

Contributing Cause 5 - PVNGS personnel with responsibility for the SI System had limited training and experience to be able to detect the need for filling the suction lines.

3/31/08 Arizona Public Service Palo Verde Nuclear Generating Station

ATTACHMENT 1 SlIP Action Plan 15 - RAS Focus Area 8 Limited Resources

1. Engineering defined the roles and responsibilities of each engineering High workloads and conflicting priorities group to improve focus of activities. (SIBP/SIIP 3.7.9.h) I Effecoveness Revhmrs/Metrics I contributed to engineers not raising issues beyond what they were specifically assigned. 2. Engineering developed a long range staffing plan that included 1 Engineering CRDR/CRAI Backlog Indicator analysis of retirement projections and yearly analysis for hiring through D Perform a Focus Area Owner review of corrective action the Legacy Program. (SIBP/SIIP 3.7.9.i) effectiveness in this Focus Area. (SIBP/SIIP 3.7.9.j and 3.7.9.k)

3. Issued for use initial baseload work schedules for Design, Systems, and Component Engineering Departments. (SIBP/SIIP 11.9.A.8)

4. Establish and conduct periodic Engineering work management meetings, between Engineering Leaders and their staffs, to review work prioritization, resource allocation, and schedule dates for assigned work activities. (SIBP/SIIP 11.9.A.9)

Contributing Cause 3 - During start-up, the Safety Injection engineers were under a high workload and had multiple tasks to perform, which deterred them from raising questions on issues not directly related to resolving the specific issues assigned to them.

Contributing Cause 6 - System engineers have been under a high workload and had multiple tasks to perform, which deterred them from raising questions on issues not directly related to resolving the specific issues assigned to him.

Reviews of IOE reports are generally narrowly focused and limited to addressing the specific issue raised in the report.

3/31/08 Arizona Public Service Palo Verde Nuclear Generating Station

ATTACHMENT 1 SlIP Action Plan 15 - RAS Focus Area 9 Limited Nuclear Assurance Department Oversight I Action Plan Stratea iting procedure, 60DP-OQQ19, was revised to include the NAD Oversight activities were not effective in ensure that pertinent technical specifications and design EffedlVen"s Reviows helping the station identify and respond to on issues are reviewed during audits:

problems. that audit scopes include provisions for an in-depth review of Po Using the NIEP assessment, determine the d Technical Specifications, as appropriate to the area effectiveness of the Nuclear Assurance Department in ed, and that audit teams include personnel (auditors or helping the station identify and respond to safety significant pecialists) with the appropriate engineering or operational problems. This review will include a review of findings in SIBP/SIIP 3.7.10.a) the Escalation, Audit, and Evaluation process areas.

that the underlying issues surrounding the RAS event are (SIBP/SIIP 8.5.13) n audit pre-job briefings (SIBP/SIIP 3.7.10.b)

• d checklists for use in evaluating the adequacy of technical SIBP/SIIP 3.7.10.c) ed and implemented a process to ensure that NAD

• are based upon a broad set of inputs, including: plant haracteristics, NRC issuances, industry advisories, Licensee orts, and other sources of plant design and operating Wxerec information, including plants of similar design, which may eas for improving plant safety. (SIBP/SIIP 3.7.10.g and 3.7.10.i Contributing Cause 9 - NAD has not had a ed a detailed stand-down with all Lead Auditors to discuss systematic approach for assessing safety ce expectations for the conduct of audits and the significant or high risk technical specification or t reporting of results. (Interim Actions) design configuration issues. 3.7.1O.d and 3.7.1O.f) 3/31/08 Arizona Public Service Palo Verde Nuclear Generating Station

ATTACHMENT 1 SlIP Action Plan 15 - RAS Focus Area 10 Limited Procedural Guidance (DBM Writer's Guide)

Ilc~nPa bae

1. Identify and resolve limitations of Design Basis Manuals (DBM):

Design and Licensing bases project guides did - Communicated to engineering personnel regarding DBM limitations _Eftmyveness Reviews/Metrics not contain necessary requirements/ guidance (Interim Action) (SIBP/SIIP 3.7.3.q, 3.7.8.k, 3.7.11 .b) on application of source document control. - Revised initial Engineering Tech Staff training to address limitations

• Quality of the Resolution of CDBR Related Actions of DBMs (SIBP/SIIP 3.7.3.o, 3.7.5.gg, 3.7.8.j) Indicator

- Add note on DBM cover page on limitations of DBMs and direction

• CDBR Project Schedule Adherence Indicator to refer to source documents (SIBP/SIIP 3.7.3.h, 3.7.11 .a) N Perform Focus Area Owner reviews of the CDBR

- Update the DBM Writer's Guide to provide guidance on addressing project. (SIBP/SIIP 3.7.11 .c and 3.7.11 .d) interface requirements and Operating Experience reviews. (SIBP/SIIP 3.7.3.w)

2. Revised the design and technical document control procedure to require personnel changing, or adding a reference to a DBM to thoroughly review the reference document. (SIBP/SIIP 11.6.11)

3. Conducted additional reviews of UFSAR to review effectiveness of CESSAR information incorporation project. (SIBP/SIIP 3.7.11 .e)

4. Identify and resolve latent design and licensing basis issues:

- Complete Component Design Bases Review for High Risk Contributing Cause 8 - The DBM Writer's Guide components (SIBP/SIIP 11.6.1 .b, 11.6.1 .a, 11.6.1 .c and 11.6.13).

(Procedure 83DP-4CC02) lacked detailed - Revise DBMs based upon results. (SIBP/SIIP 3.7.3.x and 3.7.3.y) guidance on how to review source documents Note: In addition to actions shown, Focus Area 4 contains actions for during preparation of the DBMs (e.g., there was no requirement to review the entire source extent of condition reviews related to pre-startup Independent Design Reviews. These reviews were to assure that the Independent Design documents).

Reviews were incorporated into design and licensing documents and plant procedures.

3/31/08 Arizona Public Service Palo Verde Nuclear Generating Station

Attachment 2 Key Performance Area 1 Recirculation Actuation Signal (RAS) Actions Listing of Specific Tasks and Due Dates

Attachment 2 Key Performance Area 1 Recirculation Actuation Signal (RAS) Actions Listing of Specific Tasks and Due Dates To address root and contributing causes identified in your evaluations in response to the Yellow finding associated with the voided containment sump suction piping for all three units. PVNGS will implement the following:

SlIP Action Plan 15, "RAS [Recirculation Actuation Signal] Event," Focus Areas I through 10 The following RAS Focus Area Task Lists present the specific tasks and due dates for the Strategies in each Focus Area Plan. The Task Lists also present additional tasks within each Focus Area that are not associated with a specific Strategy. These additional tasks are listed as "Other Focus Area Tasks" at the end of each Task List.

Focus Area 1 - Procedures Did Not Contain Necessary Requirements o Strategy 1 - Revised procedure "Recovery from Shutdown Cooling to Normal Operating Lineup," 40OP-9SI02, to fill the RAS penetrations with borated water by keeping the sump full.

• The above action was completed during the investigation.

o Strategy 2 - Modifications have been completed to assure that vent and drain placement supports keeping the line filled. (SIBP/SIIP 3.7.3.p and 3.7.3.d)

" Implement Design Modification Work Order (DMWO) #,2760330 to implement the ECCS Suction Piping Modification in Unit 1. This installation of this modification will add additional venting, draining and filling connections on the sections of SI piping between the inboard and outboard containment isolation butterfly valves. It will also replace the existing carbon steel parts on the inboard butterfly valves JSIAUVO673 and JSIBUVO675 with stainless steel parts. [Action to add additional venting, draining and filling connections is complete. The remaining action is not being relied upon for resolution of the pipe void issue.]

(3.7.3.p) Due: Complete

" Implement Design Modification Work Order (DMWO) # 2760330 to implement the ECCS Suction Piping Modification in Unit 2.This installation of this modification will add additional venting, draining and filling connections on the sections of SI piping between the inboard and outboard containment isolation butterfly valves. It will also replace the existing carbon steel parts on the inboard 1

butterfly valves JSIAUVO673 and JSIBUVO675 with stainless steel parts. [Action to add additional venting, draining and filling connections is complete. The remaining action is not being relied upon for resolution of the pipe void issue.]

(3.7.3.d) Due Date: 05/31/2008 DMWO 2739742 was completed for Unit 3 to add additional venting, draining, and filling connections on the ECCS suction piping. [Action completed during investigation]

o Strategy 3 - Developed test instruction "Containment Recirculation Sump Isolation Valve Leak Testing," 73TI-9ZZ21, to leak-test the inboard RAS penetration CIV using air prior to filling with borated water. Incorporated requirement to perform this leak test into procedure "Recovery from Shutdown Cooling to Normal Operating Lineup", 40OP-9SI02.

(SIBP/SIIP 3.7.2.e)

Revise 40OP-9SI02 to add the requirement to perform 73TI-9ZZ21 prior to filling the sump suction lines to assure JSIAUVO673 and JSIBUV0675 are leak tight for units that have completed the vent and drain modification. (3.7.2.e) Due:

Complete o Strategy 4 - Revised surveillance test procedure "RAS Line Fill Check," 40ST-9SI04, to verify the RAS penetrations are full of water on a monthly basis once the vent and drain modifications are completed. (SIBP/SIIP 3.7.2.b and 3.7.2.c)

" Revise 40ST-9SI04 for Unit 1 after implementation of DMWO 2760330 to verify that the ECCS sump lines remain filled. (3.7.2.b) Due: Complete

" Revise 40ST-9SI04 for Unit 2 after implementation of DMWO 2760330 to verify that the ECCS sump lines remain filled. (3.7.2.c) Due: Complete

" Revise 40ST-9SI04 for Unit 3 after-implementation of modification to install fill and vent lines. [Completed during the investigation]

o Strategy 5 - Revised surveillance test procedure 40ST-9SI04 to include time criteria for evaluating the amount of air escaping the vent valve and reordering the venting steps to eliminate one possible path for drawing air into the piping on the vent. (SIBP/SIIP 3.7.2.g)

• Revise 40ST-9SI04 to include time criteria for evaluating length of void escaping the vent valve and reordering the venting steps to eliminate one possible path for drawing air into the piping on the vent. (3.7.2.g) Due: Complete o Strategy 6 - Complete engineering study 13-MS-A102 to determine venting duration and tolerable void size criteria for surveillance test procedure 40ST-9SI04 that will ensure no adverse impact to pump operation. (SIBP/SIIP 3.7.2.j)

• Complete study 13-MS-A102 to determine venting duration and tolerable void size criteria for surveillance test procedure 40ST-9SI04 that will ensure no adverse impact to pump operation. (3.7.2.j) Due: 04/03/2008 2

o Strategy 7 - Revise surveillance test procedure 40ST-9SI04 to align the procedure acceptance criteria and contingency actions with the results of Engineering Study 13-MS-A102. Also revise the procedure for estimating void size. (SIBP/SIIP 3.7.2.k)

Revise surveillance test procedure 40ST-9SI04 to align the procedure acceptance criteria and contingency actions with the results of Engineering study 13-MS-A102. Also delete step 10.2.2 directing the STA to estimate the void size based on RWT level change. Determine or recommend Operations training to effectively implement this procedure change. Ensure new CRAI to training is initiated by parent CRDR owner. (3.7.2.k) Due: 04/16/2008 o Other Focus Area 1 Tasks:

Revise appendices A and B of procedure 40ST-9SI04 to require that the inner piping exposed by removing the pipe cap after the fill and vent be inspected to determine if water is still actively flowing after 30 seconds. Ifwater is observed after 30 seconds, then the fill and drain valves are to be checked for full closure and the penetration fill and vents re-performed. Also, similarly revise as applicable, other procedures that fill and vent the ECCS RAS lines. (3.7.2.f) Due:

Complete

" Develop a new SI venting strategy based on feedback and lessons learned from benchmarking activities. (3.7.2.h) Due: Complete

" While performing 40ST-9SI04 (STWO 2877128) on the "B"RAS fill check, the operator noticed approximately 30 seconds of intermittent bubbling air through SIB-VA28. It is suspected that the RD drain arrangement not being able to accept much flow limited the fill of the normally dry fill / drain header. [Evaluation of issue identified in April 2006 resulted in direct revision of procedure 40ST-9SI04 and 40OP-9SI04 to assure the line used to fill the RAS piping is full of water before beginning the RAS fill.] (3.7.2.i) Due:

Complete Focus Area 2 - Lack of Specific Provisions in the Licensing and Design Basis o Strategy 1 - Fixed the original condition:

" The Safety Injection (SI) Design Basis Manual (DBM) has been revised to document the requirement to fill ECCS suction lines.

. The above action was completed during the investigation

" Revised UFSAR Section 6.3.2.6 to add a new paragraph to indicate the need to have the ECCS lines (including the suction lines) filled to ensure proper operation of the CS and HPSI pumps. Evaluations have been performed to determine the need for revisions to other affected sections of the UFSAR and other affected licensing documents. (SIBP/SIIP 3.7.3.k and 3.7.3.1) 3

" Revise UFSAR section 6.3.2.6 to change reference to Safety Injection piping to ECCS piping and add new paragraph to indicate need to have ECCS lines filled to insure proper operation of the CS and HPSI pumps.

Evaluate the need for revisions to other affected sections of the UFSAR and other affected licensing documents. (3.7.3.k) Due: Complete

" Licensing to process TRM change, LDCR 05-R002, and UFSAR change, LDCR 05-F017 in accordance with procedure 93DP-0LC03 with a due date of August 30 [2005]... The proposed TRM change will add a new TRM surveillance requirement TSR 3.5.202.4 to verify that the containment sump safety injection recirculation piping is full of water every 31 days. The proposed UFSAR change will add clarification to the UFSAR 6.3.2.6 description that the suction and discharge SI piping will be maintained filled with water, and that it will be done in accordance with Technical Specification and TRM surveillance requirements. (3.7.3.1) Due:

Complete The Technical Requirements Manual has been revised to include a requirement to periodically verify that the ECCS sump suction lines are filled. (SIBP/SIIP 3.7.3.m and 3.7.3.1)

" Revise the Technical Requirement Manual to include requirement to periodically verify that the ECCS sump lines are filled. (3.7.3.m) Due:

Complete

• Licensing to process TRM change, LDCR 05-R002, and UFSAR change, LDCR 05-F017 in accordance with procedure 93DP-0LC03 with a due date of August 30 [2005]...The proposed TRM change will add a new TRM surveillance requirement TSR 3.5.202.4 to verify that the containment sump safety injection recirculation piping is full of water every 31 days. The proposed UFSAR change will add clarification to the UFSAR 6.3.2.6 description that the suction and discharge SI piping will be maintained filled with water, and that it will be done in accordance with Technical Specification and TRM surveillance requirements. (3.7.3.1) Due:

Complete After RAS specific design and licensing requirements were changed to make ECCS suction line fill requirements clear, modifications have been completed to assure that vent and drain placement supports keeping the line filled. (SIBP/SIIP 3.7.3.p and 3.7.3.d)

Implement Design Modification Work Order (DMWO) # 2760330 to implement the ECCS Suction Piping Modification in Unit 1. This installation of this modification will add additional venting, draining and filling connections on the sections of SI piping between the inboard and outboard containment isolation butterfly valves. It will also replace the existing carbon steel parts on the inboard butterfly valves JSIAUVO673 and JSIBUVO675 with stainless steel parts. [Action to add additional venting, draining and filling connections is complete. The remaining action 4

is not being relied upon for resolution of the pipe void issue.] (3.7.3.p)

Due: Complete Implement Design Modification Work Order (DMWO) # 2760330 to implement the ECCS Suction Piping Modification in Unit 2.This installation of this modification will add additional venting, draining and filling connections on the sections of SI piping between the inboard and outboard containment isolation butterfly valves. It will also replace the existing carbon steel parts on the inboard butterfly valves JSIAUV0673 and JSIBUVO675 with stainless steel parts. [Action to add additional venting, draining and filling connections is complete. The remaining action is not being relied upon for resolution of the pipe void issue.] (3.7.3.d)

Due Date: 05/31/2008 DMWO 2739742 was completed for Unit 3 to add additional venting, draining, and filling connections on the ECCS suction piping. [Action completed during investigation]

o Strategy 2 - Identify and resolve limitations of Design Basis Manuals:

G Communicated to engineering personnel regarding DBM limitations (interim action) (SIBP/SIIP 3.7.3.q)

Engineering to communicate to all potential DBM users, on the possible limitations of the DBMs and measures to effectively use the DBMs.

Accuracy of the DBMs may not be 100%; there may be errors of omission (primarily unincorporated EDCs, and other possible omissions) and possibly inaccurate content. Users should QV&V the information with other resources when possible. Users should also understand the context of set point information; the differences between safety limits, operational bands, instrument inaccuracies, etc. (3.7.3.q) Due: Complete

" Revised initial Engineering Tech Staff training to address limitations of DBMs (SIBP/SIIP 3.7.3.o, 3.7.5.gg, and 3.7.8.j)

• Revise NGT-91 to communicate the DBM usage limitations to future engineering staff. This CRAI is also related to CRAI 2825641. (3.7.3.o, 3.7.5.gg, 3.7.8.j) Due: Complete

" Add note on DBM cover page on limitations of DBMs and direction to refer to source documents. (SIBP/SIIP 3.7.3.h and 3.7.1 1.a)

Add a standard note to the cover page of each design bases manual to require personnel to refer to source documents when developing engineering work products or performing quality activities. (3.7.3.h and 3.7.11.a) Due: 05/22/2008

" Update the DBM Writer's Guide to provide guidance on addressing interface requirements and Operating Experience reviews. (SIBP/SIIP 3.7.3.w) 5

Update 83DP-4CC02, Design Basis Manual Finalization, (developed for the original design basis program) to provide guidance for the inclusion of the interface requirements and method of compliance, the high risk component listing, and an enhanced Industry Operating Experience (IOE) section. The IOE section will include the topic and the Palo Verde response. The guidance will address the following items for the systems with applicable NSSS to BOP design interface requirements:

a. Identify and discuss the applicable NSSS to BOP design interface requirements and the associated interface compliance evaluations.

b. Establish the system and component related performance interface requirements (e.g., supply x gpm); the required performance parameter'shall be identified for each system operating scenario (e.g., large break LOCA, small break LOCA, main steam line break, etc.).

c. Document the APS design calculations that demonstrate compliance with the interface requirement and the NSSS Supplier calculations identified that establish the analytical basis for the NSSS to BOP design interface requirements.

(3.7.3.w) Due: 07/25/2008 o Strategy 3 - Identify and resolve latent design and licensing basis issues:

" Complete Component Design Bases Review (CDBR) for High Risk components (SIBP/SIIP 11.6.1.a, 11.6.1.b, 11.6.1.c and 11.6.13)

• Complete CDBR on High Risk components in the Diesel Generator system. (11.6.1 .a) Due: 10/24/2008 Complete CDBR on High Risk components in the Auxiliary Feedwater system. (11.6.1.b) Due: 10/24/2008 Complete CDBR on High Risk components in the Safety Injection system.

(11.6.1.c) Due: 09/26/2008 Complete Component Design Basis Review Project per project schedule.

(11.6.13) Due: 12/13/2010 Revise DBMs based upon CDBR results. (SIBP/SIIP 3.7.3.x and 3.7.3.y)

• Revise the Design Basis Manuals for systems containing high risk components to incorporate the changes outlined in the revised Design Basis Manual Writer's Guide and other changes that were identified during the project (refer to CRAI 3069703). (3.7.3.x) Due: 11/18/2011

• Create a new Topical Design Basis Manual (DBM) for systems that have NSSS design interface requirements and do not have a system DBM.

(3.7.3.y) Due: 11/18/2011 6

o Other Focus Area 2 Tasks:

• Finalize overall (3 year) scope of CDBR High Risk, low margin components by both a qualitative & quantitative PRA/analysis. (111.6.7) Due: Complete Focus Area 3, Part 1 - Lack of Questioning Attitude and Technical Rigor of Individuals o Strategy 1 - Define and establish site standards for questioning attitude and technical rigor and incorporate in Revision 3 of the Site Standards and Expectations document.

(SIBP/SIIP 6.1.7, 6.1.8 and 3.7.4.gg)

" Develop and define what questioning attitude and technical rigor are for the site.

This should be based on benchmarking INPO, the NRC, and other utilities.

Update policy/procedure as appropriate. Present benchmarking results and recommendation to the senior leadership team. Evaluate station procedure and program that will require revision based on benchmarking effort. (6.1.7 and 6.1.8)

Due: Complete

" Establish/re-establish the expectations for a questioning attitude and technical rigor. Set expectations for questioning attitude and technical rigor, how to model, reinforce, and observed during observation/coaching. (Replaces CRAI 2825480 which an effectiveness review determined was ineffective) (3.7.4.gg) Due:

05/15/2008 o Strategy 2 - Implement training on questioning attitude and technical rigor, including a systematic approach to decision making and add to employee indoctrination training program. (SIBP/SIIP 6.4.6 and 6.4.7)

" Develop a training program based on the definition from the benchmarking for questioning attitude and-technical rigor results and include a systematic approach to decision making.... (6.4.6) Due: Complete

" Present "questioning attitude and technical rigor" training concept to the Training Oversight Committee (TOC) prior to 05/01/08 to obtain concurrence on concept, population to receive the training, schedule for development and implementation (to include a "pilot" with comment incorporation) of the training. Initiate additional actions following TOC review to track the training development, pilot presentation, and presentation due dates for the remaining populations to receive the training. Implementation of this training for key groups identified by the TOC, such as Operations, Engineering, and site leadership, shall be no later than 08/15/08. (6.4.7) Due: 05/30/2008 Strategy 3 - Established the Engineering Department Guidelines which include human performance tools relating to questioning attitude and technical rigor. (SIBP/SIIP 3.7.5.mm) 7

Develop and implement a plan for improving qualification, validation & verification (QV&V) of engineering products. [The only element of this action being relied upon to address RAS issues is the development of the engineering human performance tools (Engineering Department Guidelines)] (3.7.5.mm) Due:

Complete o Strategy 4 - Develop and implement training on the Engineering Department Guidelines.

(SIBP/SIIP 1.2.E.19)

Design and develop training for use of Engineering Department Guide EDG Engineering Human Performance Tools and EDG Engineering Human Performance Tools for Technical Task Risk/Rigor. The training should cover use

-of EDG-01 and EDG-02 on a graded approach based on risk significance of task.

Suggest training as described in December 2005 INPO Engineering Digest featured topic "Engineering Human Performance." Incorporate initial training and continuing training into the Engineering Training Program Description. (1.2.E.19)

Due: 06/30/2008

o. Strategy 5 - Established formal Engineering Principles and Expectations including expectations for technical rigor, verification of assumptions, and alertness to situations that could impact compliance with design and licensing basis. (SIBP/SIIP 11.1.1)

• Develop Engineering Principles and Expectations handbook. (11.1.1) Due:

Complete o Strategy 6 - Provided classroom training on Engineering Principles and Expectations.

(SIBP/SIIP 11.1.2)

• Distribute Engineering Principles and Expectations to Engineering via Focus Communication Groups. (11.1.2) Due: Complete o Strategy 7 - Incorporated Engineering Department Guidelines and Principles and Expectations into the Conduct of Engineering procedure. (SIBP/SIIP 11.8.30)

Develop a Conduct of Engineering procedure. The procedure should include engineering principles and standards. Incorporate a requirement into the Engineering TPD to train on the Conduct of Engineering procedure in initial training and continuing training. (111.8.30) Due: Complete o Strategy 8 - Implement an engineering leader observation and observation analysis and trending program. (SIBP/SIIP 11.4.1)

Establish an Engineering Leader Observation Program that is incorporated within the site observation program as a tool for monitoring and adjusting engineering products, practices and human performance standards and tools. (11.4.1) Due:

06/28/2008 o Strategy 9 - Implement an Engineering Product Quality Review Board including grading, feedback and metrics. (SIBP/SIIP 11.4.17) 8

Develop a procedure that describes the purpose, conduct, membership, criteria and requirements for using an Engineering Quality Product Review Board. The procedure shall include a requirement to have: Engineering Quality Product Review Board feedback on products reviewed [and] metrics to monitor and trend performance. (11.4.17) Due: 06/28/2008 o Strategy 10 - Implemented the plant walkdown procedure and provided training on the procedure and use of questioning attitude during walkdowns. (SIBP/SIIP 3.7.4.1, 3.7.4.m, 3.7.4.n, and 3.7.4.q)

Create "stand-alone" Plant Walkdown procedure to incorporate Safety System Walkdowns using the 12 week schedule (see STA Shift Conduct Procedure, 79DP-9ZZ02). Add instructions to identify personnel safety issues, transient material/transient combustible issues and other common walkdown area's of interest. Ensure weekly schedule times are coordinated with Maintenance and Engineering. Add FIN support to the walkdown team. (3.7.4.1) Due: Complete

• Develop and administer a practical demonstration of Plant Walkdowns to the Auxiliary Operators. (3.7.4.m) Due: Complete

• Provide Plant Walkdown Training/Briefing to Licensed Operators, STA, Engineering Staff and NAD. (3.7.4.n) Due: Complete

• Provide Plant Walkdown training for AO's using the NRC Plant Walkdown Guide as a reference. Provide the developed material to STA's to use as a briefing for the STA Group and Engineering. (3.7.4.q) Due: Complete o Strategy 11 - Strengthened the use of technical reviews of high tier Operating Experience. (SIBP/SIIP 3.7.4.f) (see also RAS Focus Area 6)

Revise the IOE Program (65DP-OQQ01) to require performance of an independent or back-end technical review of all high-tiered IOE evaluations (for evaluations performed by other than a team or with multiple technical reviews).

(3.7.4.f) Due: Complete o Other Focus Area 3, Part 1 Tasks:

" Evaluate what programs or processes will be included in a rollup program to determine current status of human performance. Examples include; self-assessment, corrective action program, observation data, trending data, operating experience, off-site audits or assessments, etc. Develop a process for gathering and analyzing data that will be included in the P1 rollup program. Use RAPID (change management) as part of the development of the P1 rollup program. Provide guidelines for department PI rollup to determine individual trends, both in the improving or declining performance. New Pi's will be added to the line organizations indicators, where performance issues are identified.

(6.6.1.a) Due: 02/15/2009

" Evaluate current DME indicator/metrics and provide recommendation for changes based on industry benchmarking (see CRAI 3020641) for questioning attitude, technical rigor, and decision making errors. (6.1.9) Due: 04/15/2008 9

40DP-9ZZ03 [Weekly Material Condition Inspection of Safety Significant Equipment] Appendix C will be changed to designate the required participants.

40DP-9ZZ03 guidance will be changed to require full complement of participants or re-schedule the inspection and write a PVAR. (3.7.4.x) Due: 06/06/2008 A lesson plan will be developed and incorporated into Initial Non-License Training that uses actual events for exercises with emphasis on the importance of Area Rounds and field observations as input to the control room determination of degraded safety systems. (4.1.F.17) Due: 09/30/2008 Focus Area 3, Part 2 - Lack of Questioning Attitude and Technical Rigor of Individuals - Operability Determinations o Strategy 1 - Interim actions:

• Assigned a dedicated advisor to drive rigor and consistency in Operability Determinations (OD) (SIBP/SIIP 4.1 .F.9)

As an interim action to drive consistency during the implementation and training phase of this plan, Operations will dedicate a current or previously licensed SRO (and provide an alternate), to the Corrective Action Program/ Operability Determination Process (CAP-OD SRO). This SRO will have in depth knowledge of Procedure 40DP-9OP26, Operability Determination and Functional Assessment, and NRC RIS 2005-20. The position will be staffed during normal dayshift hours. This position will be staffed until the 40DP-9OP26 changes and IOD training is complete. (4.1.F.9) Due: Complete Instituted Plant Manager Daily Challenge Board review of Immediate Operability Determinations (IOD) and Prompt Operability Determinations (POD) (SIBP/SIIP 4.1 .F.22)

As an interim action, establish a daily challenge board, sponsored by the Plant Manager, for IODs and PODs generated in the previous 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />s/weekend/holiday. A PVAR will be generated and feedback provided to the Shift Manager and engineering FIN for any identified deficiencies.

This will continue until training required by this plan is complete as described in CRAIs 3105761 and 3109581. (4.1.F.22) Due: Complete

• Issued revised expectations for system engineering for monitoring and trending system performance. (SIBP/SIIP 1.2.F.1)

• , Issue revised expectations for system engineering for monitoring and trending system performance. (1.2.F.1) Due: Complete o Strategy 2 - Training and qualification of personnel on the OD and Functional Assessment process:

10

" Develop OD process lesson plan and incorporate into initial License Training that uses actual events for exercises. (SIBP/SIIP 4.1.F.16)

An Operability Determination process lesson plan will be developed and incorporated into initial License Training that uses actual events for exercises. (4.1.F.16) Due: 09/30/2008

" Provide OD training to Engineering FIN (E-FIN) and SROs/STAs on OD changes, the standard for technical rigor including critical thinking, and the use of design basis information in support of PODs. (SIBP/SIIP 4.1 .F.211)

Provide OD training to engineering FIN team and SRO's/STAs on OD related procedure changes, the standard for technical rigor including critical thinking, and the use of design basis information in support of PODs. (4.1.F.21) Due: 09/30/2008

" Establish a formal qualification requirement and dedicated E-FIN for POD preparation. (SIBP/SIIP 4.1.F.23 and 4.1.F.19)

• Establish a formal qualification requirement for POD preparation and incorporate into the ETP. (4.1 .F.23) Due: 09/30/2008

" Establish dedicated Engineering Support (E-FIN) for the preparation of PODs. (4.1.F.19) Due: Complete

" All SROs/STAs will be trained in the IOD process (SIBP/SIIP 4.1.F.14)

• All SRO's / STA's will be trained on the IOD process and the recent changes to 40DP-9OP26. (4.1.F.14) Due: 06/30/2008 Strategy 3 - Improved entry into the OD process:

• OD procedure changed to require a documented Operability/Functionality(

Assessment for any PVAR on T.S. or T.S. support SSCs (SIBP/SIIP 4.1.F.10)

• 40DP-9OP26 will be changed to require a documented Operability /

Functionality Assessment for any PVAR on T.S. or T.S. support SSC's.

(4.1.F.10) Due: Complete Strategy 4 - Improvements in OD process:

" Revised OD procedure to support PVAR process (SIBP/SIIP 3.7.4.i)

• Implement changes to 40DP-9OP26 [Operability Determination and Functional Assessment] to support the new AR [PVAR] process for CRDRs/WOs. (3.7.4.i) Due: Complete

" Added an IOD checklist to OD procedure to aid SROs (SIBP/SIIP 4.1.F.11) 11

• A checklist will be developed and included in 40DP-9OP26 to aid the SRO in making the Immediate Operability Determination. (4.1.F.11) Due:

Complete

" Revised OD Procedure to have Operations make an initial extent of condition determination or coordinate with appropriate departments to obtain the information (SIBP/SIIP 4.1.F.12)

Revise 40DP-9OP26 to have Operations make the initial extent of condition determination. If information is required from other organizations, Operations will communicate to the appropriate department the need and time frame that the information is needed and enter the action in the CAP. (4.1.F.12) Due: Complete

" Revised OD procedure to include the requirements for "Engineering Technical Rigor" (SIBP/SIIP 4.1 .F.32)

• Revise POD procedure (40DP-9OP26) to include the requirements stated in Task 1 above. (Reference SlIP Action Plan 3, "Engineering Technical Rigor," Strategy 5). (4.1 .F.32) Due: Complete

" Revised OD procedure to document any unverified assumptions and require a corrective action to validate the assumptions (SIBP/SIIP 4.1.F.18)

Revise the OD procedure to require documentation of any unverified assumptions and require a corrective action item to validate the assumptions when not able to be validated at the time of the POD.

(4.1.F.18) Due: Complete o Strategy 5 - Improved OD metrics and OD review processes:

" Developed OD quality improvement plan & metrics (SIBP/SlIP 4.1.F.30)

• Develop operability determination improvement plan and metrics that more accurately measure the quality of ODs. (4.1 .F.30) Due: Complete

" Established updated metrics for OD performance (SIBP/SIIP 4.1.F.27)

• Establish appropriate metrics to monitor Operability Determination performance. (4.1.F.27) Due: Complete o Strategy 6 - Improve site's sensitivity to Nuclear Safety and Operability through Spray Pond training, OD training, trending improvements, and daily plant status and safety meetings. (SIBP/SIIP 11.8.22, 4.4.1, 4.4.11 and 1.2.F.4)

" Implement the site training on the case study develop for the Essential Spray Pond CRAI 2937340. (11.8.22) Due: Complete

" Integrate Safety discussions in the context of Plant Status during meetings (Nuclear, Industrial, Radiological and Safety Culture). (4.4.1) Due: Complete 12

Create a site-wide awareness/focus on the plant and corresponding safety aspects by setting the expectation to open initial daily meetings with discussions on plant status and correlating safety aspects. Subsequent meetings begin with a discussion on any changes to plant status or safety aspects (i.e., nuclear, industrial, radiological and safety culture). (4.4.11) Due: Complete Revise system engineering handbook to include the expectations identified in task 1.2.F.3 (e.g., trending and monitoring). (1.2.F.4) Due: 04/30/2008 o Strategy 7 - Review PODs approved prior to April 1, 2008 and currently in effect, and initiate necessary corrective actions to bring those determinations into compliance with current standards. (SIBP/SIIP 4.1 .F.33)

Review PODs approved prior to April 1, 2008 and currently in effect and initiate necessary corrective actions to bring those determinations into compliance with current standards. (Reference SlIP Action Plan 3, "Engineering Technical Rigor,"

Strategy 5). (4.1.F.33) Due: 07/01/2008 o Other Focus Area 3, Part 2 Tasks:

. Perform a "Needs Analysis" using the Systematic Approach to Training (SAT) process to determine the training needs for engineering FIN for POD preparation.

Develop the lesson plan for this task. (4.1.F.20) Due: 06/30/2008

. Established a daily challenge board, as an interim action, sponsored by the Plant Manager, for IODs and PODs generated in the previous 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />s/weekend/holiday. This action is requesting NAD to perform periodic observations of the challenge board. (4.1.F.34) Due: 05/23/2008 Focus Area 4 - Inadequate Communication of Design Information o Strategy 1 - Establish a process to formally provide technical information by the engineering staff. This process will apply to key operation, maintenance and regulatory activities and shall not circumvent the Corrective Action Program (e. g. CRDRs, DFWOs). The process will contain appropriate engineering review and approval requirements based on type of request. (SIBP/SIIP 3.7.5.hh and 11.4.15)

Establish a process to formally provide technical information by the engineering staff. This process should be used in lieu of white papers, emails or verbal responses when the information provided by engineering is used for key operation, maintenance and regulatory act~ities. This process shall not circumvent the Corrective Action Program (e. g. CRDRs, DFWOs). The process should contain the appropriate engineering review and approval requirements based on type of -request. (3.7.5.hh and 11.4.15) Due: 09/30/2008 o Strategy 2 - Expectations regarding communication of technical information were communicated to personnel through guidelines, expectations documents, and briefings:

13

" A RAS event case study was developed and provided to engineering, operations, nuclear assurance, and regulatory affairs personnel regarding the need for proper communication of information. Use of this case study has been embedded into pre-job briefs for self-assessments, significant investigations, and high-tier operating experience reviews. (SIBP/SIIP 3.7.5.dd and 3.7.7.b)

• Training will develop the ECCS Sump event as a case study emphasizing how the design configuration escaped detection for over 20 years during various missed opportunities due to ineffective questioning attitude and technical rigor, incorrect mindsets, and tunnel vision. (3.7.5.dd) Due:

Complete

" Performance Improvement Department (PID) will streamline the case study for RAS and initiate the expectations that it will be used during pre-job briefings for self-assessments, significant investigations, and high-tiered operating experience evaluations. (3.7.7.b) Due: 07/30/2008

" Human performance tools, including tools to ensure strong communication of technical information, were included in new Engineering Department Guidelines and Conduct of Engineering Procedure. (SIBP/SIIP 3.7.5.mm and 11.8.30)

• Develop and implement a plan for improving qualification, validation &

verification (QV&V) of engineering products. [The only element of this action being relied upon for RAS is the development of the engineering human performance tools (Engineering Department Guidelines)]

(3.7.5.mm) Due: Complete

• Develop a Conduct of Engineering procedure. The procedure should include engineering principles and standards. Incorporate a requirement into the Engineering TPD to train on the Conduct of Engineering procedure in initial training and continuing training. (11.8.30) Due:

Complete o Strategy 3 - Established additional procedural guidance for addressing vendor correspondence to assure that appropriate, cognizant personnel determine distribution of this correspondence. (SIBP/SIIP 3.7.5.kk)

Revise 87DP-OQQ08, Control of Vendor Documentation to include Vendor Bulletins into the Scope 1.2.1, as well as section 3.3.1 General Receiving Requirements. Section 3.3.1 should include information to ensure proper submittal to NIRM as required by 84DP-ORM03, PVNGS Correspondence Handling. [This action also changed the procedure to ensure that appropriate cognizant personnel determine distribution of vendor correspondence] (3.7.5.kk)

Due: Complete o Strategy 4 - Reviewed the nine Independent Design Reviews (IDRs) performed prior to plant startup to ensure that design intent has been incorporated into the design and licensing bases. (SIBP/SIIP 3.7.5.e, 3.7.5.f, 3.7.5.g, 3.7.5.i, 3.7.5.1, 3.7.5.m, 3.7.5.p, 14

3.7.5.q, 3.7.5.U, 3.7.5.r, 3.7.5.s, 3.7.5.t, 3.7.5.nn, 3.7.5.a, 3.7.3.a, 3.7.5.v, 3.7.5.n, 3.7.5.0 and 3.7.5.00)

" Review the Containment Systems, IDR to determine if any other design requirement was not incorporated in design documents. (3.7.5.e) Due: Complete

" Review the Auxiliary Feedwater System IDR to determine if any other design requirement was not incorporated in design documents. (3.7.5.f) Due: Complete

" Review the Alternating Current Power Systems IDR to determine if any other design requirement was not incorporated in design documents. (3.7.5.g) Due:

Complete

" Review the Results of the IDR reviews to determine iffurther reviews are required. Modify the corrective actions to this CRDR as appropriate based on the results. (3.7.5.i) Due: Complete

" In response to CRDR 2726509, an extent of condition review was conducted to determine if there were other instances of design or licensing commitments being identified and discussed in one of the IDR reports that were not effectively translated into requirements in the design documents .... The purpose of this CRDR is to document the results of the review of the [following systems:

Auxiliary Feedwater (3.7.5.1); Auxiliary Systems (3.7.5.v); Containment Systems (3.7.5.p); AC Power Distribution (3.7.5.q); DC Power Distribution (3.7.5.u);

Balance of Plant I&C (3.7.5.r); Equipment Qualification (3.7.5.s); Fire Protection (3.7.5.t); CE Control System (3.7.5.nn)] Due: Complete

" Track to completion Open CE control system IDR items, noted on spreadsheet attached to this CRDR 2825473. (except for item one to be handled on another CRAI) (3.7.5.a) Due: Complete

" APS was unable to locate a copy of Volume II of the CE control system IDR from the NRC's public document room. This level 4 CRAI has been initiated to track the need for further evaluation of CE control system IDR volume II based on the completed results of the other IDR reviews (refer to CRDRs 2825464, 2824066, 2824714,2824198, 2824214, 2824241, 2825472,2825202 2825460,2825372,2825474 and 2825475). To date no known Potential Significance items have been identified by these evaluations. [This action documents the review of CE Control System IDR Volume II] (3.7.3.a) Due:

Complete

" ... The purpose of this CRDR is to document a discrepancy identified during the review of the Auxiliary Systems IDR... the IDR text states that the EW to NC crosstie to supply Cooling water from EW to the Nuclear Cooling Water Heat Exchanger is classified as Seismic Category I. Contrary to this, the EW P&ID, drawing 01/02/03-M-EWP-001 shows the EW cross-tie to supply cooling water to the NC priority loads through valve EWUV145/6 and from the NC priority loads through valves EWUV65/66 classified as Seismic Category 2... (3.7.5.m) Due:

Complete 15

" The purpose of this CRDR is to document a discrepancy identified during the review of the Auxiliary Systems IDR... the IDR lists several EW heat loads and the post accident peak EW temperature. These heat loads and the post accident peak EW temperature differ slightly from those currently stated in the DBM and the design calculations... (3.7.5.n) Due: Complete

" ... The purpose of this CRDR is to document a potential discrepancy that was identified during the review of the Containment Systems IDR... the IDR has a statement regarding Regulatory Guide 1.7 compliance that states Palo Verde is in compliance with the requirement that the purge or ventilation system filter will be Seismic Category I. It is not clear ifthis commitment/requirement should be applied to the containment access purge filter MCPJ02... (3.7.5.o) Due:

Complete

" The existing calculation 01 ECPK0207 DC Battery Sizing and Minimum Voltage Calculation has analyzed class 1 E battery capacity for 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br /> during station blackout event and referenced Reg. Guide 1.155 Station Blackout. However, review of Reg. Guide 1.155 did not find any 2 hour2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br /> capacity requirement for the class 1 E battery during station blackout event. A brief research indicated that the previous calculations 13ECPK202 and 13ECPK161 (SBY 01,02,03ECPK207) had considered 2 hour2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br /> battery capacity requirement during SBO with reference of Reg. Guide 1.155. [This CRDR resolved an issue identified under CRDR 2824066 as part of the IDR extent of condition review] (3.7.5.00) Due: Complete o Strategy 5 - Strengthen engineering to operations interface by providing the Operability Determinations Discovery Evaluation Checklist to assist in identifying degraded/nonconforming conditions requiring immediate control room contact.

(SIBP/SIIP 3.7.5.k)

Improve engineering involvement in the Operability Determination (OD) process by:

- Revising the OD Procedure to address RIS 2005-20.

- Developing guidance for Engineering personnel on when to communicate potential nonconforming and degraded conditions to Operations, the type of information to be provided to Operations to support immediate operability determinations, the type of information to provide in engineering evaluations to support prompt ODs (e.g., focus on whether the structure, system, or component (SSC) can perform its specified safety function). This guidance will include a checklist to guide engineering personnel through a process to provide input to ODs. [The only facet of this action being relied upon to address RAS issues is the creation of the Discovery Checklist]

(3.7.5.k) Due: Complete o Strategy 6 - Develop and conduct training of engineering (non-administrative) personnel on the station vendor documentation procedure. (SIBP/SIIP 3.7.5.11)

• Include within 2nd Quarter 2008 Engineering Quarterly Events, Generic Topic Training instruction on the process used to receive vendor documentation. The instruction should include expectations for personnel who receive vendor 16

documentation, outside of the formal process, to ensure that potentially impacted groups receive the information. (ref. CRAI 2903206) ( 3.7.5.11) Due: 07/16/2008 o Other Focus Area 4 Tasks:

" Re-review the PVNGS response to Information Notice 88-23 Supplement 5.

Consideration should be given to modify the response since the Safety Injection Tanks were the origin of the gas which caused the Turkey Point event and Safety Injection Tanks are components also at PVNGS. (3.7.5.h) Due: Complete

" Cover lessons learned from technical communications trends during engineering events training: technical justifications are not used to bypass the OD process and judgment/justifications are recognized by engineering/operations and prompt operability determinations are performed. [Short-term check and adjust action.

Not intended for sustainability] (3.7.5.z) Due: Complete

" Actions completed for impact review program improvement have not identified a means of tracking or sampling the impact reviews get to all of the correct groups and that the review is accurate. Determine action plan to improve this aspect of impact review. Generate any required corrective action documents needed to implement action plan.... (3.7.5.aa) Due: Complete

" CDBR Item. As of 05/11/2007; 26 out of 178 PVARs/CRDRs are in the area of Procedure Quality. CDBR has identified procedural inadequacies that are inconsistent with design assumptions. iEvaluation needs to be performed to determine the apparent cause for so many issues in this area. (3.7.5.ii) Due:

Complete

" Develop and implement interim communications from the PVNGS VP of Engineering that Prompt Operability Determinations (PODs) prepared subsequent to April 1, 2008 may not be based upon informal information. In addition, those PODs may not be based upon previous PODs or CRDRs prepared before April 1, 2008 without Engineering review and approval.

(4.1.F.31) Due: Complete

. Develop Checklists for high-tiered OE evaluations (SOER, SEN, SER, IN, etc.)

for use during disposition and analysis. This should include guidance for expansive OE review so that personnel do not focus only on the particular conditions identified in the OE report. In addition revise Self-Assessments and Significant CRDR evaluations to include evaluation and emphasize of using high-tiered OE. (3.7.7.c) Due: Complete Focus Area 5 - Inadequate Problem Identification and Resolution o Strategy 1 ,- Reviewed PVNGS programs and processes to identify processes outside the CAP that may be used for identification of items needing corrective action. As necessary, revise processes to ensure that any items needing correctiveaction are addressed through the CAP. (SIBP/SIIP 3.4.4.c) 17

Review other departmental programs/processes used in implementing UFSAR programs to identify potential corrective action processes outside the formal CAP. (3.4.4.c) Due: Complete o Strategy 2 - Established the Action Request Review Committee (ARRC) to review PVARs and ensure that condition statements, risk assessments, and prioritizations are appropriate. Established qualification requirements based upon NRC and INPO guidance for ARRC members. (SIBP/SIIP 3.2.1 .d and 3.3.3.b)

" Establish the ARRC. Implement an Action Request Review Committee (ARRC) to improve condition statement, risk assessment, and prioritization. Implement the new ARRC. (3.2.1.d) Due: Complete

" Develop and implement qualification requirements for members of the ARRC.

These requirements should include the review of the following, as a minimum:

- Review of INPO guidance for performance improvement and human performance

- Review of NRC Inspection criteria related to Problem Identification and Resolution

- Review of PVNGS CAP Procedures and Process Guidance, with an emphasis on classification and evaluation level of effort. (3.3.3.b) Due:

Complete o Strategy 3 - Established the Condition Review Group (CRG) to ensure participation and buy-in of responsible management in the disposition of PVARs and definition of

.corrective actions. (SIBP/SIIP 3.2.4)

Evaluate the establishment of a Condition Review Group (CRG). Present results of evaluation to Senior management and. incorporate actions resulting from Senior management meeting into this building block initiative, as necessary.

(3.2.4) Due: Complete Strategy 4 - Required Corrective Action Review Board (CARB) review of root and apparent cause evaluations under the CAP and provision for feedback from CARB reviews to applicable leaders and trending of CARB review results. Develop and implement job familiarization requirements for CARB members, including appropriate training on cause evaluation and the CAP. (SIBP/SIIP 3.2.31 3.2.5.f and 3.3.3.c)

" Require CARB to review root cause and apparent cause evaluations and provide performance feedback (immediate to applicable leader and site via trending) for continuous learning to station staff and leadership and review backlog of apparent cause evaluations completed after May 1, 2007 and determine whether CARB review is warranted. (3.2.3) Due: Complete

" Implement a process for periodic review of CARB scorecard results and provision of roll-up score card results to the management team, training department, Performance Improvement Department (PID), root and apparent cause investigators, oversight groups, and Advocates. (3.2.5.f) Due: Complete 18

Develop and implement a "Job Familiarization Guidance document" for members of the CARB. These requirements should include the following, as a minimum:

- INPO guidance for performance improvement and human performance

- NRC Inspection criteria related to Problem Identification and Resolution

- Training on Root Cause and ACE Evaluation tools and techniques

- PVNGS CAP Procedures and Process Guidance (3.3.3.c) Due: Complete o Strategy 5 - Provided additional and ongoing training and familiarization regarding the PVAR process and CAP fundamentals to PVNGS personnel. (SIBP/SIIP 3.3.3.i and 3.3.3.j)

" Revise the station access training materials based on the information and direction as a result of task 3.3.3.h. Implement the revised training to ensure that station personnel receive the training through Site Access Training. (3.3.3.i)

Due: Complete

" Develop and communicate CAP Fundamentals for Station Personnel and for Managers and Supervisors. (3.3.3.j) Due: Complete o Other Focus Area 5 Tasks:

" Provide ability to anonymously initiate a PVAR. Reference CRDRs 3022621 and 3015865. (3.4.1) Due: Complete

" (Interim Action) Commence review of 100% of closed CRDRs on a month to month basis using the existing CRDR closure quality review criteria, including Significant, ERCFA2, ERCFA1, Apparent Cause, and Adverse. Document the reviews and populate performance indicators. Perform CRDR reject activities as required by Condition Reporting. To be discontinued when performance indicators indicate sustained acceptable performance. (3.3.12) Due: Complete

" Re-incorporate the "adverse" evaluation process into 90DP-01P10. (3.4.2.b)

Due: Complete Focus Area 6 - Limited or Weak Operating Experience Program o Strategy 1 - Operating experience (OE) usage has been/is being integrated into station work documents, 'procedures, and expectations to ensure day-to-day usage:

" Process to be developed to add OE to work packages. (SIBP/SIIP 6.7.11)

• Planning Department Leader will develop process which will add operating experience to work packages. (6.7.11) Due: 08/10/2008

" Streamlined RAS event case study and embedded in pre-job briefs for self-assessment, significant CRDR, and high-tier OE evaluations. (SIBP/SIIP 3.7.7.b) 19

Performance Improvement Department (PID) will streamline the case study for RAS and initiate the expectations that it's use during prejob briefings for self-assessments, significant investigations, and high-tiered operating experience evaluations. (3.7.7.b) Due: 07/30/2008 Developed and institutionalized the OE books emphasizing OE use. (SIBP/SIIP 6.7.13 and 6.1.15)

• Operating Experience Outage books developed and published prior to each refueling outage, outlining internal and external Operating Experience and the behaviors to prevent occurrence. (6.7.13) Due:

Complete

• Evaluate and implement a method to institutionalize outage preparation for HU/CL and IS activities, to include programs and tools such as team PRIDE, and operating experience booklets. (6.1.15) Due: Complete

" Briefing of selected leaders on the use of OE in day-to-day activities, program changes, roles and responsibilities. (SIBP/SIIP 3.7.7.p and 3.7.7.q)

• Develop and provide briefing to selected leaders for communication of procedure 65DP-OQQ01 program definition, responsibilities and process flow. (3.7.7.p) Due: 05/13/2008

• Develop and provide briefing to selected leaders for communication of expectations and guidance to effectively use OE in day-to-day activities for the prevention and mitigation of events. Reference other CRAls as appropriate for individual actions previously identified for use of OE:

CRAls 2988507 (use of OE in Operability Determinations), 3104862 (development of a desktop guide for OE tools), 2922028 (OE usage during CDBR reviews), 2938870 (Use of OE during Shop Meetings and Safety Meetings), 2938874 (Outage OE books), and 2941720 (Use of OE during work planning). (3.7.7.q) Due: 08/13/2008 o Strategy 2 - Train personnel on use of Operating Experience search tools:

" Develop a database for the retrieval and knowledge management of operating experience and train target population on its use. (SIBP/SIIP 6.7.10)

Develop a database for the retrieval and knowledge management of operating experience. Identify target population and train on how to use the database efficiently. Include a shortcut to current Kiosk menu for retreivability. (6.7.10) Due: 12/28/2008

" Identify and train operating experience points of contact in departments and pertinent Performance Improvement staff members on the use of external INPO website. (SIBP/SIIP 6.7.5)

• Train and identify operating experience points of contact in departments and pertinent PIT staff members on the use of external INPO website.

20

This website provides the user with access to OE on an as-needed basis, which negates the need for current mechanical distribution process.

(6.7.5) Due: 12/14/2008 Train significant and ACE CRDR evaluators on OE use and evaluation methods.

(SIBP/SIIP 6.7.8)

Develop and implement training for investigators of significant events and apparent cause evaluation on use/evaluation methods associated with operating experience. (6.7.8) Due: Complete o Strategy 3 - Reviewed a 95/95 sample of past high-tier OE to identify any potential operability concerns that were not appropriately addressed. (SIBP/SIIP 3.7.7.i)

Perform an assessment of the technical adequacy of past high-tiered IOE evaluations. Criteria should be judged on whether any deficient IOE evaluation impacted any SSC Technical Specification OPERABILITY or safety related function (i.e., caused an SSC to be INOPERABLE or resulted in a reportable condition). Review IOEs at least since 1985; provide a technical. resolution if necessary; include a random (95/95) sample of high risk systems, but biased to not include any IOEs that are human performance issues exclusively (e.g.,

System Status Control SOER 98-01); should be performed by technical experts but not any who have previously worked on the issue here at PVNGS (use outside expertise if necessary); include SOER 97-1, SEN 243, IN 88-23, and GL 97-04 / IN 96-55. If the reviews do not meet the above criteria, then expand the sample size. (3.7.7.i) Due: Complete o Strategy 4 - Operating Experience Process Improvements:

Modify the process of reviewing high-tier OE to require independent or backend

• review, a checklist to assure broad analysis, roles and responsibilities, and other process improvements. (SIBP/SIIP 3.7.4.f, 3.7.7.c, 3.7.4.g, 3.7.7.f, 3.7.7.1, 3.7.7.o, 6.7.16, and 6.7.1)

" Revise the IOE Program (65DP-0QQ01) to require performance of an independent or back-end technical review of all high-tiered IOE evaluations (for evaluations performed by other than a team or with multiple technical reviews). (3.7.4.f) Due: Complete

" Develop Checklists for high-tiered OE evaluations (SOER, SEN, SER, IN, etc.) for use during disposition and analysis. This should include guidance for expansive OE review so that personnel do not focus only on the particular conditions identified in the OE report. In addition revise Self-Assessments and Significant CRDR evaluations [guidance or procedures] to include evaluation and emphasize using high-tiered OE.

(3.7.7.c) Due: Complete

• Engineering will apply an independent verification process for the technical quality of high-tiered IOE evaluations for use by all of Engineering (e.g., similar to the modification process or calculation 21

process). This is only necessary if the IOE evaluation is not performed by a multi-disciplined team. (3.7.4.g and 3.7.7.f) Due: Complete

• Revise the IOE Program (65DP-0QQ01) to provide guidance for ensuring that IOE reviews broadly consider related conditions that could have similar consequences. The problem associated with this action is from some IOE evaluations having narrow focus, i.e., those that zeroed in on the narrow focused questions and not on the broader focused issues or questions of the IOEs. (3.7.7.1) Due: Complete

" Establish a method of checks and balances that verify IOE high-tiered documents are appropriately processed per program requirements (65DP-0QQ01). (3.7.7.o) Due: Complete

• Develop and implement an operating experience screening committee, include criteria, charter, roles / responsibilities for cross-disciplinary review of in-coming (external) operating experience. (6.7.16) Due:

04/18/2008

• Revise 65DP-0QQ01 to include conduct of operating experience elements from INPO 05-05 and 97-011, including in the procedure, roles, responsibilities, and ownership expectations. (6.7.1) Due: Complete Performance Improvement Department (PID) will perform or coordinate review of all high tier OE. (SIBP/SIIP 3.7.7.d)

• The Performance Improvement Dept. will either perform or coordinate all reviews on High-Tiered IOE CRDR evaluations in accordance with the requirements of 65DP-OQQ01 (Industry Operating Experience Review).

This includes reviewing the adequacy of scope and rigor as documented within the completed IOE Checklists (Appendix D). This CRAI can be closed once this review process is established. (3.7.7.d) Due: Complete Methods and controls to be developed to assure procedure changes made as a result of OE reviews cannot be eliminated without appropriate review. (SIBP/SIIP 6.7.6)

Develop/implement methods and controls to ensure that corrective actions taken to address high-tier operating experience (as defined by the 65DP-OQQ01 procedure) are not eliminated without appropriate review.

(6.7.6) Due: 08/13/2008 Evaluated and implemented improved metrics for station OE Program.

(SIBP/SIIP 6.7.7)

• Evaluate and implement metrics/indicators to include station performance on and overall health of the Operating Experience program. (6.7.7) Due:

Complete 22

o Strategy 5 - Review active SOERs for adequate disposition and sustainability of actions.

(SIBP/SIIP 6.7.17)

Evaluate the SOER listing from INPO and re-evaluate the analysis and corrective actions taken by the station in response to implementing the recommendations.

Develop additional actions, if determine previous actions were inadequate or inappropriate, to resolve and ensure that recommendations are properly disposition for the long-term. (6.7.17) Due: 10/15/2008 o Strategy.6 - Trained selected Engineering, Operations, Regulatory Affairs and Nuclear Assurance personnel on RAS event and importance of fully addressing high-tier OE.

(SIBP/SIIP 3.7.5.dd)

Training will be provided to the Palo Verde organization: "RAS event case study." Training will develop the ECCS Sump event as a case study emphasizing how the design configuration escaped detection for over 20 years during various missed opportunities due to ineffective questioning attitude and technical rigor, incorrect mindsets, and tunnel vision. This case study will be presented to non-admin PVNGS personnel, in Operations, Engineering, NFM, OCS Engineering, (Engineering Tech Staff), Regulatory Affairs, and Nuclear Assurance. Include the following in the training (specific issues from the event):

- That if a technical question cannot be answered with "qualified",

"validated", AND "verified", information in a timely manner, then the issue needs to be elevated to the next level of supervision. The amount of QV&V applied, should be commensurate with the potential safety significance of the issue.

- Individuals will be trained on the importance of ensuring that all issues identified in high-tiered OE reports (per 65DP-0QQ01) and CRDRs (per 90DP-OIP10) are fully addressed, e.g., avoid narrow focus approaches, think in broader terms.

(3.7.5.dd) Due: Complete Strategy 7 - Validated Nuclear Regulatory Affairs Procedure technical rigor requirements for incoming NRC documents. (SIBP/SIIP 3.7.4.h and 3.7.7.k)

Review the guidance in 93DP-OLCO5 (Regulatory Interaction & Correspondence Control) to ensure that adequate technical reviews are performed for responses to Generic Letters, Bulletins and other NRC correspondence. (3.7.4.h and 3.7.7.k) Due: Complete o Strategy 8 - Sampled past OE Digests (previously Tracking Trends) and Topical Reports for adequate evaluation. (SIBP/SIIP 3.7.7.g)

A sample of past [Tracking Trends] documents and Topical Reports will be reviewed to determine whether PVNGS should take additional actions to address the conditions identified in the reports. A collective evaluation will be performed of the results of the review to determine whether the sample size should be expanded. (Tracking Trends started in 2002.) (3.7.7.g) Due: Complete 23

Focus Area 7 - Limited Experience and Training o Strategy 1 - For System Engineers, developed a design and licensing bases knowledge assessment and turnover process for assigned systems. Completed incumbent analysis of system engineers per the system engineering handbook work authorization checklist and identified gaps in knowledge. (SIBP/SIIP 3.7.8.h and 3.7.8.1)

• System Engineering will develop an appropriate system turnover process to include accomplishment of the necessary technical and administrative material prior to turnover. This turnover process will assure engineers review specific system technical and operational information (high risk significant systems first).

This includes specific design and licensing requirements (e.g., information from the Technical Specifications, UFSAR, DBM, STM, etc.). The process should be structured to suit both .current needs (experienced engineers) and for future needs (inexperienced engineers) and should include provisions for the Legacy Project. (3.7.8.h) Due: Complete

" Revise the SE Handbook to include the SE Work Authorization Checklist.

(3.7.8.1) Due: Complete o Strategy 2 - Perform remediation of system engineering derived from incumbent analysis gaps. (SIBP/SIIP 3.7.8.i and 3.7.8.b)

" Review completed System Engineer Incumbent and Section Leader analysis.

Develop plan for remediation for areas identified by Jan 30th, 2007 with completion of remediation by June 30th, 2007. (3.7.8.i) Due: Complete

" Complete remediation in areas identified from incumbent and section leader analysis performed under CRAI 2950481 [that were completed] by June 30th, 2007 (3.7.8.b) Due: 06/01/2008 o Strategy 3 - Developed and implemented a procedure to identify design and licensing basis knowledge gaps among incumbent engineering personnel. (SIBP/SIIP 3.7.8.m, 3.7.8.n, and 3.7.8.0)

" Based on the review of action taken by System Engineering to address the issues identified CRAI 2825660, it was determined that a similar initiative should be implemented in the Design and Maintenance Engineering departments therefore, a CRAI has been initiated for each Department: Design Engineering I&C/Electrical, Design Engineering Mechanical and Maintenance Engineering to develop and implement a work assignment checklist, similar to System Engineering, for the Engineers assigned to that section. The work assignment checklists most likely will revolve around Topical areas instead of system areas.

[Electrical/l&C Design Engineering] (3.7.8.m) Due: Complete

" Based on the review of action taken by System Engineering to address the issues identified CRAI 2825660, it was determined that a similar initiative should be implemented in the Design and Maintenance Engineering departments therefore, a CRAI has been initiated for each Department: Design Engineering 24

I&C/Electrical, Design Engineering Mechanical and Maintenance Engineering to develop and implement. a work assignment checklist, similar to System Engineering, for the Engineers assigned to that section. The work assignment checklists most likely will revolve around Topical areas instead of system areas.

[Mechanical/Civil Design Engineering] (3.7.8.n) Due: Complete Based on the review of action taken by System Engineering to address the issues identified CRAI 2825660, it was determined that a similar initiative should be implemented in the Design and Maintenance Engineering departments therefore, a CRAI has been initiated for each Department: Design Engineering I&C/Electrical, Design Engineering Mechanical and Maintenance Engineering to develop and implement a work assignment checklist, similar to System Engineering, for the Engineers assigned to that section. The work assignment checklists most likely will revolve around Topical areas instead of system areas.

[Maintenance Engineering] (3.7.8.0) Due: Complete o Strategy 4 - For Design and Component engineers, perform incumbent analyses to identify training and knowledge weaknesses. (SIBP/SIIP 11.8.8 and 11.8.7)

. Perform an incumbent analysis for the Component Performance Engineering department to identify training/knowledge weaknesses and identify backups.(11.8.8) Due: 06/01/2008

. Perform an incumbent analysis for the design engineering department to identify training/knowledge weaknesses. (11.8.7) Due: 06/01/2008 o Strategy 5 - Perform remediation for design and component engineering derived from incumbent analysis gaps. (SIBP/SIIP 3.7.8.v, 3.7.8.c, and 3.7.8.d)

• Develop a remediation plan and complete remediation of component engineers where analysis performed under CRAI 3033591 identified knowledge gaps (3.7.8,v) Due: 12/19/2008

- Implement and complete remediation plan for identified Design Engineers following completion of incumbent analysis conducted in CRAI 3021273.

[Mechanical/Civil Design Engineering] (3.7.8.c) Due: 12/19/2008

• Implement and complete remediation plan for identified Design Engineers following completion of incumbent analysis conducted in CRAI 3021285.

[Electrical/l&C Design Engineering] (3.7.8.d) Due: 12/19/2008 o Strategy 6.- Develop and implement Computer Based Training for methods and critical aspects of understanding of the design and licensing bases of interfacing systems.

(SIBP/SIIP 3.7.8.u, 3.7.8.w, 3.7.8.x, and 3.7.8.y)

Develop a short CBT course to describe how to identify each interfacing system design basis as part Of the System Engineering Work Assignment Authorization.

The CBT course would direct System Engineers to not only identify their system interfaces, but how those interfaces may change during a Design Basis Accident (e.g., pressure, temperature, voltage). (3.7.8.u) Due: Complete 25

Each System Engineer will complete the CBT course ECT01 - Impact of Supporting Systems. [System Engineering Mechanical NSSS] (3.7.8.w) Due:

Complete Each System Engineer will complete the CBT course ECT01 - Impact of Supporting Systems. [System Engineering Mechanical BOP] (3.7.8.x) Due:

Complete

• Each System Engineer will complete the CBT course ECT01 - Impact of Supporting Systems. [System Engineering Electrical and I&C] (3.7.8.y) Due:

Complete o Strategy 7 - Develop and implement improved initial training for engineering personnel on design and licensing basis. (SIBP/SIIP 11.8.4)

Conduct needs analysis with engineering management to determine the frequency and content of design and licensing basis training for specific

• engineering positions. This analysis will also determine the content and method for initial training. (11.8.4) Due: Complete Focus Area 8 - Limited Resources o Strategy 1 - Engineering defined the roles and responsibilities of each engineering group to improve focus of activities. (SIBP/SIIP 3.7.9.h)

Engineering will define the roles, responsibilities, and expectations of the various departments of the Engineering Organization to Palo Verde. Consider incorporating related INPO guidance. (Note in discussions with investigation team the intent of looking at INPO guide is to capture items to add to roles, responsibilities, and expectations write-up). (3.7.9.h) Due: Complete o Strategy 2 - Engineering developed a long range staffing plan that included analysis of retirement projections and yearly analysis for hiring through the Legacy Program.

(SIBP/SIIP 3.7.9.i)

• Develop a long-term plan (pursuant to the Legacy Program) for personnel hiring and development to address expected workforce retirements. (3.7.9.i) Due:

Complete o Strategy 3 - Issued for use initial baseload work schedules for Design, Systems, and Component Engineering Departments. (SIBP/SIIP 11.9.A.8)

• Issue for use initial base load work schedules for Design, System, &

Maintenance Engineering Department. (11.9.A.8) Due: Complete o Strategy 4 - Establish and conduct periodic Engineering work management meetings, between Engineering Leaders and their staffs, to review work prioritization, resource allocation, and schedule dates for assigned work activities. (SIBP/SIIP 11.9.A.9) 26

Establish and conduct periodic Engineering work management meetings, between Engineering Leaders and their staff, to review work prioritization, resource allocation, and schedule dates for assigned work activities and incorporate results into the engineering schedule. (11.9.A.9) Due: 04/15/2008 o Other Focus Area 8 Tasks:

" Monitor performance indicators applicable to the backlog of undispositioned DFs, EDCs and CRDR evaluations assigned to Nuclear Engineering. Action plans for improvement are developed and implemented for those cases in which the goals are not satisfied. CRAI 2856973 is being used as an Effectiveness Review related to Engineering Staffing. (3.7.9.a) Due: Complete

" Assigning the responsibility for performance of modifications to contractors while maintaining a core of experienced design engineers to maintain oversight of the technical adequacy of the work products of the contractors. (3.7.9.c) Due:

Complete

" Develop a Conduct of Engineering procedure. The procedure should include engineering principles and standards. Incorporate a requirement into the Engineering TPD to train on the Conduct of Engineering procedure in initial training and continuing training. (11.8.30) Due: Complete

" Issue revised expectations for system engineering for monitoring and trending system performance. (1.2.F.1) Due: Complete Revise system eng. handbook to include the expectations identified in task 1.2.F.3 (e.g., trending and monitoring). (1.2.F.4) Due: 04/30/2008

" Validate/Resolve or delete general Engineering Product Review Board comments on emergent issues impacting preventive activities. Collect' data through interviews to determine work or functions not getting done by the various engineering groups. Include potential safety significance and whether any items are not captured in the station corrective action system. (3.7.9.e) Due: Complete 27

Focus Area 9 - Limited Nuclear Assurance Department Oversight o Strategy 1 - The auditing procedure, 60DP-OQQ19, was revised to include the following to ensure that pertinent technical specifications and design configuration issues are reviewed during audits:

Ensured that audit scopes include provisions for an in-depth review of LCO-related Technical Specifications, as appropriate to the area being audited, and that audit teams include personnel (auditors or technical specialists with the appropriate engineering or operational expertise. (SIBP/SIIP 3.7.1O.a)

Revise procedure 60DP-OQQ19 (Internal Audits) [to ensure] that during planning for Nuclear Assurance audits, the audit scopes should include provisions for an in-depth review of LCO-related Technical Specifications, as appropriate to the area being audited. The intent of this in-depth review is to verify the technical specification and related surveillance requirement acceptance criteria are consistent with supporting design and licensing documents. Audits that perform these in-depth reviews should include personnel (auditors or technical specialists) with the appropriate engineering or operational expertise. The overall intent is to perform an in-depth review of all safety-significant Technical Specifications over time during the course of audit performance. During planning for the required biennial Technical Specification audits, the scope of the in-depth reviews performed in other audits shall be used to focus the technical specification audit on selected Technical Specifications which have not had an in-depth review. (3.7.1O.a) Due: Complete

" Required that the underlying issues surrounding the RAS event are discussed in audit pre-job briefings. (SIBP/SIIP 3.7.10.b)

NAD should incorporate the streamlined case study from Performance Improvement Department (PID) CRAI 2825482 RAS Case Study and initiate the expectation that it be used during pre-job briefs for audits.

Emphasis should be placed on ensuring the proper communications are made of pertinent information (including design information) to responsible organizations. (3.7.10.b) Due: Complete Developed checklists for use in evaluating the adequacy of technical products.

(SIBP/SIIP 3.7.10.c)

NAD should coordinate with Performance Improvement Department (PID) and incorporate the appropriate information from the checklists developed by Performance Improvement Department (PID) in CRAI 2825483 into audit checklists. See CRAI 2825483 for guidance to be included. These checklists define attributes to be examined during reviews of technical products to determine their adequacy. (3.7.10.c) Due: Complete Strategy 2 - Developed and implemented a process to ensure that NAD evaluations are based upon a broad set of inputs, including: plant operating characteristics, NRC issuances, industry advisories, Licensee Event Reports, and other sources of plant 28

design and operating experience information, including plants of similar design, which may indicate areas for improving plant safety. (SIBP/SIIP 3.7.1O.g and 3.7.10.i)

" Determine and implement a process to review from a broad, composite method "plant operating characteristics, NRC issuances, industry advisories, Licensee' Event Reports, and other sources of plant design and operating experience information, including plants of similar design, which may indicate areas for improving plant safety." Also determine the method to document these reviews.

(3.7.10.g) Due: Complete

" Coordinate this action with CRDR 2820745 which will focus on improving the Independent Safety Reviews. Develop methodology to conduct fewer and more in-depth assessments. The purpose of this action is for the NAD leaders to select specific, high impact activities during the weekly work planning meeting to perform in depth ER's on. (3.7.10.i) Due: Complete Strategy 3 - Conducted a detailed stand-down with all Lead Auditors to discuss and reinforce expectations for the conduct of audits and the subsequent reporting of results (interim actions). (SIBP/SIIP 3.7.10.d and 3.7.10.f)

Using the Sequence of Events table provided in the evaluation of significant CRDR 2833743 as talking points, conduct a detailed stand-down with. all Lead Auditors to discuss and reinforce expectations for the conduct of audits and the subsequent reporting of results. At a minimum, the Director of NAD needs to communicate his expectations regarding the importance of:

a. clearly identifying and developing issues/deficiencies,

b. leaving emotions and personal opinions out of conclusions,

c. clearly stating/wording conclusions based on supporting facts, and

d. not putting a positive spin on conclusions because of peer or management pressure, i.e., tell it like it is.

(3.7.10.d) Due: Complete Implement post audit conference with each ATL for audits conducted in the 1st quarter to determine if there are any areas where management did not provide the necessary level of support. Implement actions to address any concerns.

(3.7.10.f) Due: Complete o Other Focus Area 9 Tasks:

Revise Procedure 60DP-0QQ17 [Conduct of Nuclear Assurance Evaluations] to add instructions for the UFSAR 13.4.4.1 [Independent Safety] reviews based on the prior CRAIs results [Implement CRAI 2833209]. (3.7.10.h) Due: Complete Nuclear Assurance to pilot a NAD Product Review Board, utilizing independent technical expertise, to ensure desired improvements is being achieved. (3.7.10.o)

Due: Complete 29

Focus Area 10 - Limited Procedural Guidance (DBM Writers Guide) o Strategy 1 - Identify and resolve limitations of Design Basis Manuals (DBM):

. Communicated to engineering personnel regarding DBM limitations (interim action),(SIBP/SIIP 3.7.31q, 3.7.8.k and 3.7.11.b)

Engineering to communicate to all potential DBM users, on the possible limitations of the DBMs and measures to effectively use the DBMs.

Accuracy of the DBMs may not be 100%; there may be errors of omission (primarily unincorporated EDCs, and other possible omissions) and possibly inaccurate content. Users should QV&V the information with other resources when possible. (3.7.3.q, 3.7.8.k and 3.7.11.b) Due:

Complete

. Revised initial Engineering Tech Staff training to address limitations of DBMs (SIBP/SIIP 3.7.3.o)

• Revise NGT-91 to communicate the DBM usage limitations to future engineering staff. This CRAI is also related to CRAI 2825641. (3.7.3.o)

Due: Complete

. Add note on DBM cover page on limitations of DBMs and direction to refer to source documents (SIBP/SIIP 3.7.3.h and 3.7.11.a)

• Add a standard note to the cover page of each design bases manual to require personnel to refer to source documents when developing engineering work products or performing quality activities. (3.7.3.h and 3.7.11.a) Due: 05/22/2008 N Update the DBM Writer's Guide to provide guidance on addressing interface requirements and Operating Experience reviews (SIBP/SIIP 3.7.3.w)

• Update 83DP-4CC02, Design Basis Manual, Finalization, (developed for the original design basis program) to provide guidance for the inclusion of the interface requirements and method of compliance, the high risk component listing, and an enhanced Industry Operating Experience (IOE) section. The IOE section will include the topic and the Palo Verde response. The guidance will address the following items for the systems with applicable NSSS to BOP design interface requirements:

a. Identify and discuss the applicable NSSS to BOP design interface requirements and the associated interface compliance evaluations.

b. Establish the system and component related performance interface requirements (e.g., supply x gpm); the required performance parameter shall be identified for each system operating scenario (e.g., large break LOCA, small break LOCA, main steam line break, etc.).

30

c. Document the APS design calculations that demonstrate compliance with the interface requirement and the NSSS Supplier calculations identified that establish the analytical basis for the NSSS to BOP design interface requirements. (3.7.3.w)

Due: 07/25/2008 Strategy 2 - Revised the design and technical document control procedure to-require personnel changing, or adding a reference to a DBM to thoroughly review the reference document. (SIBP/SIIP 11.6.11)

Engineering to revise the 81DP-0CC05 (Design and Technical Document Control) and 81TD-OEE10 (Plant Design and Modification) as appropriate to specify for any changes to the DBMs, any new reference or source documents

,used for the revision or changes needs to be reviewed in its entirety for pertinent information and not just using abbreviated summary information. This is to preclude using the reference or source documents out-of-context and missing pertinent information. (11.6.11) Due: Complete Strategy 3 - Conducted additional reviews of UFSAR to review effectiveness of CESSAR information incorporation project. (SIBP/SIIP 3.7.11 .e)

Conduct additional UFSAR reviews using the identified scope. [CESSAR to UFSAR Conversion Project] The reviews should be documented similar to the matrix model concept and criteria from Attachment 2 of CRDR 2726509. See also CRAI 2830487 which contains the matrices for the original systems picked during 2726509. This effort may be modified to integrate with other site reviews.

(3.7.1 1.e) Due: Complete Strategy 4 - Identify and resolve latent designand licensing basis issues:

" Complete Component Design Bases Review for High Risk components (SIBP/SIIP 11.6.7, 11.6.1.a, 11.6.1.b, 11.6.1.c and 11.6.13)

• Finalize overall (3 year) scope of CDBR High Risk, low margin components by both a qualitative & quantitative PRA/analysis. (11.6.7)

Due: Complete

• Complete CDBR on High Risk components in the Diesel Generator system. (11.6.1 .a) Due: 10/24/2008

• Complete CDBR on High Risk Components in the Auxiliary Feedwater system. (11.6.1.b) Due: 10/24/2008

• Complete CDBR on High Risk Components in the Safety Injection system. (11.6.1.c) Due: 09/26/2008 Complete Component Design Basis Review Project per project schedule.

(11.6.13) Due: 12/31/2010 Revise DBMs based upon results. (SIBP/SIIP 3.7.3.x and 3.7.3.y) 31

Revise the Design Basis Manuals for systems containing high risk components to incorporate the changes outlined in the revised Design Basis Manual Writer's Guide and other changes that were identified during the project (refer to CRAI 3069703). (3.7.3.x) Due: 11/18/2011 Create a new Topical Design Basis Manual (DBM) for systems that have NSSS design interface requirements and do not have a system DBM.

(3.7.3.y) Due: 11/18/2011 32

Attachment 3 Key Performance Area 2 Unit 3 Emergency Diesel Generator (EDG) K-1 Relay Actions Listing of Specific Tasks and Due Dates

Attachment 3 Key Performance Area 2 Unit 3 Emergency Diesel Generator (EDG) K-1 Relay Actions Listing of Specific Tasks and Due Dates To address root and contributing causes identified in your evaluations in response to the White finding associated with the Unit 3 Train A EDG electrical relay failures. PVNGS will implement the following:

SlIP Action Plan 14, "EDG K-1 Relay Event," Strategies 1 through 7 0 Strategy 1 - Straightened metal actuator arm in the Unit 3 DG (A) K1 relay to restore sufficient contact compression. Inspected and straightened 5 other DG's K-1 relay actuator arms as necessary. (SIBP/SIIP 3.6.49)

• ERCFA [Equipment Root Cause Failure Analysis] root cause investigation Report (CRDR 2926830) has identified:

Straightened metal actuator arm in K1 relay to restore sufficient contact compression. (For DG-3A under work order 2926829 and other DG's under work orders 2919670, 2919671, 2919672, 2919666 and 2919673).

The above action was completed as part of ERCFA investigation. This CRAI provides documentation of closure in accordance with 01 DP-0AC06. (3.6.49)

Due: Complete o Strategy 2 - Updated vendor tech manual and Model Work Scope Library (WSL) revised to ensure proper contactor set-up and DC coil switch cleaning instructions are provided. (SIBP/SIIP 3.6.5, 3.6.47 and 3.6.48)

" Revise WSL 243880 (or create a new task specifically for the DG FF/K1 contactors) to provide instructions for how to remove/clean the auxiliary contacts, verifying as found/as left contact resistance values for the main/auxiliary contacts, verify proper switching of the main/auxiliary contacts and the need to perform functional testing if components on the FF contactor are removed for any reason.

(3.6.5) Due: Complete

" ERCFA root cause investigation (CRDR 2926830) has identified:

• "Model Work Scope Library (WSL) 2960093 created to ensure proper contactor set-up and DC coil switch cleaning instructions are provided."

The above action was completed as part of ERCFA investigation. This CRAI provides documentation of closure in accordance with 01DP-OAC06. (3.6.47) Due: Complete

" ERCFA root cause investigation (CRDR 2926830) has identified:

• "Vendor Technical Manual VTD-P-292-00004 for DG cabinet updated with Engineering Design Change (EDC) 2007-00048" 1

(Additional information: This EDC 2007-00048 added additional information for the purpose of providing better detail for the inspection of the K1 DC Coil auxiliary contact module.) :

The above action was completed as part of ERCFA investigation. This CRAI provides documentation of closure in accordance with 01 DP-0AC06. (3.6.48) Due: Complete o Strategy 3 - Reviewed PM templates for the DG [Diesel Generator] System to ensure that identified single point vulnerabilities are effectively managed. (SIBP/SIIP 3.6.57)

Ensure Reliability Centered Maintenance (RCM) templates effectively manage identified single point vulnerabilities (SPVs) on the diesel generator (DG) system.

Specifically, determine if maintenance tasks are effective in ensuring DG reliability or if DG modifications are needed. (3.6.57) Due: Complete o Strategy 4 - Reviewed similar relays in other safety related systems for extent of cause. (SIBP/SIIP 3.6.59 through 3.6.65)

• Identify and classify the components in the PB [Class 1E 4.16KV Power] system designated to have moving parts which break or make contacts and/or physical adjustments which control the actuation of the device. See table in CRAI 3014243 for initial evaluation of components in the PB system.

Determine if the moving part affects the safety function of the device. If the safety function of the device is not affected or there are no adjustments or measurements possible then no further investigation is required.

Evaluate current Palo Verde documentation to determine if dimensional criteria are given for the components. If criteria is given, determine if this criteria verified during PM tasks via WSL documentation.

If dimensional criteria are not found, the vendor will be contacted to attempt to establish this criterion. (3.6.59) Due: Complete Identify and classify the components in the PG [Class 1 E 480V Power Switchgear] system designated to have moving parts which break or make contacts and/or physical adjustments which control the actuation of the device.

See table in CRAI 3014243 for initial evaluation of components in the PG system.

Determine if the moving part affects the safety function of the device. If the safety function of the device is not affected or there are no adjustments or measurements possible then no further investigation is required.

Evaluate current Palo Verde documentation to determine if dimensional criteria are given for the components. If criteria is given, determine if this criteria verified during PM tasks via WSL documentation.

If dimensional criteria are not found, the vendor will be contacted to attempt to establish this criterion. (3.6.60) Due: Complete Identify and c!assify the components in the PH [Class 1E 480V Power MCC]

system designated to have moving parts which break or make contacts and/or physical adjustments which control the actuation of the device. See table in CRAI 3014243 for initial evaluation of components in the PH system.

2

Determine if the moving part affects the safety function of the device. If the safety function of the device is not affected or there are no adjustments or measurements possible then no further investigation is required.

Evaluate current Palo Verde documentation to determine if dimensional criteria are given for the components. If criteria is given, determine if this criteria verified during PM tasks via WSL documentation.

If dimensional criteria are not found, the vendor will be contacted to attempt to establish this criterion. (3.6.61) Due: Complete Identify and classify the components in the PK [Class 1 E 125V DC Power]

system designated to have moving parts which break or make contacts and/or physical adjustments which control the actuation of the device. See table in CRAI 3014243 for initial evaluation of components in the PK system.

Determine if the moving part affects the safety function of the device. If the safety function of the device is not affected or there are no adjustments or measurements possible then no further investigation is required.

Evaluate current Palo Verde documentation to determine if dimensional criteria are given for the components. If criteria is given, determine if this criteria verified during PM tasks via WSL documentation.

If dimensional criteria are not found, the vendor will be contacted to attempt to establish this criterion. (3.6.62) Due: Complete Identify and classify the components in the DG [Diesel Generator] system designated to have moving parts which break or make contacts and/or physical adjustments which control the actuation of the device. See table in CRAI 3014243 for initial evaluation of components in the DG system.

Determine if the moving part affects the safety function of the device. If the safety function of the device is not affected or there are no adjustments or measurements possible then no further investigation is required.

Evaluate current Palo Verde documentation to determine if dimensional criteria are given for the components. If criteria is given, determine if this criteria verified during PM tasks via WSL documentation.

If dimensional criteria are not found, the vendor will be contacted to attempt to establish this criterion. (3.6.63) Due: Complete Identify and classify the components in the AF [Auxiliary Feedwater] system designated to have moving parts which break or make contacts and/or physical adjustments which control the actuation of the device. See table in CRAI 3014243 for initial evaluation of components in the AF system.

Determine ifthe moving part affects the safety function of the device. If the safety function of the device is not affected or there are no adjustments or measurements possible then no further investigation is required.

Evaluate current Palo Verde documentation to determine if dimensional criteria are given for the components. If criteria is given, determine if this criteria verified during PM tasks via WSL documentation.

If dimensional criteria are not found, the vendor will be contacted to attempt to establish this criterion. (3.6.64) Due: Complete 3

• Identify and classify the components in the HP [Containment Hydrogen Control]

system designated to have moving parts which break or make contacts and/or physical adjustments which control the actuation of the device. See table in CRAI 3014243 for initial evaluation of components in the HP system.

Determine if the moving part affects the safety function of the device. If the safety function of the device is not affected or there are no adjustments or measurements possible then no further investigation is required.

Evaluate current Palo Verde documentation to determine if dimensional criteria are given for the components. If criteria is given, determine if this criteria verified during PM tasks via WSL documentation.

If dimensional criteria are not found, the vendor will be contacted to attempt to establish this criterion. (3.6.65) Due: Complete o Strategy 5 - Implement 01 DP-9ZZ01, Systematic Troubleshooting, as the Palo Verde troubleshooting and problem solving process and provide training to selected Operations, Maintenance, and Engineering personnel. (SIBP/SIIP 3.6.55, 3.6.72 and 11.8.21)

" Implement 01 DP-9ZZ01, Systematic Troubleshooting as the Palo Verde troubleshooting and problem solving process. (3.6.55) Due: Complete

" Provide training to selected Operations, Maintenance and Engineering personnel on the new troubleshooting and problem solving process. (3.6.72) Due: Complete

" Provide training on the systematic problem solving and decision-making methodology/techniques (CRAI 3065762). Training should be given to specified leaders, engineering, operations, maintenance, NAD as determined by Senior Engineering and Operations Leadership. The training will be given in stages with the following selection:

- Selected EFIN members - 06/15/08

- Selected Operations and Maintenance Members - 09/30/08

- Specified leaders and selected NAD members - 09/30/08 (11.8.21) Due: 09/30/2008 o Strategy 6 - Develop and provide training to ERCFA qualified personnel on failure modes considerations, use of OE, and accountability to assure quality investigations.

(SIBP/SIIP 3..6.7)

Develop and provide training to ERCFA qualified personnel that will included:

- The need to consider all failure modes as part of initial troubleshooting and root cause activities.

- Reviewing any applicable OE as part of the initial troubleshooting and root cause activities.

- A discussion of establishing appropriate priority to ensure a quality analysis.

- A discussion of accountability and expectations for both quality and timeliness.

(3.6.7) Due: 10/30/2008 o Strategy 7 - Replace the K1 relays in the EDG control cabinets XJDGA(B)B02 for all six onsite Class 1 E EDGs. Implement mod in all-three units. (SIBP/SIIP 3.6.11) 4

DMWO 3089358-Kl Relays replacement in the EDG control Cabinet XJDGA(B)B02 (x=1,2&3) for all six Class 1 E EDG's. Implement mod in all three units and close DMWO paperwork (U1- DIWO 3126811, 3126813), (U2- DIWO 3126815, 3126816), (U3 - DIWO 3126817, 3126818) (3.6.11) Due: 06/30/2009 5

Attachment 4 Key Performance Area 3 Problem Identification and Resolution (PI&R) Actions Listing of Specific Tasks and Due Dates

Attachment 4 Key Performance Area 3 Problem Identification and Resolution (PI&R) Actions Listing of Specific Tasks and Due Dates To address problem identification and resolution issues, PVNGS will implement the following:

SlIP Action Plan 3, "Engineering Technical Rigor," Strategies 3 and 4 o Strategy 3 - Implement an Engineering Operations Support team with a charter for Operations interface and support on the Operability Determination process.

(SIBP/SIIP 4.1 .G.16)

Implement an Engineering Operations Support (EOS) team with a charter for Operations interface and support on the operability determination process. The charter will include the Engineering function to support assessment of CAP conditions routed through Operations for functionality assessment and potential impact on operability. (Note: This action is complete and was given an 11/30/2007 due date in the SIBP to submit a closure package) (4.1.G.16) Due:

Complete o Strategy 4 - Develop and incorporate Operability Determination training into initial and continuing engineering training. (SIBP/SIIP 5.1 .E.3 and 5.1 .E.4)

" Incorporate Operability Determination in Engineering Continuing Training program requirements. (5.1.E.3) Due: Complete

" Develop and incorporate initial training on Operability Determinations into ETP.

Revise the ETP Plan, as needed. (5.1.E.4) Due: 05/31/2008 SlIP Action Plan 6, "Performance Improvement," Part 1, Strategies 4, 6 (Tasks 3.2.5 and 3.3.2), and 10 o Strategy 4 - Incorporate performance objectives for CAP timeliness and quality into the Performance Management Plans (PMPs) for each position. (SIBP/SIIP 3.5.3.f)

• Root Cause CRDR 3015327 actions - monitoring for performance. (Major Task)

Based on the metrics and standards developed from the Business Plan as directed by CRAI 3037445, develop performance objectives for:

1) Evaluation timeliness and quality

2) Closure timeliness and quality Incorporated these performance objectives into the PMP for each position.

The Corrective action Department will provide the criteria to be incorporated into the PMP from task 3.5.3.d (CRAI 3037445). (3.5.3.f) Due: 06/15/2008 o Strategy 6 - Improve quality and consistency of root and apparent cause evaluations.

(SIBP/SIIP 3.2.5 and 3.3.2) 1

Improve quality and consistency of root and apparent cause evaluations through the development of a consistent oversight process using CARB, Performance Improvement Department and Nuclear Assurance Department. Reference CRDRs 3004975, 2963246, 3023548. (Major Task)

" Determine/define roles and responsibilities of oversight functions (e.g.

Performance Improvement Department (PID), CARB, and NAD). (3.2.5.a)

Due: Complete

" Develop and implement a methodology for resolving differences between oversight group conclusions (e.g. compliance versus continuous learning).

(3.2.5.b) Due: Complete

" Implement root and apparent cause review checklists to be used by Performance Improvement Department (PID), CARB, and NAD. Checklists should be compliance based, yet allow for identification of areas for improvement, and allow for a comparison of oversight group results -

continuous learning. (3.2.5.c) Due: Complete

• NAD to implement use of the Significant CRDR Root Cause evaluation grade sheet and provide to the CAP for tracking and trending. Reference CRDR 3018463. (3.2.5.d) Due: Complete

" Develop and implement Root Cause review and quality grading training for CARB and NAD. Reference CRDR 3018463. (3.2.5.e) Due: Complete Implement a process for periodic review of CARB scorecard results and provision of roll-up score card results to the management team, training department, Performance Improvement Department (PID), root and apparent cause investigators, oversight groups, and Advocates. (3.2.5.f) Due:

Complete Develop a core group of root cause and apparent cause evaluators. (3.3.2)

• Establish a core group of six (6) root-cause evaluators, assigned to the Performance Improvement Department to perform event investigations. [See task 3.3.2.c in SlIP Action Plan 6, Strategy 6, for the job qualification piece of this performance improvement effort. Due: 07/31/2008] (3.3.2.a) Due:

Complete

• Establish a core group of apparent-cause evaluators to perform causal evaluations. [See action 3.4.10.i in SlIP Action Plan 10, which addresses evaluator qualifications for the quality piece of this performance improvement effort. Due: 07/31/2008] (3.3.2.b) Due: Complete

• Implement a job qualification for Root Cause investigations, reviews, and approvals that describes and specifies initial, continuing, and requalification training requirements. The qualification guide stakeholders include Root Cause investigators, Investigation Directors, CARB, and NAD. Reference CRDR 3018463. (3.3.2.c) Due: 07/31/2008 o Strategy 10 - Implement process changes to include reinstitution of the adverse evaluation, improvement of CAP governing procedures, and improvement of trending processes. (SIBP/SIIP 3.4.7.a through 3.4.7.k, 3.4.2.b, 3.4.9.d, and 3.4.10.a through 3.4.1 0.j) 2

Improve trending program/process in a phased approach, with level of sophistication increasing with improved CAP performance. It is acknowledged that some trends may be missed in the early phases; however, this approach is consistent with comprehensive performance improvement plans wherein actions must be prioritized due to limited resources. (Major Task)

• Phase 0 - Review existing trend capabilities and implement interim actions to provide immediate capabilities to perform simple trending. (Programs, processes, and human performance) (3.4.7.a) Due: Complete

" By November 30,2007 conduct a meeting with the Performance Improvement Department Management Team to:

1) Determine desired trend capabilities and

2) Develop a plan to implement these capabilities which will be documented in new CRAI(s).

The meeting notes and plan will be included in this CRAI as evidence of completion of action. If it is determined that additional IS support will be required, generate new CRAI(s) to document and track this under the initiative parent CRDR. (3.4.7.b) Due: Complete

• Establish priority and schedule for implementing electronic business revisions in support of monitoring of CAP. Present to senior management. (3.4.7.c)

Due: 06/27/2008

• Implement trending process wherein the advocates review departmental data and identify potential trends in a quarterly report for each department.

(3.4.7.d) Due: Complete

" Benchmark industry for trending programs. Present to senior management.

(Develop actions plan as a result of 3.4.7.f and incorporate into this initiative)

(3.4.7.e) Due: 04/04/2008

• Implement a monthly departmental "trend day" and quarterly "trend day" process wherein departments review their trends on a monthly basis and senior management reviews the roll-ups on a quarterly basis. (3.4.7.f) Due:

Complete

• Phase 1 -- Modify existing Palo Verde trend program to a basic level to track gross subjects and numbers associated with program, process, and equipment failures (e.g. 20 failures against the CH system). [reactive]

(3.4.7.g) Due: 05/30/2008

• Phase 2 -- Incorporate changes into the Palo Verde trend program to be forward looking to provide insights on why trends are occurring (e.g. 20 failures have occurred on the CH system because of a lack of PM implementation). [proactive] (3.4.7.h) Due: 11/30/2008

• Phase 3 -- Incorporate changes into the Palo Verde trend program such that the line organizations trend their own data and identify developing trends, including the area of human performance on a proactive basis. (e.g. 20 failures Have occurred on the CH system because of a lack of PM implementation because personnel failed to recognize applicable operating experience). [proactive] (3.4.7.i) Due: 05/30/2009 3

" Phase 4 -- Implement an interactive automated trending program to facilitate identification of developing trends at both the line and site levels. [continuous learning organization] Present to senior management. (Incorporate into Information Services Building Block) (3.4.7.j) Due: 09/19/2009

• Provide training to and engage advocates in the trending process. Evidence of completion will be demonstrated by:

1. Completing briefing during weekly advocate meeting (attach attendance sheet and topic summary) and

2. Advocate input to the trend report (develop new section for advocate input)

(3.4.7.k) Due: Complete Reinstitute the "adverse evaluation." (Major Task) 0 Re-incorporate the "adverse" evaluation process into 90DP-0IP10.

(Reference task # 3.4.1 0.g) (3.4.2.b) Due: Complete Review and implement, as appropriate, previously identified process improvements. (Major Task)

• Improve CAP-related procedures by developing separate procedures for root cause, apparent cause, and common cause analyses. (3.4.9.d) Due:

07/31/2008 Root Cause CRDR 3015327 actions for process improvements. (Major Task)

• Revise the CARB Charter and CAP Procedures to require CARB review of closeout actions and documentation for Priority 2 corrective actions.

(3.4.10.a) Due: Complete

• Provide dedicated resources to support ARRC PVAR review and classification activities and ensure that the ARRC is their primary job function.

(3.4.10.b) Due: Complete

• Revise procedure 01 DP-OAP12, Palo Verde Action Request Processing, to ensure that Substantive Cross-Cutting Issues identified in NRC Reports and Confirmatory Action Letters are classified as "Significant." (3.4.10.c) Due:

Complete

• Develop and establish procedural Advocate duties and responsibilities to support the Site Integrated Business Plan. Reference CAP Building Block -

task 3.2.2.b. (3.4.10.d) Due: Complete

" Incorporate SMART (SPECIFIC, MEASURABLE, ACHIEVABLE, RELEVANT, TIMELY) Corrective Action development criteria into procedure 90DP-01P10, Condition Reporting, and into the PVNGS Root Cause Evaluation Manual. (3.4.10.e) Due: Complete

• Revise the Root Cause Evaluation Manual for Significant CRDR's, based on benchmarking of the industry. The revision should include the following, as a minimum:

- Update to reflect the PVAR Process

- SMART Corrective Action Criteria

- Organizational and Programmatic Assessment Tools 4

(3.4.10.f) Due: 07/31/2008

• Develop and implement in station CAP procedures an evaluation category for "simple evaluations" that do not require the level of rigor of an ACE but will ensure that minor issues are evaluated and CA's are determined using a logical and consistent method. (Reference task 3.4.2.b) (3.4.10.g) Due:

Complete

• Revise 90DP-01PI0, to require that procedure changes implemented as CAPR's for significant adverse conditions be annotated. (3.4.10.h) Due:

Complete

• Incorporate ACE Qualification requirements into Training Program Description to ensure that ACE evaluations are only assigned to personnel who are qualified. (3.4.10.i) Due: 07/31/2008

" Proceduralize the Station Quality Issues (SQI) reporting mechanism and ensure that it contains a graded, pre-determined sequence of actions for escalation if quality issues are not being resolved by the organization.

(3.4.10.j) Due: Complete SlIP Action Plan 6, "Performance Improvement," Part 2, Strategies 2, 4, 6, 7 and 8 o Strategy 2 - Develop and implement an operating experience screening committee, include criteria, charter, roles/responsibilities for cross-disciplinary review of in-coming (external) operating experience. (SIBP/SIIP 6.7.16)

• Develop and implement an operating experience screening committee, include criteria, charter, roles / responsibilities for cross-disciplinary review of in-coming (external) operating experience. (6.7.16) Due: 04/18/2008 o Strategy 4 - Develop a process to add OE to work packages. (SIBP/SIIP 6.7.11)

• Planning Department Leader will develop process which will add operating experience to work packages. (6.7.11) Due: 08/10/2008 o Strategy 6 - Develop and implement controls to ensure corrective actions implemented into procedures, processes, and training to address high-tier OE are not inadvertently deleted. (SIBP/SIIP 6.7.6)

Develop/implement method and controls to ensure operating experience, particularly high-tier operating experience as defined by 65DP-OQQ01 procedure, so that corrective actions incorporated into other procedures, processes and training can not be eliminated. (6.7.6) Due: 09/19/2008 o Strategy 7 - Evaluate and implement a robust self assessment and benchmarking process program aligned with industry best practices. (SIBP/SIIP 15.1.2, 15.1.7, 15.1.10, and 15.2.1)

• Transition current station policy for self-assessment to a station procedure and enhance to include, at a minimum:

- training requirements for team leaders and team members 5

- guidance regarding when to enter the self-assessment process, such as declining trends, upcoming assessment/audits, etc.- instructions for conducting self-assessments

- station quality review board, including charter and checklist

- planning and scheduling self-assessments. (15.1.2) Due: Complete

" Develop a process to identify and schedule overall station self-assessments, by department. The process will include submittal of self-assessment plan by department, integration of the plans into a tracking tool, annual review and approval of the station integrated self-assessment plan/schedule. (15.1.7) Due:

Complete

" Develop and implement station metrics/indicators associated with self-assessments. Base the indicators on benchmarking activity for industry best practices. (15.1.10) Due: Complete

" Develop guidelines which delineate station benchmarking expectations to include the following actions: (Major Task)

" Requirements for participation in benchmarking activities including but not limited to: Teleconferences, trips to other utilities, participation in industry committees, INPO, assist and evaluation teams, WANO, and attendance in industry conferences. (15.2.1 .a) Due: 05/15/2008

• Trip report guidance, including lessons learned and recommendations for incorporation. of good practices into SWMS. (15.2.1.b) Due: Complete

• Identify metrics to track benchmarking activities by department and by employee. Provide input to (Performance Improvement Department (PID) for incorporation into the site procedure, as necessary, under task 15.2.2.

(15.2.1.c) Due: Complete

• Identify a process to schedule/track employee participation in INPO/WANO activities by department. Provide input to Performance Improvement Department (Performance Improvement Department (PID)) for incorporation into the site procedure, as necessary, under SIBP task 15.2.2. (15.2.1.d)

Due: Complete o Strategy 8 - Conduct station quality review boards for reviewing and approving self assessment and benchmarking reports. (SIBP/SIIP 15.1.9)

• Conduct station quality review board for reviewing and approving self-assessment plans and completed reports, as part of the approval process, including a charter, with a minimum outline of roles and responsibilities, type of self-assessment to be approved, quality check, schedule, and review of self-assessment metrics/indicators. Upon completion/approval of the station quality review board, results will be communicated to the station via various methods, examples; leaders digest, HU/IS awareness newsletters, PV Online, etc. (15.1.9)

Due: 06/10/2008 6

Attachment 5 Key Performance Area 4 Human Performance Actions Listing of Specific Tasks and Due Dates

Attachment 5 Key Performance Area 4 Human Performance Actions Listing of Specific Tasks and Due Dates To address human performance issues, PVNGS will implement the following:

SlIP Action Plan 9, "Programs/Procedures/Work Instructions," Strategies 4, 5, 7, and 10 o Strategy 4 - Re-establish a procedures administrative control program and develop upper tier documents for implementation of vital processes and controls for procedural hierarchy. (SIBP/SIIP 12.2.8)

Develop and implement upper tier documents to define major processes identified through benchmarking and process mapping (CRAl 3062736). The process documents shall establish management controls necessary to ensure quality procedures are developed and used to support activities at PVNGS. The key elements should include a defined Nuclear Procedures Hierarchy, program sponsorship, and controls consistent with each procedure's safety significance.

(reference CRAI 3028938, CRDR 3015926; CRAI 3063627, CRDR 3079100)

(12.2.8) Due: 12/15/2008 o Strategy 5 - Identify major programs and processes vital to ensuring performance at PVNGS is maintained. (SIBP/SIIP 12.2.7)

• Identify the major programs/processes at PVNGS. (Reference CRAI 3028938, CRDR 3015926) (12.2.7) Due: 04/15/2008 o Strategy 7 - Complete Process mapping for development of a PV process inventory infrastructure. (SIBP/SIIP 12.3.2 and 12.3.3)

" Using a top down approach, create a high level integrated process map of Palo Verde's major processes per the Program Simplification process mapping methodology. (12.3.2) Due: 06/30/2008

" Based on the results of the high level process mapping sessions and benchmarking conducted in tasks 12.3.1 and 12.3.2, develop Palo Verde's process inventory infrastructure including process owners. (12.3.3) Due:

08/28/2008 o Strategy 10 - Identify and develop SWMS usability improvements. (SIBP/SIIP 16.2.A.4.b and 16.2.A.4.c)

Support the ImPACT process improvement efforts by implementing business defined usability improvements and the overall user interface upgrade for SWMS.

This requires migration from Oracle 6i client server forms/reports to Oracle 1 OG web forms/reports. (Major Task) 1

• Present the proposed plan to provide SWMS usability improvement to Senior Management for review and approval. (16.2.A.4.b) Due: Complete

" Establish funding and schedule SWMS usability improvements for implementation. (16.2.A.4.c) Due: 06/30/2008 SlIP Action Plan 11, "Human Performance/Industrial Safety," Part 1, Strategies 1, 2, 6, and 8.

o Strategy 1 - Revise and implement standards and expectations, including HU fundamentals. (SIBP/SIIP 6.1.1 through 6.1.3, 6.1.6, and 6.1.11)

" Update Standards and Expectations Preventing Events to include leadership fundamentals, which should include questioning attitude, technical rigor and decision making process. (Major Task)

• Revised policy for human performance program for inclusion of leadership fundamentals. (6.1.1.a) Due: 11/01/2008

• Incorporate leadership fundamentals into the HR Performance Management Process (PMP) for enhancing behaviors associated with shift manager, department leaders, section/team leaders and above. (6.1.1.b) Due:

01/09/2009

• Conduct effectiveness review or self-assessment on the implementation of the standards/expectations for leadership fundamentals. (6.1.1 .c) Due:

07/15/2009

" Update Standards and Expectations Preventing Events to include engineering fundamentals, which should include questioning attitude, technical rigor and decision making process. (Major Task)

• Revise policy for human performance program for inclusion of engineering fundamentals. (6.1.2.a) Due: 06/30/2008

• Incorporate Engineering principles and expectations (ref. 11.1) into conduct of Engineering procedure for enhancing engineering staff and leaders behavior. (6.1.2.b) Due: 06/30/2008 0 Develop and implement graded approach to HU error-prevention tools for engineering, which should include questioning attitude, technical rigor and decision making process. (Major Task)

• Identifystation procedures that contain direction for use of HU tools associated with engineering tools and revise as appropriate. Obtain additional resources from engineering as team members and align with resources from performance improvement human performance group.

(Reference Engineering Building Block - initiative 11.4) (6.1.3.a) Due:

04/15/2008

• Identify revised stations standard for graded approach to engineering error prevention tools. (6.1.3.b) Due: 04/15/2008

• Conduct effectiveness review or self-assessment on the implementation of the engineering human performance tools, standard/expectations for 2

engineering, and engineering fundamentals observations. (6.1.3.c) Due:

04/15/2009

" Review HU program to include appendix on risk assessment process. Develop additional actions, if appropriate, for implementation and inclusion into other station programs/processes. (6.1.6) Due: 11/15/2008

" Revise and implement standards and expectations, including fundamentals and graded approach to HU tools. (6.1.11) Due: Complete Strategy 2 - Implement Observation Program, analyze data quarterly to determine areas for improvement, and identify corrective actions. (SIBP/SIIP 6.2.1.a, 6.5.2.a through 6.5.2.k)

" Implement Management Observation Program. (Major Task)

Implement Observation Program for the.station' (6.2.1.a) Due: Complete

" Conduct quarterly analysis from data demonstrating declining performance associated with site and department indicators, corrective action data, and observation data. Analysis will be conducted with the corrective action program elements, such as apparent cause analysis, root cause investigations, common cause analysis and stream analysis. Individual action for each quarter, 2007-2009, will be generated. (Major Task)

• Second quarter 2007, review and determine if additional analysis is required for declining human performance, including organizational and programmatic trends. Generate and document PVAR/CRDR for trends. (6.5.2.a) Due:

Complete

• Third quarter 2007, review and determine if additional analysis is required for declining human performance, including organizational and programmatic trends. Generate and document PVAR/CRDR for trends. (6.5.2.b) Due:

Complete Fourth quarter 2007, review and determine if additional analysis is required for declining human performance, including organizational and programmatic trends. Generate and document PVAR/CRDR for trends. (6.5.2.c) Due:

Complete First quarter 2008, review and determine if additional analysis is required for declining human performance, including organizational and programmatic trends. Generate and document PVAR/CRDR for trends. (6.5.2.d) Due:

04/25/2008

" Second quarter 2008, review and determine if additional analysis is required for declining human performance, including organizational and programmatic trends. Generate and document PVAR/CRDR for trends. (6.5.2.e) Due:

07/25/2008

• Third quarter 2008, review and determine if additional analysis is required for declining human performance, including organizational and programmatic trends. Generate and document PVAR/CRDR for trends. (6.5.2.f) Due:

10/25/2008 3

" Fourth quarter 2008, review and determine if additional analysis is required for declining human performance, including organizational and programmatic trends. Generate and document PVAR/CRDR for trends. (6.5.2.g) Due:

01/25/2009

" First quarter 2009, review and determine ifadditional analysis is required for declining human performance, including organizational and programmatic trends. Generate and document PVAR/CRDR for trends. (6.5.2.h) Due:

04/25/2009

• Second quarter 2009, review and determine if additional analysis is required for declining human performance, including organizational and programmatic trends. Generate and document PVAR/CRDR for trends. (6.5.2.i) Due:

07/25/2009

• Third quarter 2009, review and determine if additional analysis is required for declining human performance, including organizational and programmatic trends. Generate and document PVAR/CRDR for trends. (6.5.2.j) Due:

10/25/2009

• Fourth quarter 2009, review and determine if additional analysis is required for declining human performance, including organizational and programmatic trends. Generate and document PVAR/CRDR for trends. (6.5.2.k) Due:

01/25/2010 o Strategy 6 - Develop and implement training for coach-the-coach, including situations awareness, observations, and how to provide feedback skills. (SIBP/SIIP 6.2.4.b and 6.4.4.b)

Develop and implement "Coach the Coach" training. (Major Task)

• Present "Coach the Coach" training concept to the Training Review Group (TRG) prior to 5/1/08 to obtain concurrence on concept, population to receive the training, schedule for development and implementation (to include a "pilot" with comment incorporation) of the training. Define additional actions following TRG review to track the training development, pilot presentation, and presentation due dates for the remaining populations to receive the training on or prior to 5/30/08. (6.2.4.b) Due: 05/30/2008 Develop and implement instructor training for reinforcement of human performance and industrial safety behaviors during classroom, lab, simulator, etc.

This should include the core and leadership fundamentals, individual department fundamentals attributes and the role of training instructors when changing behaviors. (Major Task)

• Implement training with training instructors, including some type of hands-on activity to reinforce the HU and IS behaviors. (6.4.4.b) Due: Complete o Strategy 8 - Develop Integrated Issues Identification Team (lilT) to be used in conjunction with coach-the-coach program. lilT should include cross-functional members, a charter, observation training, field time (physical walk downs),

identification of issues. (SIBP/SIIP 6.2.10)

• Develop Integrated Issues Identification Team (lilT) to be used in conjunction with coach-the-coach program. lIlT should include a charter, observation 4

training, field time (physical walk downs), identification of issues, and cross-functional members. Develop additional actions for implementation, as appropriate during the development of the process/team. (6.2.10) Due:

11/15/2008 SlIP Action Plan 13, "Training and Qualification," Strategy 3 o Strategy 3 - Establish guidance for and training on analysis of performance data such as field observations, corrective actions, human performance clock resets and line performance indicators for possible training solutions. (SIBP/SIIP 5.3.A.7 and 5.3.A.8)

" Establish guidance for analysis of performance data such as field observations, corrective actions, human performance clock resets and line performance indicators for possible training solutions. (5.3.A.7) Due: Complete

" Provide training on established guidance for analysis of performance data such as field observations, corrective actions, human performance clock resets and line performance indicators for possible training solutions. (5.3.A.8) Due:

Complete 5

Attachment 6 Key Performance Area 5 Engineering Programs Actions Listing of Specific Tasks and Due Dates

Attachment 6 Key Performance Area 5 Engineering Programs Actions Listing of Specific Tasks and Due Dates To address problems with the implementation of engineering programs, PVNGS will implement the following:

SlIP Action Plan 2, "Equipment Reliability," Strategies 2, 3, and 6 o Strategy 2 - Develop and implement a Long Range Planning process which includes major repetitive activities, major modifications, major maintenance activities, appropriate approval processes, and process metrics to measure its health.

(SIBP/SIIP 19.1.1.c, 19.1.1.f, 19.1.1.h, and 19.1.14)

Implement short-term actions for the establishment of a site-wide long-range plan including: (Major Task)

• Coordinate with feeder organizations and obtain input on items which should be considered for the long-range plan including major repetitive activities, major modifications, major maintenance activities (outage and on-line).

(19.1.1.c) Due: Complete

• Develop and implement a process for review and approval of items to be included into the long-range plan. Establish a long-range plan committee. The process should include a means to visibly display items which have been proposed for addition to the long-range plan, items which have received preliminary approval pending completion of estimating process, and items which have been formally approved and added to the plan, including resource and costing approval. (19.1.1.f) Due: Complete

• Develop metrics used to monitor the long-range planning process. (19.1.1.h)

Due: 06/27/2008 Conduct a focused assessment of the short-term actions implemented in steps task 19.1.1.a-g, and incorporate learnings. Assess the long-range plan to ensure it includes major repetitive activities, major modifications, and major maintenance activities identified by the Plant Health Committee for improving system and component health and these activities are integrated with other major site activities. (19.1.14) Due: 12/19/2008 o Strategy 3 - Revise the Equipment Root Cause of Failure Analysis (ERCFA) program to require that ERCFA level 1 evaluations include consideration and documentation of corrective actions to minimize the likelihood of recurrence including revisions to the PM Program. (SIBP/SIIP 1.2.D.2, 1.2.D.3, and 1,2.D.4).

• Revise the ERCFA program to require that ERCFA level 1 evaluations include consideration and documentation of corrective actions to minimize the likelihood of recurrence. (1.2.D.2) Due: Complete 1

" Notify or brief personnel performing ERCFA I evaluations on Corrective Action to Prevent Recurrence (CAPR CRAI 3065256) and Corrective Action (CA CRAI 3065259) from the root cause investigation. ERCFA I evaluations will require documentation of the consideration of actions to minimize the likelihood of recurrence. The ERCFA program owner will provide oversight to ensure that ERCFA I evaluations contain this documentation until the ERCFA program/procedure is revised. This is an interim action taken prior to ERCFA program revision. (1.2.D.3) Due: Complete

" Revise the ERCFA program to require that equipment failure analysis will consider the PM program as a barrier to failure. Evaluations shall determine if changes to the PM program are needed, i.e. revision to the PM template scope of tasks or their interval, and document the determination. (1.2.D.4) Due:

Complete o Strategy 6 - Implement a minor modifications process to better address small equipment challenges. (SIBP/SIIP 1.4.2 and 1.4.6)

" Implement a minor modifications process procedure. (1.4.2) Due: Complete

" Dedicate resources to implement the minor mods process. (1.4.6) Due: Complete SlIP Action Plan 3, "Engineering Technical Rigor," Strategies 2, 7, 10, and 11 o Strategy 2 - Develop and train on a Conduct of Engineering procedure. The procedure should include engineering principles and standards. Incorporate a requirement into the engineering Training Program Description (TPD) to train on the Conduct of Engineering procedure in initial training and continuing training.

(SIBP/SIIP 11.1.6 and 11.8.30)

" Identify the target population and provide training on the Conduct of Engineering procedure developed under SIBP task 11.8.30 (CRAI 3065735) to the engineering staff and implement the procedure. (11.1.6) Due: 06/30/2008

" Develop a Conduct of Engineering procedure. The procedure should include engineering principles and standards. Incorporate a requirement into the Engineering TPD to train on the Conduct of Engineering procedure in initial training and continuing training. (11.8.30) Due: Complete o Strategy 7 - Establish an Engineering Leader Observation Program that is incorporated within the site observation program as a tool for monitoring and adjusting engineering products, practices and human performance standards and tools. (SIBP/SIIP 11.4.1)

• Establish an Engineering Leader Observation Program that is incorporated within the site observation program as a tool for monitoring and adjusting engineering products, practices, and human performance standards and tools. (Reference Human Performance Building Block - initiative 6.2) (11.4.1) Due: 06/28/2008 o Strategy 10 - Implement an Engineering work management and scheduling department and issue for use initial base load work schedules for Design, System, &

Maintenance Engineering Department. (SIBP/SIIP 11.9.A.1 and 11.9.A.8) 2

N Implement an Engineering work management and scheduling department.

(11.9.A.1) Due: Complete 0 Issue for use initial base load work schedules for Design, System, &

Maintenance Engineering Department. (11.9.A.8) Due: Complete o Strategy 11 - Develop a procedure that describes the purpose, conduct, membership, criteria and requirements for using an Engineering Quality Product Review Board.(SIBP/SIIP 11.4.17)

• Develop a procedure that describes the purpose, conduct, membership, criteria and requirements for using an Engineering Quality Product Review Board. The procedure shall include a requirement to have:

- Engineering Quality Product Review Board feedback on products reviewed.

- Metrics to monitor and trend performance. (11.4.17) Due: 06/28/2008 SlIP Action Plan 4 "Design Control/Configuration Management" Strategies 2 and 5 o Strategy 2 - Improve configuration change processes, including control of temporary changes and train personnel on the improved processes. (SIBP/SIIP 11.7.1, and 11.7.4 through 11.7.6)

" Revise 01 DP-0CC01 to implement the INPO AP-929 model as well as use EPRI based guidance to give simplified configuration change options. (11.7.1) Due:

Complete

" Coordinate with training and maintenance to identify target population within maintenance department on configuration change process. Perform training for identified Maintenance department personnel, as needed. Incorporate into initial and continuing Maintenance training programs as necessary. (11.7.4) Due:

08/29/2008

" Coordinate with training and Operations to identify target population within Operations department on configuration change process. Perform training for identified Operations department personnel, as needed: Incorporate into initial and continuing Operations training programs as necessary. (11.7.5) Due:

08/29/2008

" Coordinate with training and Work Controls to identify target population within Work Controls department on configuration change process. Perform training for identified Work Control department personnel, as needed. Incorporate into initial and continuing Work Control (Work Management) training programs as necessary. (11.7.6) Due: 08/29/2008 o Strategy 5 - Implement the CDBR for high risk/low margin components in accordance with the project schedule. (SIBP/SIIP 11.6.1 .a, 11.6.1.b, 11.6.1 .c, 11.6.7, and 11.6.13)

• Complete CDBR on High Risk, Low Margin Components in Safety Injection, Diesel Generator, and Auxiliary Feedwater systems. (Major Task) 3

" Complete CDBR on High Risk components in the Diesel Generator system.

(11.6.1.a) Due: 10/24/2008

• Complete CDBR on High Risk Components in the Auxiliary Feedwater system. (11.6.1 .b) Due: 10/24/2008

• Complete CDBR on High Risk Components in the Safety Injection system.

(11.6.1.c) Due: 09/26/2008

" Finalize overall (3 year) scope of CDBR High Risk, low margin components by both a qualitative & quantitative PRA/analysis. (11.6.7) Due: Complete

" Complete Component Design Basis Review Project per project schedule (reference task 11.6.7). (11.6.13) Due: 12/31/2010 SlIP Action Plan 5, "Engineering Programs," Strategies 1 and 6 through 10 o Strategy 1 - As an interim measure to determine full extent of condition, Engineering is to evaluate what existing programs need to be immediately assessed or assessed near term and complete the assessments. (SIBP/SIIP 1.2.E.21, 1.2.E.22, and 1.2.E.35)

" As an interim measure to determine full extent of condition, Engineering is to evaluate what existing programs need to be immediately assessed or assessed near term; this evaluation should take into consideration programs that have high risk impact to the plant, potential regulatory risk, and/or programs with temporary or short term ownership. Initiate actions as necessary to implement program assessment commensurate with safety significance. (1.2.E.21) Due: Complete

" Perform self assessments on all Engineering Programs based on the schedule and criteria identified in the SIBP: #15.1.7 and developed as part of the interim action for CRAI 3065077. (1.2.E.22) Due: 08/20/2010

" Ensure CRAIs are in place and linked to CRDR 3048870 for each program owner to complete self-assessments using Policy Guide 120 based on the ranking and recommended schedule developed in CRAI 3065077. Specify that each self-assessment will have external expertise on the self-assessment team.

It is recommended that the six programs ranked 21 and above be completed as a priority before the end of the second quarter 2008. The 7 programs ranked between 8 and 21 should be completed by the end of 2008. The remaining four programs should be completed in 2009. Reference CRAI 3065077 for details.

(1.2.E.35) Due: Complete o Strategy 6 - Revise the Engineering Program Health Reporting procedure (73DP-0AP05) to address self-assessment expectations, revise metrics using industry input, establish MRM program health indicator rollup presentations, require that program documents are maintained current, and to use change management when modifying engineering programs. (SIBP/SIIP 1.2.E.8, 1.2.E.13, and 1.2.E.16)

Revise procedure 73DP-OAP05, Engineering Programs and Health Reporting, to establish oversight of Engineering Program Health utilizing the MRM. Procedure revision will include in the responsibilities section the requirement for the Engineering Department Leader Technical Services (section 2.2) to provide this presentation. (1.2.E.8) Due: Complete 4

" Established procedure 73DP-0AP05, Engineering Programs Management and Health Reporting, to address the lack of timely self assessments, benchmarking, and resource assignment.

This CRAI is initiated to provide closure documentation in support of the above completed action in accordance with 01DP-0AC06. (1.2.E.13) Due: Complete

" Revise 73DP-0AP05, "Engineering Programs Management and Health Reporting" to specify self-assessment expectations, revise required program metrics based on industry review (as necessary), maintain program documents current, and to use change management when modifying Engineering Programs.

(1.2.E.16) Due: Complete o Strategy 7 - Realign engineering to consolidate system engineer responsibilities for the Maintenance Rule Program and establish a section leader responsible for management oversight of the program. Complete a self-assessment of the Maintenance Rule Program using external expertise. (SIBP/SIIP 1.2.E.24 and 1.2.E.27)

N Perform a Self Assessment of the Maintenance Rule Program using industry experts per Policy Guide PG-120. From the assessment results, develop the actions necessary to ensure effective program implementation at PVNGS.

(1.2.E.24) Due: Complete W Realign engineering to consolidate the system engineer responsibilities for Maintenance Rule Program implementation, and establish a dedicated section leader responsible for management oversight of the program. (1.2.E.27) Due:

Complete o Strategy 8 - Complete corrective actions from the evaluation of the U3R1 3 transient combustible material procedure violations (CRDR 3077502). Complete benchmarking of transient combustible material processes and organizational structures for Fire Protection program implementation. (SIBP/SIIP 1.2.E.29, 1.2.E.30, and 1.2.E.32)

" Complete benchmarking of industry processes for the control of transient combustibles and enter an action plan in the corrective action program to address identified improvements. (1.2.E.29) Due: Complete

" Complete benchmarking and provide recommendations to Senior Management to improve the organization of personnel needed to support implementation of the Fire Protection Program. (1.2.E.30) Due: Complete

" An apparent cause evaluation of the non-compliance with site procedures for the control of transient combustibles during U3R1 3 has been completed (reference CRDR 3077502). Complete the corrective actions from CRDR 3077502.

(1.2.E.32) Due: 04/25/2008 o Strategy 9 - Enter actions from the 2007 Equipment Qualification Program Self-Assessment into the corrective action program and benchmark the Equipment Qualification Program using the INPO Engineering Program Guide (EPG-02).

(SIBP/SIIP 1.2.E.28, 1.2.E.31)

• Review the Equipment Qualification self-assessment performed in 2007 (ref SWMS 2957427) and enter improvement actions or areas needing follow-up in the corrective action program. (1.2.E.28) Due: Complete 5

• Complete benchmarking of the Equipment Qualification Program to the INPO Program Guide (EPG-02) and enter an action plan in the corrective action program to address identified improvements. (1.2.E.31) Due: Complete o Strategy 10 - Based on industry best practices, identify ifthere are other engineering processes that should be managed as an Engineering Program. (SIBP/SIIP 1.2.E.15)

Perform a review of the definitions and scope of what is considered an Engineering Program at other stations. Based on the review and management input, adjust the scope of Engineering activities managed as an Engineering Program in 73DP-OAP05. (1.2.E.15) Due: 06/27/2008 6

Attachment 7 Key Performance Area 6 Quality of Equipment Evaluations Actions Listing of Specific Tasks and Due Dates

Attachment 7 Key Performance Area 6 Quality of Equipment Evaluations Actions Listing of Specific Tasks and Due Dates To mitigate the potential for previous decisions to affect the quality of current evaluations associated with significant equipment problems, PVNGS will implement the following:

SlIP Action Plan 3, "Engineering Technical Rigor," Strategies 5 and 13 o Strategy 5 - Establish a process to ensure technical information used for key operations, maintenance and regulatory activities contains appropriate engineering review and approval requirements. (SIBP/SIIP 4.1.F.31, 4.1 .F.32, 4.1 .F.33, and 11.4.15)

" Develop and implement interim communications from the PVNGS VP of Engineering that Prompt Operability Determinations (PODs) prepared subsequent to April 1, 2008 may not be based upon informal information. In addition, those PODs may not be based upon previous PODs or CRDRs prepared before April 1, 2008 without Engineering review and approval.

(4.1.F.31) Due: Complete

" Revise POD procedure (40DP-9OP26) to include the requirements stated in Task 4.1 .F.31, above. (4.1 .F.32) Due: Complete

" Review PODs approved prior to April 1, 2008 and currently in effect and initiate necessary corrective actions to bring those determinations into compliance with current standards. (4.1 .F.33) Due: 07/01/2008

" Establish a process to formally provide technical information by the engineering staff. This process should be used in lieu of white papers, emails or verbal responses when the information provided by engineering is used for key operations, maintenance and regulatory activities. This process shall not circumvent the Corrective Action Program (e.g., CRDRs, DFWOs). The process should contain the appropriate engineering review and approval requirements based on type of request. (11.4.15) Due: 09/30/2008 o Strategy 13 - Review selected equipment causal analyses and PMs outside their grace period between January 1, 2002 and December 31, 2007 that could potentially affect plant safety to ensure that those determinations were appropriate from a safety perspective. (SIBP/SIIP 3.2.9.a and 3.2.9.b)

• Develop and implement plan for review of selected documents reflecting decision-making between January 1, 2002 and December 31, 2007 to confirm that items potentially affecting plant safety were dispositioned consistent with 1

results that would be achieved under current standards. This plan will include the following categories of determinations: (Major Task)

" Equipment failure causal evaluations performed via CRDRs (excluding "adverse" and "review" CRDRs). The reviews will performed on the risk significant safety systems. The plan will include review of equipment-related causes, extent of condition, extent of cause (where applicable), and corrective actions. (3.2.9.a) Due: 07/15/2008

• Preventive maintenance items currently planned to be performed past their due date plus grace period. The reviews will be performed on the risk significant safety systems. (3.2.9.b) Due: 07/15/2008 SlIP Action Plan 6, "Performance Improvement," Part 2, Strategy 3 o Strategy 3 - Review and validate site actions taken for high tier INPO/NRC OE.

(SIBP/SIIP 6.7.17, 6.7.29 and 6.7.30)

" Evaluate the SOER listing from INPO (see below) and re-evaluate the analysis and corrective actions taken by the station in response to implementing the recommendations. Develop additional actions, if determine previous actions were inadequate or inappropriate, to resolve and ensure that recommendations are properly disposition for the long-term. [See SWMS for detailed list] (6.7.17) Due:

10/15/2008

" Perform validation and effectiveness reviews of INPO designated "select" Significant Operating Event Reports (SOERs). Update master SOER spread sheet to document site actions taken for each recommendation to each SOER.

(6.7.29) Due: 06/30/2008

" Develop plan, based on gaps identified in Task 6.7.29, to validate and perform effectiveness reviews on other past high tier OE received from INPO/NRC to include NRC Information Notices and Generic Letters (IN, IEN, GL), INPO Significant Event Notifications (SEN), INPO Significant Event Response (SER),

INPO Significant Operating Event Reports (SOERs) not designated "select", and INPO Topical Reports (TR). (6.7.30) Due: 08/31/2008 2

Attachment 8 Key Performance Area 7 Safety Culture Assessment Actions Listing of Specific Tasks and Due Dates

Attachment 8 Key Performance Area 7 Safety Culture Assessment Actions Listing of Specific Tasks and Due Dates To address the issues identified during your 2007 independent safety culture assessment, PVNGS will implement the following:

SlIP Action Plan 12, "Safety Culture, Strategies 4, 7, 8, 10 and Effectiveness Review Task 4.4.8.b.

o Strategy 4 - Establish a Safety Culture Team to better focus the site on safety culture and implement a more formal process for periodic evaluation of PVNGS Safety Culture and SCWE. (SIBP/SIIP 4.4.16 and 4.4.10)

" Establish and implement a more formal process for periodic evaluation of PV safety culture and SCWE by the SC team, HR, Legal, Reg Affairs and mechanisms for reporting results to Senior Mgmt and taking responsive actions.

(4.4.16) Due: Complete

" Establish a specific Safety Culture organization to better focus the site on Safety Culture. The organization should help facilitate the development of improvement actions for Safety Culture issues, and assist in the tracking, closure and follow-up assessment of those issues. (4.4.10) Due: Complete o Strategy 7 - Develop and implement leadership training on nuclear fundamentals, including: Nuclear Safety, Safety Culture, SCWE, Operations Focus, Safety Culture, and SCWE behaviors for key positions and implement a formal Management Succession Plan. (SIBP/SIIP 2.3.C.1.a, 2.4.A.8, 2.4.B.4, and 4.4.17)

Evaluate current leaders, or update recent evaluations, to ensure leaders possess the necessary skills, abilities and behaviors for effective leadership.

Establish and implement a process to rate each Palo Verde leader's effectiveness. Define each leader's strengths and areas for improvement.

Develop plans for each leader that include expectations for improvement, advancement, or corrective action and include in leader PMPs. The process will include as a minimum the following actions (CA-10 thru 14)

Evaluations/screening should include director level positions down to first line leaders, assessing areas for improvement and incorporating actions to improve supervisory effectiveness into each individual's Performance Management Plan (PMP). The results of the evaluations are to be used to adjust organization positions, target leaders for succession planning, and address and behavior issues. The evaluation must consider the following:

- Whether the leader has the skill set and ability to continue in their current position.

1

- If leaders are identified who lack the necessary skills, consider reassignment or remediation.

- Identify leaders who are chosen to remain in leadership positions and provide training/coaching to develop the necessary skills. (Major Task)

• Establish attributes/competencies for key positions, at a minimum department leaders and above, to include Nuclear Safety, Safety Culture, and SCWE Behaviors. (2.3.C.1.a) Due: Complete Develop and implement leadership training to address the following nuclear fundamentals:

- Nuclear Safety/Safety Culture/Safety Conscious Work Environment

- Operational Focus

- Corrective Action Program

- Core mission and fundamental focus areas

- Risk awareness/risk significance

- Accountability

- Professionalism Senior Management and Director level leaders should be involved in providing key aspects of this training, as appropriate. Emphasis should be on first line and middle management with each session consisting of diverse mix of leaders (i.e.,

multi-discipline, multi-organization). (2.4.A.8) Due: 06/30/2008

" Develop and implement a formal Management Succession Plan and associated policy. Include the following elements:

- PVNGS nuclear leadership standards as identified in the management model

- Leadership skill set specific to Operational Focus

- Leadership development plan to support the model

- Plan to ensure future leaders have fundamental plant knowledge

- Rotation of selected Operations leaders to other organizations

- Establish attributes/competencies for key positions, at a minimum department leaders and above

- Development of compensatory actions for identified gaps to attributes/competencies for key positions

- Plan should cover a minimum of five years

- Provide periodic follow-up (2.4.B.4) Due: 12/17/2008

" Verify that the competencies in 2.3.C.1.a address Nuclear Safety, Safety Culture, and SCWE behaviors. (4.4.17) Due: Complete o Strategy 8 - Implement specific action plans, including targeted staffing strategies, for each Safety Culture priority group and follow up with other site groups to assure they address safety culture weaknesses in their areas. (SIBP/SIIP 2.2.B.1 through 2.2.B.5, 2.2.B.8, 4.4.35, 4.4.36, and 20.2 through 20.14)

" Develop a targeted staffing strategy for Operations detailing types of hires, how and where to find and attract needed talent. (2.2.B.1) Due: Complete

" Develop a targeted staffing strategy for Engineering detailing types of hires, how and where to find and attract needed talent. (2.2.B.2) Due: Complete

" Develop a targeted staffing strategy for Maintenance detailing types of hires, how and where to find and attract needed talent. (2.2.B.3) Due: Complete 2

" Develop a targeted staffing strategy for RP/Chemistry detailing types of hires, how and where to find and attract needed talent. (2.2.B.4) Due: Complete

" Develop a targeted staffing strategy for other positions as required detailing types of hires, how and where to find and attract needed talent. (2.2.B.5) Due:

Complete

" Develop a (longer-term) targeted staffing strategy for Operations / Engineering/

Maintenance / RP / Chemistry and other groups detailing types of hires, how and where to find and attract needed talent. (2.2.B.8) Due: 12/15/2008

" Provide the Safety Culture Driver action plan and the individual departmental Synergy banner report to the applicable Department Leader and above with instructions on completing a discussion with their staffs on Safety Culture. The intent of this discussion is to provide a progress report to frontline on Safety Culture actions, assess the current status of their organization relative to the concerns their frontline had raised, and identify any additional concerns that may require follow-up. The Safety Culture Team will provide a template to use to report out the results of the review. Each department leader or above will present their findings to their Vice President and provide a copy of the report to the Safety Culture Team by April 15th, 2008. (4.4.35) Due: Complete

[Note: Task 4.4.35 provided the information to the applicable leaders to complete the discussion with their staffs. This task is completed as noted above. CRAI'S were issued for each applicable leader with a due date of 4/15/08 to report back on the results. The Safety Culture Team, in Task 4.4.36, will review the findings, determine appropriate adjustments and issue a consolidated report.]

" Obtain feedback from each department that the activity in CRAI 3106479 was completed and what, if any additional actions are required to address concerns within their organization. Review the findings and determine if there are any adjustments that need to be made to the Drivers Action Plan or if additional Priority Groups need to be considered. Assure that any additional actions have been entered into CAP. Consolidate the input into a report and attach to this action to support closure. (4.4.36) Due: 04/30/2008

" Complete the Safety Culture Improvement Plan.

This CRAI is for: 12. Planning (Maintenance) (20.2.1) Due: 05/15/2008

Description:

Close the Plan based on the results of the Department's Site Wide Fall 2008 Safety Culture Assessment showing:

1) An improving trend to the issues contained in this Plan.

• 2)The Department is no longer identified as a Priority Group based on the results of the Site Wide Fall 2008 Safety Culture Assessment.

3) An effectiveness review by the Safety Culture Team.

This CRAI is for: 12. Planning (Maintenance) (20.2.2) Due: 02/28/2009

" Complete the Safety Culture Improvement Plan.

This CRAI is for: 9. Finance and Community (20.3.1) Due: 09/30/2008

" Close the Plan based on the results of the Department's Site Wide Fall 2008 Safety Culture Assessment showing:

3

1) An improving trend to the issues contained in this Plan.

2) The Department is no longer identified as a Priority Group based on the results of the Site Wide Fall 2008 Safety Culture Assessment.

3) An effectiveness review by the Safety Culture Team.

This CRAI is for: 9. Finance and Community (20.3.2) Due: 02/28/2009

" Complete the Chemistry Safety Culture Improvement Plan for Chemistry (CRAI 3068556). (20.4.1) Due: 08/01/2008

" Close the Chemistry Safety Culture Improvement Plan (CRAI 3068556) based on results of the department's Site Wide Fall 2008 Safety Culture Assessment showing an improving trend to the issues contained in the plan and the department no longer being identified as a Priory Group and completion of an effectiveness review by the Safety Culture Team. (20.4.2) Due: 02/28/2009

" Complete the Safety Culture Improvement Plan.

This CRAI is for: 4.Maintenance Services (20.5.1) Due: 06/30/2008

" Close the Plan based on the results of the Department's Site Wide Fall 2008 Safety Culture Assessment showing:

1) An improving trend to the issues contained in this Plan.

2) The Department is no longer identified as a Priority Group based on the results of the Site Wide Fall 2008 Safety Culture Assessment.

3) An effectiveness review by the Safety Culture Team.

This CRAI is for: 4. Maintenance Services (20.5.2) Due: 02/28/2009

" Complete the Safety Culture Improvement Plan.

This CRAI is for: 7. Training (20.6.1) Due: 05/30/2008

" Close the Plan based on the results of the Department's Site Wide Fall 2008 Safety Culture Assessment showing:

1) An improving trend to the issues contained in this Plan.

2) The Department is no longer identified as a Priority Group based on the results of the Site Wide Fall 2008 Safety Culture Assessment.

3) An effectiveness review by the Safety Culture Team.

This CRAI is for: 7. Training (20.6.2) Due: 02/28/2009

" Complete the Safety Culture Improvement Plan.

This CRAI is for: 8. Operations (20.7.1) Due: 08/28/2008

" Close the Plan based on the results of the Department's Site Wide Fall 2008 Safety Culture Assessment showing:

1) An improving trend to the issues contained in this Plan.

2) The Department is no longer identified as a Priority Group based on the results of the Site Wide Fall 2008 Safety Culture Assessment.

3) An effectiveness review by the Safety Culture Team.

4

This CRAI is for: 8. Operations (20.7.2) Due: 02/28/2009

" Complete the Safety Culture Improvement Plan.

This CRAI is for: 13. Project Engineering (20.8.1) Due: 12/26/2008

" Close the Plan based on the results of the Department's Site Wide Fall 2008 Safety Culture Assessment showing:

1) An improving trend to the issues contained in this Plan.

2) The Department is no longer identified as a Priority Group based on the results of the Site Wide Fall 2008 Safety Culture Assessment.

3) An effectiveness review by the Safety Culture Team.

This CRAI is for: 13. Project Engineering (20.8.2) Due: 02/28/2009

" Complete the Safety Culture Improvement Plan.

This CRAI is for: 1. RP Operations (20.9.1) Due: 09/30/2008

" Close the Plan based on the results of the Department's Site Wide Fall 2008 Safety Culture Assessment showing:

1) An improving trend to the issues contained in this Plan.

2) The Department is no longer identified as a Priority Group based on the results of the Site Wide Fall 2008 Safety Culture Assessment.

3) An effectiveness review by the Safety Culture Team.

This CRAI is for: 1. RP Operations (20.9.2) Due: 02/28/2009

" Complete the Safety Culture Improvement Plan.

This CRAI is for: 5. Security (20.10.1) Due: Complete

" Close the Plan based on the results of the Department's Site Wide Fall 2008 Safety Culture Assessment showing:

1) An improving trend to the issues contained in this Plan.

2) The Department is no longer identified as a Priority Group based on the results of the Site Wide Fall 2008 Safety Culture Assessment.

3) An effectiveness review by the Safety Culture Team.

This CRAI is for: 5. Security (20.10.2) Due: 02/28/2009

" Complete the Safety Culture Improvement Plan.

This CRAI is for: Work Management (20.11.1) Due: 08/01/2008

" Close the Plan based on the results of the Department's Site Wide Fall 2008 Safety Culture Assessment showing:

1) An improving trend to the issues contained in this Plan.

2) The Department is no longer identified as a Priority Group based on the results of the Site Wide Fall 2008 Safety Culture Assessment.

3) An effectiveness review by the Safety Culture Team.

This CRAI is for: Work Management (20.11.2) Due: 02/28/2009 5

" Complete the priority groups Safety Culture Improvement Plan.

This CRAI is for: 11. Procedures and Standards (20.12.1) Due: 12/15/2008

" Close the Safety Culture Improvement Plan if the results of the Department's Site Wide Fall 2008 Safety Culture Assessment showing:

1)An improving trend to the issues contained in this Plan.

2) The Department is no longer identified as a Priority Group based on the results of the Site Wide Fall 2008 Safety Culture Assessment.

3) An effectiveness review by the Safety Culture Team.

This CRAI is for: 11. Procedures and Standards (20.12.2) Due: 02/28/2009

" Complete the priority groups Safety Culture Improvement Plan.

This CRAI is for: 2. Mechanical Design (20.13.1) Due: 07/27/2008

" Close the Safety Culture Improvement Plan if the results of the Department's Site Wide Fall 2008 Safety Culture Assessment showing:

1)An improving trend to the issues contained in this Plan.

2) The Department is no longer identified as a Priority Group based on the results of the Site Wide Fall 2008 Safety Culture Assessment.

3) An effectiveness review by the Safety Culture Team.

This CRAI is for: 2. Mechanical Design (20.13.2) Due: 02/28/2009

" Complete the Safety Culture Improvement Plan.

This CRAI is for: 10. Radiation Services (20.14.1) Due: 09/30/2008

" Close the Safety Culture Improvement Plan if the results of the Department's Site Wide Fall 2008 Safety Culture Assessment showing:

1)An improving trend to the issues contained in this Plan.

2) The Department is no longer identified as a Priority Group based on the results of the Site Wide Fall 2008 Safety Culture Assessment.

3) An effectiveness review by the Safety Cult ure Team.

This CRAI is for: 10. Radiation Services (20.14.2) Due: 02/28/2009 o Strategy 10 - Perform evaluation of weaknesses and complexity in site processes, procedures, programs, and work instructions, and establish an organizational structure to focus on control and improvement of site processes with particular focus on CAP and Work Management. (SIBP/SIIP 4.4.19, 4.4.20 and 4.4.32)

" Establish an organizational structure to focus on control and improvement of site processes with particular focus on CAP and Work Management. (4.4.19) Due:

Complete

" Perform an Apparent Cause Evaluation to determine causes of programmatic weaknesses in PV programs, procedures and processes. The ACE should address complexity in site processes and identify appropriate corrective actions to improve those processes and prevent recurrence of the identified weaknesses.

(4.4.20) Due: Complete 6

The Apparent Cause Evaluation on Programmatic Weaknesses in PV Programs, Procedures, and Processes - ImPACT FOP 11 and Safety Culture, CRDR 3079100, and its identified corrective [action plan] will include evaluation and action to: ensure appropriate interdisciplinary input and review, review of products and processes to ensure their technical adequacy and to place priority on improvements to the Corrective Action Program and Work Management. (4.4.32)

Due: Complete o Effectiveness Review - Complete 2008 Safety Culture Assessment. (4.4.8.b) Due:

11/30/2008 7

Attachment 9 Key Performance Area 8 Standards and Expectations for Performance and Accountability Actions Listing of Specific Tasks and Due Dates

Attachment 9 Key Performance Area 8 Standards and Expectations for Performance and Accountability Actions Listing of Specific Tasks and Due Dates To address problems associated with standards and expectations for performance and holding individuals accountable for nuclear safety, PVNGS will implement the following:

SlIP Action Plan 1, "Operational Focus," Strategies 4, 8, 11 and 12 o Strategy 4 - Identify and review for aggregate impact, imbedded operator-work-arounds and burdens that challenge nuclear safety and institutionalize the process.

(SIBP/SIIP 4.1.G.10 and 4.1.G.1 1)

" Identify and review for aggregate impact, imbedded operator work arounds and burdens that challenge nuclear safety. Initiate corrective action documents as necessary. (4.1.G.10) Due: Complete

" Proceduralize periodic aggregate impact reviews for operator work arounds and burdens. (4.1 .G. 11) Due: Complete o Strategy 8 - Identify key Operations department attributes and behaviors of an operationally focused organization from INPO 01-002, Conduct of Operations and incorporate them into procedures and training. (SIBP/SIIP 4.1 .G.4, 4.1 .G.5, and 4.1 .G.6)

" Review INPO 01-002, Conduct of Operations to identify key operations department attributes and behaviors of an operationally focused organization.

(4.1.G.4) Due: Complete

" Incorporate key operations department attributes and behaviors of an operationally focused organization identified in task 4.1 .G.4 (CRAI 3064339) into procedures. (4.1.G.5) Due: 05/30/2008

" Develop Operational Focus training module. Perform a Needs Analysis using the Systematic Approach to Training (SAT) process to determine the training required for establishment of an operationally focused organization. Incorporate into initial and continuing training for licensed operator, non-licensed operator, shift manager, shift technical advisor training programs as well as maintenance, engineering, radiation protection, and chemistry training programs. (Major Task)

" Operations (licensed operator, non-licensed operator, Shift Manager, and Shift Technical Advisor) (4.1 .G.6.a) Due: 06/30/2008

• Maintenance (4.1.G.6.b) Due: 06/30/2008

• Engineering (4.1.G.6.c) Due: 06/30/2008 1

• Radiation Protection (4.1.G.6.d) Due: 06/30/2008

" Chemistry (4.1.G.6.e) Due: 06/30/2008 o Strategy 11 - Develop and implement plans and training to ensure that Operations management defines, communicates, and reinforces Operations Fundamentals such as high professional standards, control board monitoring, communications, and ownership of equipment problems. (SIBP/SIIP 6.11.1 and 6.11.2)

" To raise standards for operations professionalism and leadership we will perform the following actions. (Major Task)

• Senior Management will communicate station expectations and industry standards for operations ownership of equipment problems at Palo Verde Station. This will be communicated at the Operations Leadership Seminar.

These Seminars will be conducted with Senior Operations and Executive Management. CRAI 3101348 INPO AFI OF.1-1 (6.11.1.a) Due: Complete

• Incorporate into initial licensed and non-licensed operator training programs the stations expectations and industry standards regarding operations ownership of equipment deficiencies. Perform needs analysis of requisite fundamentals not contained in the knowledge based initial training program.

(6.11.1.b) Due: 06/30/2008

• All available CRS's will attend the INPO Operations Supervisor Professional Development seminar in 2008. (6.11.1.c) Due: 12/31/2008

• The Operations Director will re-define the roles and responsibilities of the operations leadership team in 40DP-9OP02 "Conduct of Operations". The objective will be to enhance the quality of the oversight, coaching and mentoring of the on shift team. (6.11.1 .d) Due: 06/30/2008

" To raise the standards for control board monitoring, communications, turnover, log keeping, alarm response, peer verification, and operator fundamentals in the control room, the following actions will be implemented: (Major Task)

• A focused self assessment will be performed to identify the specific weaknesses in operator fundamentals. Weaknesses and areas for improvement from the assessment will be evaluated per the SAT process to determine training needs and/or interventions. (6.11.2.a) Due: Complete

• Benchmarking will be performed to specifically address current standards for communication of control room alarms, status changes, and expected alarm announcements. (6.11.2.b) Complete

• Based on benchmark results, ODP-01, "Operations Department Practices",

and 40DP-9OP02, "Conduct of Operations", will be revised to reflect industry best practices. (6.11.2.c) Due: 04/30/2008

• Incorporate changes in ODP-01, "Operations Department Practices", and 40DP-9OP02, "Conduct of Operations" into requal training for operators and operations training instructors. (6.11.2.d) Due: 06/30/2008

" Develop a lesson plan that provides training communication of control room alarms and status change into initial simulator training. (6.11.2.e) Due:

06/30/2008 2

• The Operating Crews and operations training instructors will be trained in the changes in standards during cycle 2 of simulator training, communication of control room alarms and status changes will be simulator training and critique focus areas. (6.11.2.f) Due: 06/30/2008

• An assessment will be performed on the operations team's execution of these performance standards in both the Simulator and on-shift. (6.11.2.g) Due:

07/31/2008 o Strategy 12 - Ensure potentially degraded or non-conforming conditions receive a timely, thorough and appropriately prioritized Operability Determination and provide training for key operations and engineering personnel. (SIBP/SIIP 4.1 .F.9 through 4.1.F.27, 4.1.F.34)

As an interim action to drive consistency during the implementation and training phase of this plan, Operations will dedicate a current or previously licensed SRO (and provide an alternate), to the Corrective Action Program/ Operability Determination Process (CAP-OD SRO). This SRO will have in depth knowledge of Procedure 40DP-9OP26, Operability Determination and Functional Assessment, and NRC RIS 2005-20. The position will be staffed during normal dayshift hours. This position will be staffed until the 40DP-9OP26 changes and IOD training is complete. (4.1.F.9) Due: Complete

" 40DP-9OP26 will be changed to require a documented Operability / Functionality Assessment for any PVAR on T.S. or T.S. support SSC's. (4.1.F.10) Due:

Complete

" A checklist will be developed and included in 40DP-9OP26 to aid the SRO in making the Immediate Operability Determination. (4.1.F.11) Due: Complete

" Revise 40DP-9OP26 to have Operations make the initial extent of condition determination. If information is required from other organizations, Operations will communicate to the appropriate department the need and time frame that the information is needed and enter the action in the CAP. (4.1.F12) Due: Complete

" All SRO's / STA's will be trained in the IOD process. (4.1.F.13) Due: 06/30/2008

" All SRO's / STA's will be trained on the IOD process and the recent changes to 40DP-9OP26. (4.1 .F.14) Due: 06/30/2008

" Provide a briefing for ARRC and CARB on the recent changes to 40DP-9OP26.

(4.1.F.15) Due: 06/30/2008

" An Operability Determination process lesson plan will be developed and incorporated into initial License Training that uses actual events for exercises.

(4.1.F.16) Due: 09/30/2008

" A lesson plan will be developed and incorporated into Initial Non-License Training that uses actual events for exercises with emphasis on the importance of Area Rounds and field observations as input to the control room determination of degraded safety systems. (4.1 .F.17) Due: 09/30/2008

" Revise the OD procedure to require documentation of any unverified assumptions and require a corrective action item to validate the assumptions when not able to be validated at the time of the POD. (4.1.F.18) Due: Complete 3

" Establish dedicated Engineering Support (E-FIN) for the preparation of POD's.

(4.1.F.19) Due: Complete

" Perform a "Needs Analysis" using the Systematic Approach to Training (SAT) process to determine the training needs for engineering FIN for POD preparation.

Develop the lesson plan for this task. (4.1.F.20) Due: 06/30/2008

" Provide OD training to Engineering FIN team and SRO's/STAs on OD related procedure changes, the standard for technical rigor including critical thinking, and the use of design basis information in support of PODs. (4.1 .F.21) Due:

09/30/2008

" As an interim action, establish a daily challenge board, sponsored by the Plant Manager, for IODs and PODs generated in the previous 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />s/weekend/holiday. A PVAR will be generated and feedback provided to the Shift Manager and engineering FIN for any identified deficiencies. This will continue until training required by this plan is complete as described in CRAl's 3105761 and 3109581. (4.1.F.22) Due: Complete

" Establish a formal qualification requirement for POD preparation and incorporate into the ETP. (4.1 .F.23) Due: 09/30/2008

" During the daily OD review process (see CRAI 3105745), the CAP-OD SRO will identify those OD's with loss of CLB design margin and/or use of compensatory measures and add those to the list of significant ODs. This will create a focused list of priority OD's that address conditions on equipment that have lost CLB design margin or depend on compensatory measures. (4.1.F.24) Due: Complete

" Revise the OD procedure to require the Operations Unit Department Leader to periodically review OD's corrective action due dates for those that involve loss of CLB design margin and/or use of compensatory measures and initiate changes to due dates as necessary based on safety significance or aggregate impacts.

(4.1.F.25) Due: 06/30/2008

" Revise the Shift Manager Turnover to link the list of significant OD's to the Shift Manager Turnover. The Shift Manager Turnover will require daily review of the Significant OD list. (4.1.F.26) Due: 06/30/2008

" Establish appropriate metrics to monitor Operability Determination performance.

(4.1.F.27) Due: Complete

" Established a daily challenge board, as an interim action, sponsored by the Plant Manager, for IODs and PODs generated in the previous 24 hour2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />s/weekend/holiday. This action is requesting NAD to perform periodic observations of the challenge board. (4.1.F.34) Due: 05/23/2008 SlIP Action Plan 6, "Performance Improvement," Part 1, Strategies 1 and 5 o Strategy 1 - Develop and communicate Corrective Action Program (CAP) fundamentals for station personnel and for managers and supervisors. (SIBP/SIIP 3.3.3.j)

• Implement a training program associated with the Corrective Action Program (CAP). (Major Task) 4

• Develop and communicate CAP Fundamentals for Station Personnel and for Managers and Supervisors. (3.3.3.j) Due: Complete o Strategy 5 - Develop and implement the Leadership / Management Model and the Accountability Model from the Organizational Effectiveness Root Cause (SIBP/SIIP 2.1 .D.5 and 2.1 .D.6).

Develop and implement a Palo Verde leadership/management model. The purpose of the leadership/management model is to establish standards of performance and use them as the basis for improving individual behaviors and station performance.

The leadership/management model should address each of the areas identified by the ImPACT team as fundamental problem areas including the Corrective Action Program, Design Control/Configuration Management, Emergency Preparedness, Engineering Programs, Engineering Technical Rigor, Equipment Reliability, Human Performance, Industrial Safety, Operational Focus, Procedures and Work Instructions, Managing of Plant Workloads and Training and Qualification. Additionally, the leadership/management model should address Nuclear Safety, Accountability, Change Management, Leadership, Operating Experience, Self Assessment/Benchmarking, and Execution and Use of the Management Model. (Major Task)

" Benchmark and develop a leadership/management model that establishes the vision, mission, values and expected behaviors for each of the problem areas identified by the ImPACT team and the additional areas as noted below. Additionally, the management model should address ownership, the Palo Verde core fundamental areas (Plant Equipment, People, Corrective Action Program, Safety, and Knowledge/Training), a mechanism for continuous monitoring and improvement, and metrics to measure effectiveness. (2.1 .D.5.a) Due: 06/30/2008

• Develop training to incorporate the expected behaviors for all leaders and frontline workers to ensure personnel understand their roles and responsibilities for each of the management model areas and accountability process. (2.1.D.5.b) Due: 09/30/2008

• Provide training developed under SIBP Action 2.1.D.5.b (CRAI 3075713) to Directors and above. (2.1.D.5.c) Due: 12/15/2008

• Provide training developed under SIBP Action 2.1.D.5.b (CRAI 3075713) to Department Leaders and Managers. (2.1 .D.5.d) Due: 03/30/2009

" Provide training developed under SIBP Action 2.1.D.5.b (CRAI 3075713) to Section Leaders and Team Leaders. (2.1 .D.5.e) Due:09/30/2009

• Incorporate the expected behaviors from SIBP Action 2.1.D.5.b (CRAI 3075713) into individual mid-year 2009 PMPs for Department Leaders and above. (2.1.D.5.f) Due: 07/30/2009

" Incorporate the expected behaviors from SIBP Action 2.1.D.5.b (CRAI 3075713) into all individual 2010 PMPs. (2.1.D.5.g) Due: 02/15/2010 5

• Incorporate the expected behaviors from SIBP Action 2.1.D.5.b (CRAI 3075713) into the Observation Program/Workplace Observation tool used by the site to observe work behaviors. (2.1 .D.5.h) Due: 11/30/2008 Benchmark and develop an accountability model/accountability process.

Note: The actions to implement the accountability model/process (i.e., training of leaders, communication to frontline, use of PMPs, and revising the Observation Program tool) are captured in the actions to develop and implement the management model. (2.1.D.6) Due: 06/30/2008 SlIP Action Plan 10, "Organizational Effectiveness," Strategies 1, 6 (Task 2.2.E.1.b), and 9 o Strategy 1 - Develop and implement a Management Review Meeting (MRM) process for Performance Indicators (PI) to include cross cutting reviews, deep dives, and an accountability process for improving performance. (SIBP/SIIP 8.4.1, 8.4.4, 8.4.5, 8.4.6, and 8.4.15)

Implement a Management Review Meeting (MRM) process. Process should include the utilization of site/department indicators to create visible intrusive reviews of site-wide performance. Require multiple discipline/departments to participate in order to create aggregate learnings, address accountability, and improve teamwork within and between organizations. (8.4.1) Due: Complete Develop a process to conduct crosscutting reviews during MRMs including corrective action program, human performance, and safety culture. (8.4.4) Due:

Complete

" Implementation of crosscutting reviews as noted in task 8.4.4 to commence second quarter 2008. (8.4.5) Due: 06/30/2008

" Develop and implement plan for external senior industry representation on the MRMs. External senior industry leaders will periodically attend MRMs and provide feedback to ensure an external perspective is maintained, to broaden industry knowledge and provide external challenges. (8.4.6) Due: Complete

" Develop and implement external senior industry representation on the MRMs.

External senior industry leaders will periodically attend MRMs and provide feedback to ensure an external perspective is maintained, to broaden industry knowledge and provide external challenges. Note: This action was completed under CRAI 3063857. The purpose of this CRAI is to establish this as a Priority, 2 action and to provide closure documentation. (8.4.15) Due: Complete o Strategy 6 - Develop and implement leadership training to address key nuclear fundamentals and improve overall leadership training. (SIBP/SIIP 2.2.E.1.b)

• Improve the selection and development of new leaders by completing the following five actions: (Major Task)

Evaluate the site portion of current initial and continuing training contained in the supervisory leadership program and provide recommendations for changes to Senior Management. The supervisory leadership training should address the following items, at a minimum:

- Nuclear Safety/Safety Culture/Safety Conscious Work Environment 6

- Operational Focus

- Corrective Action Program

- Core mission and fundamental focus areas

- Risk awareness/risk significance

- Accountability

- Professionalism

- Key aspects from the leadership/management model and accountability model/process. (2.2.E.1.b) Due: 09/30/2008 o Strategy 9 - Implement a Safety Culture Team and a Recovery Team (Implementation and Monitoring Team) to assure continued focus on improving PVNGS performance. (SIBP/SIIP 4.4.10 and 8.10,1)

Establish a specific Safety Culture organization to better focus the site on Safety Culture. The organization should help facilitate the developrment of improvement actions for Safety Culture issues, and assist in the tracking, closure and follow-up assessment of those issues. (4.4.10) Due: Complete Utilize the ImPACT team approach and establish a 'recovery team' to support and monitor the integration, implementation and closure of actions in the Site Integrated Business Plan/Site Integrated Improvement Plan. (8.10.1) Due:

Complete 7

Attachment 10 Key Performance Area 9 Change Management Process Actions Listing of Specific Tasks and Due Dates

Attachment 10 Key Performance Area 9 Change Management Process Actions Listing of Specific Tasks and Due Dates To define and implement a change management process, PVNGS will implement the following:

SlIP Action Plan 1, "Operational Focus," Strategy 7 o Strategy 7 - Develop and implement a site-wide communication and meeting strategy to address site alignment, operational focus, and site-wide penetration of messages (SIBP/SIIP 7.1.B.1 and 7.1.B.5).

Develop and implement a site-wide communication strategy to address site alignment, operational focus and site-wide penetration of messages. The strategy should include the following: develop a message priority and cycle time model for internal and external communications to ensure that priority messages are delivered to appropriate audiences and stakeholders for prompt dissemination and action as appropriate. This model will include identification of audiences for message type and method of conveyance. (7.1.B.1) Due:

Complete

" Develop and implement a meeting strategy to help ensure alignment throughout the organization and frontline exposure to senior leadership to include a hierarchy of current meetings, attendees, agendas, and how the meetings contribute to overall information flow. Include alignment meetings for department leaders and above, skip, all-hands and small-group meetings and 2Cs.

Coordinate with People Building Block Initiative 2.3.B. (7.1 .B.5) Due: Complete SlIP Action Plan 12, "Safety Culture," Strategy 9 o Strategy 9 - Establish a formal process for use of a change management tool and communicate to site personnel the requirements for use of the tool. (SIBP/SIIP 4.4.18, 6.10.1, and 6.10.5)

" Verify that the formal process for Change Mgmt being established under OE CA-29, task 6.10.1 (CRAI 3076290) requires solicitation of employee input in appropriate cases. (4.4.18) Due: Complete

" Develop and establish a formal process for use of a change management tool and communicate to site personnel the requirements for use of the tool. (6.10.1)

Due: Complete

" Working with the CNO, issue interim guidance on implementation of the Change Management process to assure that changes being implemented prior to completion of CRAI 3076290 are adequately communicated. (6.10.5) Due:

Complete 1

Attachment 11 Key Performance Area 10 Emergency Preparednessý Program Actions Listing of Specific Tasks and Due Dates

Attachment 11 Key Performance Area 10 Emergency Preparedness Program Actions Listing of Specific Tasks and Due Dates To address problems with the emergency preparedness program, PVNGS will implement the following:

SlIP Action Plan 8, "Emergency Preparedness," Strategies 1, 3 through 9, and 11 o Strategy 1 - Revise policy guidance on Emergency Planning to incorporate revised roles and responsibilities. (SIBP/SIIP 9.1 .A.1 and 9.1 .A.5)

" Implement Policy and Policy Guide 1503-01 to require ERO Team Members to respond and fill Emergency Plan positions within required timeframes. (9.1 .A.1)

Due: Complete

" Revise Policy Guide 150 Emergency Planning. (9.1.A.5) Due: Complete o Strategy 3 - Emergency Planning to institute alignment meetings between Emergency Response Organization's Emergency Coordinators (EC) and Emergency Operations Directors (EOD). (SIBP/SIIP 9.1 .A.22)

• Emergency Planning instituted alignment meetings between ERO Team ECs and EODs.

This CRAI is initiated to provide closure documentation in support of the initiative 9.1 .A actions in accordance with 01DP-0AC06. (9.1 .A.22) Due: Complete o Strategy 4 - Enhance the training program and conduct training for EC's and EOD's on EAL's. (SIBP/SIIP 9.2.A.15, 9.2.A.16, and 9.2.A.22)

" Conduct training on EALs with EC and EOD qualified individuals. Conduct training on each individual EAL in EPIP-99, Appendix A, Emergency Action Levels with EC and EOD qualified individuals. The training should include terminology, EAL Technical Basis and practice classifications. (9.2.A.15) Due:

Complete

" Ensure the initial training programs for Emergency Coordinators contains training on Emergency Action Levels and their bases. This includes the EC in the control room and the EC in the TSC. (9.2.A.16) Due: 06/15/2008

" Ensure the continuing training programs for Emergency Coordinators contains biennial training on the Emergency Action Levels. (9.2.A.22) Due: 06/15/2008 o Strategy 5 - Create an EP Training Review Group as well as the appropriate number of Training Advisory Committees and control EP training similar to accredited training programs. (SIBP/SIIP 9.2.A.23, 9.2.A.31 and 9.1.A.33) 1

" Administratively control Emergency Preparedness Training similarly to accredited training programs by creation of an Emergency Preparedness Training Program Description, which as a minimum places controls on the following:

- Description that defines failure and remediation criteria for each ERO position.

This would encompass failures during the training, drills, exercises, and actual plant events.

- Implement a program to track named* Emergency Response Organization team (*a defined set of ERO per Emergency Planning) positions to ensure that these personnel receive proper training and drill participation on an annual basis.

- Develop a plan for drills, specifically on continuance of "training drills", in 2009 and beyond based on performance. (9.2.A.23) Due: 06/15/2008

" Each Emergency Response Organization team to have one training drill and one evaluated drill or exercise in 2008. (For purposes of this task, the team is defined as the Emergency Response Organization personnel to meet minimum staffing requirements for the OSC, TSC, and EOF.) (9.2.A.31) Due: 12/19/2008

" Create an Emergency Preparedness Training Review Group as well as the appropriate number of Training Advisory Committees (TAC). (9.1 .A.33) Due:

04/28/2008 o Strategy 6 - Develop and implement a strategy (posters, lanyard cards, etc) to communicate Emergency Planning Program elements to the line organization.

(SIBP/SIIP 9.1.A.6 and 9.1.A.21)

" Develop strategy (posters, lanyard cards, etc) to communicate Emergency Planning Program elements to line organization. (9.1.A.6) Due: 06/1/2008

" Implement communication strategy developed in task 9.1.A.6 (CRAI 3063200).

(9.1.A.21) Due: 07/15/2008

" Strategy 7 - Revise EOD Performance Management Plans to include an expectation that they are responsible for their team's performance commencing 2008. (SIBP/SIIP 9.1.A.4)

• EOD PMPs to include an expectation that they are responsible for their team's performance commencing 2008. (9.1.A.4) Due: Complete o Strategy 8 - Develop and implement a multi-discipline E-Plan Steering Committee that will provide oversight of the Emergency Preparedness program. (SIBP/SIIP 9.1 .A.24)

• Develop and implement a multi-discipline E-Plan Steering Committee that will provide oversight of the Emergency Preparedness program. The Department Leader of Emergency Planning will be the chairman of the steering committee.

(9.1.A.24) Due: Complete o Strategy 9 - Revise 21 SP-OSK1 1 to address implementation of EALs 7-1, 7-2, and 7-3 and provide applicable training. (SIBP/SIIP 9.5.5 and 9.5.6)

Revise 21 SP-0SK1 1 to address implementation of EALs 7-1, 7-2, and 7-3.

Provide applicable information to Operations Training in support of CRAI 3065613 and to ESD Training in support of CRAI 3121416 (9.5.5) Due:

Complete 2

• After procedural revision is complete (see CRAI 3065531 - task#9.5.5), provide training on procedure changes to EC qualified personnel. (9.5.6) Due: Complete Strategy 11 - Develop a plan for implementation of NEI 99-01 Rev.5 for EAL upgrade and present to Senior Management. (SIBP/SIIP 9.5.1 and 9.5.2)

" Evaluate implementation of NEI 99-01 strategy and develop recommendations for presentation to senior leadership. (9.5.1) Due: Complete

" Present the strategy and development recommendations defined in task 9.5.1 (CRAI 3063488) to senior leadership. (9.5.2) Due: 05/30/2008 3

Attachment 12 Key Performance Area 11 Longstanding Equipment Actions Listing of Specific Tasks and Due Dates

Attachment 12 Key Performance Area 11 Longstanding Equipment Actions Listing of Specific Tasks and Due Dates To address the potential for latent and longstanding issues associated with equipment deficiencies (e.g., water intrusion into underground vaults, check valve degradation, and EDG fluid leaks), PVNGS will implement the following:

SlIP Action Plan 2, "Equipment Reliability," Strategy 7 o Strategy 7 - Establish a site Top 10 process for identifying and prioritizing equipment issues and address specific long-standing issues associated with known equipment deficiencies. (SIBP/SIIP 1.2.A.3, 11.3.1 through 11.3.7, and 11.3.15)

" Develop necessary program documents to support the Top 10 Technical Issues process including site personnel roles and responsibilities. (1.2.A.3) Due:

Complete

" Develop an action plan to resolve the long-standing issues associated with the Auxiliary Feedwater Steam Admission Solenoid Valve (SG-UV-1 34A and SG-UV-138A). (11.3.1) Due: Complete

" Develop an action plan to resolve the long-standing issues associated with the Unit 1 BOP/ESFAS Sequencer. (11.3.2) Due: 04/30/2008

" Develop an action plan to resolve the long-standing issues associated with the Unit 2 Main Feedwater Pump Oil Seal. (11.3.3) Due: 04/20/2008

" Develop an action plan to resolve the long-standing issues associated with the Secondary Chemical System Hydrazine Pumps. (11.3.4) Due: 04/30/2008

" Develop an action plan to resolve long-standing issues associated with the SI System (RWT Air entrainment, HPSI unavailability, SI check valves). RAS issues are to be addressed separately under 95002. (11.3.5) Due: 04/30/2008 Develop an action plan to resolve the long-standing issues associated with the Emergency Diesel Generators (2B Fuel Strainer, Air, Oil and water Leaks, etc.).

(11.3.6) Due: Complete Develop an action plan to resolve the long-standing issues associated with the Spray Pond Flow. (11.3.7) Due: 04/30/2008 Develop an action plan to address program requirements for control of the manholes and vaults. (11.3.15) Due: 04/22/2008 1

Attachment 13 Key Performance Area 12 Backlog Tracking and Prioritization Actions Listing of Specific Tasks and Due Dates

Attachment 13 Key Performance Area 12 Backlog Tracking and Prioritization Actions Listing of Specific Tasks and Due Dates To address problems in backlog tracking systems and prioritization, PVNGS will implement the following:

SlIP Action Plan 2, "Equipment Reliability", Strategy 1 o Strategy 1 - Revise and implement the plan to complete the Reliability Centered Maintenance (RCM) project. (SIBP/SIIP 1.2.C.11 and 1.2.C.12)

• Revise and implement the plan to complete the RCM project.

Include ownership of the project and actions to prioritize and resolve existing backlog of RCM recommendations, and develop repetitive tasks from RCM templates. Develop metrics to ensure visibility to the PHC and MRM and establish periodic reviews to assure completion to project targets. Present and obtain PHC approval for plan.

Complete the RCM project in accordance with the approved plan. (1.2.C.1 1)

Due: 09/30/2008 Plant Health Committee will review and approve the revised RCM project plan and establish periodic monitoring of plan implementation to ensure ownership, visibility, and accountability. This action is CA-1 1 for RC-01 in the Equipment Reliability Root Cause Report. (1.2.C.12) Due: Complete SlIP Action Plan 4, "Design Control/Configuration Management,"

Strategies 3 and 6 o Strategy 3 - Inventory engineering backlogs, complete significance reviews, and

'develop work-off plans. (SIBP/SIIP 11.9.A.4 through 11.9.A.6, and 11.9.A.18)

• Identify/Inventory Engineering backlogs working with ImPACT team. (Major Task)

" Mech/Civil Design (11.9.A.4.a) Due: Complete

• Electrical/l&C Design (11.9.A.4.b) Due: Complete

• System Eng. (11.9.A.4.c) Due: Complete

• Maintenance Eng. (11.9.A.4.d) Due: Complete

" Fuel Management (11 .9.A.4.e) Due: Complete

" Modifications (11.9.A.4.f) Due: Complete 1

• Procurement Eng. (11.9.A.4.g) Due: Complete

" Complete Significance Review of Engineering Backlog working with ImPACT team. (Major Task)

" Mech/Civil Design (11.9.A.5.a) Due: Complete

" Electrical/l&C Design (11.9.A.5.b) Due: Complete

• System Eng. (11.9.A.5.c) Due: Complete

• Maintenance Eng. (11.9.A.5.d) Due: Complete

• Fuel Management (11.9.A.5.e) Due: Complete

• Modifications (11.9.A.5.f) Due: Complete

• Procurement Eng. (11.9.A.5.g) Due: Complete

" Ensure that significant latent issues identified in step 11.6.A.5 (if any) are scheduled for completion in the Site Work Management Process. ( Major Task)

• Mech/Civil Design (11.9.A.6.a) Due: Complete

• Electrical/l&C Design (11.9.A.6.b) Due: Complete

• System Eng. (11.9.A.6.c) Due: Complete

• Maintenance Eng. (11.9.A.6.d) Due: Complete

• Fuel Management (11.9.A.6.e) Due: Complete

• Modifications (11.9.A.6.f) Due: Complete

• Procurement Eng. (11.9.A.6.g) Due: Complete

" Present the results and recommendations of the significance review conducted in task 11.9.A.5 of major engineering backlog categories identified in task 11.9.A.4 and contained in Table 2 of Revision 1 of the Plan for Backlog Significance Review to Senior Management. (11.9.A.18) Due: 06/13/2008 o Strategy 6 - Inventory, plan, and work off backlogs of temporary changes and degraded conditions. (SIBP/SIIP 4.1 .G.1 through 4.1 .G.3, 11.3.11, and 11.3.14)

" Complete an aggregate review, utilizing a risk informed determination process such as the [other utility] process, of installed temp. mods, degraded-nonconforming work orders, CRDLs, installed jumpers, operability determinations, number of work orders on safety systems, longstanding permits, OWAs that have been proceduralized, to determine overall impact to operational nuclear safety of the plant.

This CRAI is for Unit 1 and is related to CRAI 3064336. (4.1 .G.1) Due: Complete

" Complete an aggregate review, utilizing a risk informed determination process such as the [other utility] process, of installed temp. mods, degraded-nonconforming work orders, CRDLs, installed jumpers, operability determinations, number of work orders on safety systems, longstanding permits, OWAs that have been proceduralized, to determine overall impact to operational nuclear safety of the plant.

This CRAI is for Unit 2 and is related to CRAI 3064337. (4.1 .G.2) Due: Complete 2

" Complete an Aggregate Review, utilizing a risk informed determination process such as the [other utility] process of installed temp. mods, degraded-nonconforming work orders, CRDLs, installed jumpers, operability determinations, number of work orders on safety systems, longstanding permits, OWAs that have been proceduralized, to determine overall impact to operational nuclear safety of the plant.

This CRAI is for Unit 3 and is related to CRAI 3064338. (4.1.G.3) Due: Complete

" Identify and inventory the following items: 1) temporary modifications, 2) temporary jumpers (mechanical and electrical), 3) scaffolding, 4) permits, 5) imbedded Operator Work Arounds, and 6) apparent defacto changes (i.e., non-approved design or configuration changes) and provide to Engineering for input into CRAI 3064842. (11.3.11) Due: Complete

" Engineering develop metrics to facilitate and monitor burn-off of temporary installations identified in task 11.3.13. Incorporate metrics into site performance indicators. (11.3.14) Due: 12/30/2008 SlIP Action Plan 7, "Managing Plant Workloads," Strategy 8 o Strategy 8 - Identify PVNGS work tracking system backlogs. Screen and perform significance reviews of items contained in the work tracking systems. (SIBP/SIIP 14.2.21, 14.2.22, and 14.2.23)

" Identify PVNGS work inventory tracking systems. For purposes of this review, a tracking system is defined as a system that is used by a group to track or manage an inventory of work issues. (14.2.21) Due: Complete

" Screen the tracking systems identified in Task 14.2.21 to identify those tracking systems which are likely to contain items with the following characteristics: (a) potential for activities that are adverse to quality but are not entered into the Corrective Action Program, (b) potential for existence of latent issues affecting the performance or design capability of safety-significant Structures, Systems and Components, (c) potential impact on corrective actions to prevent recurrence, or (d) potential challenge to plant safety or operations. (14.2.22)

Due: Complete

" Perform Significance Review of the items contained in the work inventory tracking systems identified in Task 14.2.22 to identify any significant latent issues or any conditions adverse to quality and enter any such conditions identified into the PVNGS CAP. This review may rely upon sampling if large numbers of items are involved and the likelihood that they include conditions adverse to quality (CAQs) is low. (14.2.23) Due: 06/30/2008 3

Attachment 14 Descriptions of Metrics

Attachment 14 Descriptions of Metrics The PVNGS Site Integrated Improvement Plan metrics are listed below, along with a brief description of each metric. The correlation of these metrics to the SlIP Action Plans is shown in Attachment 1.

Metric Description Status of Core Shows how many of the PVNGS core performance indicators are in the Performance Indicators - "Green," "White," "Yellow," and "Red" performance bands, providing an Overall Indicator overall indication of trends in PVNGS performance.

Operational Focus Shows aggregate impact of various items on the operating units. Items Indicator measured include: Operator Work Arounds; Operator Burdens; Lit Annunciators; Control Room Discrepancy Log items; Long-Term Tagouts; Fire System Component Condition Records; Temporary Modifications; Unplanned Entries into Limiting Conditions of Operation; Site Corrective and Elective Maintenance.

Operator Work Arounds Shows number of Operator Work Arounds, defined as an operator challenge resulting from equipment deficiencies that affects transient plant operations and would require operators to take compensatory actions in order to comply with an Emergency Operating Procedure or Abnormal Operating Procedure Operator Burdens Shows number of Operator Burdens, defined as an operator challenge resulting from equipment deficiencies that would require operators to take compensatory measures to comply with normal plant Operating Procedures.

Lit Annunciators Shows number of Annunciator Discrepancies that involve any annunciator on a main control board that is lit and the condition is not currently under maintenance action or that will be lit for greater than 14 days while maintenance occurs.

Control Room Shows Control Room Discrepancy Log items (on-line only) that have Discrepancy Logs been open greater than 14 days Long-Term Tagouts Shows Tagout Permits that have been in place for greater than 180 days.

Fire System Component Shows the number of open Fire System Component Condition Reports Condition Reports (FSCCRs) in the power block.

Temporary Modifications Shows the number of outstanding Temporary Modifications of any age that are not outage-related Unplanned Entries Into Shows the number of unplanned Limiting Condition of Operation (LCO)

Limiting Conditions of entries per month that would result in plant shutdown within 15 days if Operation not resolved.

1

Site Corrective Shows number of open Corrective Maintenance (CM) items. CM items Maintenance include any work on power block Structures, Systems or Components (SSCs) where the SSC has failed or is significantly degraded to the point that failure is imminent (within operating cycle or preventive maintenance interval) and no longer conforms to or is capable of providing the SSCs design function. Excludes maintenance work orders classified as outage (priority 5) or forced outage (priority 6).

Site Elective Shows the number of open Elective Maintenance (EM) items. EM items Maintenance include any work on power block equipment in which identified potential or actual degradation is minor and does not threaten the component's design function or performance criteria.

Site Chemistry Shows the effectiveness of chemistry control of various secondary and Effectiveness Indicator primary components as compared to industry standards. Focuses attention on a broad area of fuel and equipment reliability and corrosion mitigation.

Forced Loss Rate Shows the rate of loss of generation as a result of total planned and unplanned power losses calculated over an 18 month period.

Unplanned Power Shows the number of unplanned power changes that are greater than Change (NRC Indicator) 20% power per 7000 reactor critical hours.

Unplanned Power Shows the number of unplanned power changes that are greater than Change (PVNGS Site 20% power per 7000 reactor critical hours. This indicator is a leading Indicator) indicator to monitor PVNGS performance in the NRC green band.

Operability Determination Shows the quality of Operability Determinations (ODs). The quality is measured by the percent of ODs found acceptable as determined by the OD Quality Board.

Engineering Systems Shows how many of the PVNGS Engineering Systems are in the Health Report Total Color "Green," "White," "Yellow," and "Red" performance bands, providing an Progress overall indication of trends in PVNGS System Health performance.

CDBR Project Schedule Shows monthly progress of the Component Design Basis Review Adherence program to ensure the project remains on track.

Quality of the Resolution Shows the effectiveness in the resolution of CDBR project-related of CDBR Related Actions deficiencies identified in design and licensing basis. The quality is measured by the percent of items found acceptable by third party reviews including Performance Improvement Department, Nuclear Assurance Department and the Corrective Action Review Board.

Engineering CRDR/CRAI Shows the number of active Condition Report Disposition Requests Reduction (CRDRs) and Condition Report Action Items (CRAIs), including Significant and Adverse, assigned to Engineering for resolution.

Engineering Work Shows the effectiveness of engineering-related technical rigor in their Product Quality products. The quality is measured by the percent of items found acceptable by third party reviews including Performance Improvement Department, Nuclear Assurance Department, the Corrective Action Review Board (CARB), and the Engineering Products Review Board (EPRB). The EPRB reviews will commence in March 2008.

Engineering Program Shows how many of the PVNGS Engineering Programs are in the Health Report Total Color "Green," "White," "Yellow," and "Red" performance bands, providing an Progress overall indication of trends in PVNGS Engineering Program Health performance.

2

CRDR Inventory Shows the total monthly inventory of Condition Report Disposition Requests (CRDRs). This indicator is a measure of CRDR inventory.

CAP Quality Index Shows the effectiveness of Root, Apparent Cause and Adverse evaluations and Condition Report Disposition Request (CRDR) closure documents. The quality is measured by the percent of items found acceptable by third party reviews including Performance Improvement Department, Nuclear Assurance Department and the Corrective Action Review Board. The total value is weighted 50% on evaluations and 50%

on CRDR closure.

CRDR Evaluation Age Shows the average time to complete Condition Report Disposition Request (CRDR) evaluations. This indicator measures the station's timeliness in evaluating Significant, Apparent Cause and Adverse conditions.

Average Age of Open Shows the average age of corrective actions determined to prevent Corrective Actions to recurrence resulting from Significant cause evaluations. This indicator Prevent Recurrence measures the station's timeliness in fixing Significant cause-related conditions.

Timeliness of Operating Shows the timeliness in the review and evaluation of Operating Experience Screening Experience (OE) identified in high-tier industry OE reports. This indicator trends the percent of items reviewed in accordance with established program timelines dependent on the level of significance of the OE report.

ERO Drill/Exercise Shows the percent of successful Classifications, Notifications and Performance (NRC Protective Action Recommendations in emergency response- related Indicator) drills and exercises as compared to the associated opportunities.

ERO Drill/Exercise Shows the percent of successful Classifications, Notifications and Performance (PVNGS Protective Action Recommendations in emergency response- related Site Indicator) drills and exercises as compared to the associated opportunities. This indicator is a leading indicator to monitor PVNGS performance in the NRC green band.

Emergency Drill Shows the percent of key Emergency Response personnel who have Participation (NRC participated in emergency drills over the last eight quarters.

Indicator)

Alert and Notification Shows the reliability of the Emergency Response-related Alert and System (NRC Indicator) Notification System. The reliability is measured by the percent of operable equipment over a twelve month period.

Online Schedule Shows the percent of work activities completed on schedule. This Adherence indicator trends the monthly average of weekly work activities completed.

Online Scope Stability T- Shows the percent of work in scope of a particular target week at five 5 through T-1 weeks prior to execution against the work remaining in scope the week prior to execution. This indicator trends the effectiveness in the preparation of work activities.

3

Total/Adverse Procedure Shows the total inventory of technical procedure changes in progress as Change Inventory tracked by both the corrective action program (adverse) and in the ACT program (non-adverse). The indicator is a measure of the number of adverse procedure changes in working status.

Site Plant Performance Shows the cumulative average of the three units' performance. This Index (Annualized) indicator measures site performance against a composite of industry standards including: Unit Capability Factor; Forced Loss Rate; High Pressure Safety Injection, Residual Heat Removal and Emergency Power System performance; Unplanned SCRAMS, Collective Radiation Exposure; Fuel Reliability; Chemistry Effectiveness.

Site Clock Reset Shows the number of monthly events reaching the site threshold for significance averaged over an 18 month period. This indicator measures the site performance against a composite of standards in various areas of safety significance.

Consequential Human Shows the number of human performance-related errors with Error Rate consequential results per month. This indicator is a measure of site behaviors associated with activities of safety significance.

APSIPVNGS Industrial Shows a*twelve month rolling average of PVNGS utility employee-Safety Accident Rate related injuries per 200,000 man-hours of work resulting in a lost (ISAR) workday, restricted duty or fatality.

Non-Utility Industrial Shows a twelve month rolling average of PVNGS non-utility employee-Safety Accident Rate related injuries per 200,000 man-hours of work resulting in a lost (ISAR) workday, restricted duty or fatality.

Industrial Safety Work Shows the average number of days to implement industrial safety work Orders and Average Age orders. This indicator is a measure of the timeliness in addressing

____________________industrial safety work orders over a three-month rolling average.

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