ML11269A147

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2009 Mid-Cycle Plant Safety Performance Summary, Assessment Period: Jul 1, 08 Thru Jun 30, 09, Exemption 4, Exemption 5
ML11269A147
Person / Time
Site: San Onofre  Southern California Edison icon.png
Issue date: 09/23/2011
From:
- No Known Affiliation
To:
Office of Information Services
References
FOIA/PA-2011-0159
Download: ML11269A147 (21)
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San Onofre Nuclear Generating Station 2009 Mid-Cycle Plant Safety Performance Summary Assessment Period: July 1, 2008 - June 30, 2009 1 Operating Summary, A. Power Operations - Noteworthy Unplanned Operating Events and Forced Outages Unit 2 Power Operations September 22 Power reduced to 65 percent to repair main feedwater Turbine K005 lube oil pipe flange leak September 26 Reactor returned to full power Unit 3 Power Operations August 14 Power was reduced to 65 percent to repair main feedwater Turbine K006 trip mechanism August 18 Reactor returned to full power September 1 Reactor was shutdown to comply with Technical Specification 3.8.1 limiting condition for operation for an inoperable emergency diesel generator.

September 11 Following emergency diesel generator repairs, commenced reactor startup September 13 Reactor at full power September 17 Power reduced to 98 percent due to a tripped heater drain pump September 20 Power reduced to 75 percent to alleviate an extraction steam line bellow leak and to accommodate condenser tube leak repairs.

October 12 Reactor shutdown for refueling outage December 15 Commenced reactor start up B. Planned Outages - Noteworthy UnDlanned Outane Events Information in this record was deeted in accordance with th E Act, exemptonl-EWA~ ..A Vý /I

Unit 2 Planned Outages - Reactor was shutdown on December 28, 2008 for a planned midcycle outage. This outage was to perform weld overlays of piping in accordance with industry guidance. The reactor was restarted on February 17, 2009 Unit 3 Planned Outages - Reactor was shutdown on October 12, 2008 for refueling outage 3R15. The unit started up on December 15, 2008. It reached 65 percent on

  • December 20, due to restrictions caused by a main feedwater pump being out of service. The reactor reached full power on December 24, 2008.

Upcoming RFOs Unit 2 - 2R16: October 2, 2009 - January 20, 2010 - Steam Generator Replacement Unit 3 - 3R16: September 2010- December 2010 - Steam Generator Replacement

2. Safety Performance Overview A. Previous Assessment Results 3rd Qtr 2008 4 th Qtr 2008 13' Qtr 2008 Action Matrix Licensee Unit 2: Regulatory Response Unit 2: Regulatory Response Column Response Unit 3: Licensee Response Unit 3: Licensee Response Basis All findings and Unit 2: 1 White finding Unit 2: 1 White finding Pl's were Green. Unit 3: All findings and Pl's Unit 3: All findings and Pi's were Green. were Green.

Summary of results from Previous End-of-Cycle Letter Plant performance from the End-of-Cycle assessment period for Unit 2 was within the Regulatory Response Column of the NRC's Action Matrix, based on one inspection finding being classified as having low to moderate safety significance (White) and all Performance Indicators indicating performance at a level requiring no additional NRC oversight (Green).

Plant performance from the End-of-Cycle assessment period for Unit 3 was within the Licensee Response Column of the NRC's Action Matrix, based on all inspection findings being classified as having very low safety significance (Green) and all Performance Indicators indicating performance at a level requiring no additional NRC oversight (Green).

B. Proposed 2009 Mid-Cycle Assessment Plant performance for the most recent quarter for Unit 2 was in the Regulatory Response Column of the NRC's Action Matrix, based on one inspection finding being

4- - nl es"" e "c classified as having low to moderate safety significance (White) and all Performance Indicators indicating performance at a level requiring no additional NRC oversight (Green). On August 4, 2008, the NRC commenced a special inspection at Southern California Edison to inspect activities associated with deficient electrical connections with the potential to adversely affect the safety function of multiple safety systems used for accident mitigation. In Inspection Report 2008013, the NRC issued a violation of low to moderate safety significance (White) for the failure to establish appropriate instructions for performing maintenance activities on a safety-related 125 Vdc station battery breaker. The NRC will be conducting Supplemental Inspection 95001, "Supplemental Inspection for One or Two White Inputs in a Strategic Performance Area."

Plant performance for the most recent quarter for Unit 3 was within the Licensee Response Column of the NRC's Action Matrix, based on all inspection findings being classified as having very low safety significance (Green) and all Performance Indicators indicating performance at a level requiring no additional NRC oversight (Green).

Therefore, we plan to conduct reactor oversight process (ROP) baseline inspections.

(b)(5)

3. Inspection and Performance Indicator Results A. Results by Cornerstones Initiating Events Inspection Findings: Seven green NCV's and one green finding were evaluated by inspectors during this assessment period.
1) Green NCV - Licensee failed to include maintenance activities in or near the electrical switchyard and offsite power components in the on-line risk assessment (HP, IR 2009003-04, PIM# 79273)
2) Green NCV - Licensee failed to follow procedures for performing reactivity manipulations (HP, IR 2009002-04, PIM# 79260)
3) Green NCV - Licensee failed to properly perform an evaluation of reactor coolant pump vapor seal boric acid accumulation caused by a clogged vapor seal drain line in accordance with procedures (HP, IR 2009002-05, PIM# 79265)
4) Green NCV - Licensee failed to follow procedures to place Ion Exchanger ME074 into service, resulting in an interruption of letdown flow and diversion of approximately

160 gallons of reactor coolant to the radiological waste system (HP, IR 2009002-07, PIM# 79261)

5) Green FindinQ - Licensee failed to perform an adequate inspection of a main generator stator water pump discharge check valve, resulting in an unrecognized degraded condition that caused a main generator trip and subsequent reactor trip (PI&R, IR 2008005-01, PIM# 79252)
6) Green NCV - Licensee failed to consider the risk associated with the increased likelihood of an initiating event during emergent work on energized safety-related 125 Vdc battery breakers (HP, IR 2008013-04, PIM# 79232)
7) Green NCV - Licensee took ineffective corrective actions to address blended flow evolutions, resulting in multiple reactivity excursions occurring in the plant over the past two years (PI&R, IR 2008010-07, PIM# 79246)
8) Green NCV - Licensee failed to follow procedures for nuclear fuel movement in the spent fuel pool, resulting in the placement of spent fuel assemblies into storage locations different from those evaluated and approved by the procedure (HP, IR 2008004-01, PIM# 79227)

Performance Indicators: All performance indicators were Green throughout the assessment period.

Mitigating Systems Inspection Findinqs: Twenty-four NCV's, one severity level IV violation and one white violation were evaluated by inspectors during this assessment period.

1) White Violation - Licensee failed to establish appropriate instructions for performing maintenance activities on safety-related 125 Vdc breaker, resulting in an electrical connection whose integrity was inadequate to ensure the equipment would be able to perform its safety function (HP, IR 2008013-05, PIM# 79236)
2) SL-IV NCV - Licensee failed to submit a required Licensee Event Report within 60 days after discovering an event requiring a report, specifically safety-related 125 Vdc battery 2B008, which had been inoperable for greater than the technical specification allowed outage time (PI&R, IR 2008013-06, PIM# 79237)
3) Green NCV - Licensee failed to evaluate scaffolding for its impact on fire protection systems (HP, IR 2009003-01, PIM# 79270)
4) Green NCV - Licensee failed to implement timely corrective actions to preclude repetition of a significant condition adverse to quality involving the failure of a safety-related 480 volt circuit breaker (HP, IR 2009003-02, PIM# 79271)
5) Green NCV - Licensee failed to assess and manage the increase in risk associated with planned maintenance activities on an emergency chiller (PI&R, IR 2009003-03, PIM# 79272)
6) Green NCV - Licensee failed to provide adequate work instructions to control the connection of electrical monitoring devices on operable plant equipment (HP, IR 2009003-06, PIM# 79275)
7) Green NCV - Licensee failed to follow procedures while inspecting coating systems applied more than 20 mils think of saltwater cooling valve discs, resulting in defects in the coating not being detected (HP, IR 2009003-07, PIM# 79277)
8) Green NCV - Licensee failed to establish adequate procedures for scaffolding erection in safety-related areas (IR 2009003-08, PIM# 79278)
9) Green NCV - Licensee failed to maintain written procedures covered in Regulatory Guide 1.33, resulting in 54 uncontrolled procedures available for use on safety-related systems without flagging the required changes (PI&R, IR 2009003-09, PIM# 79279)
10) Green NCV - Licensee failed to follow maintenance instructions to fully remove fuses from fuse holder, resulting in plastic deformation of the fuse holder impacting the ability of the auxiliary feedwater control system to perform its required design function under all design basis accident conditions (HP, IR 2009002-01, PIM# 79262)
11) Green NCV - Licensee failed to follow procedures to adequately evaluate degraded conditions on the CCW tube leak was identified and subsequently when the tube exhibited a degrading trend (HP, IR 2009002-02, PIM# 79263)
12) Green NCV - Licensee failed to properly install and inspect scaffolding in safety-related areas in accordance with written procedural requirements (HP, IR 2009002-03, PIM# 79264)
13) Green NCV- Licensee failed to resolve degraded or nonconforming conditions at the first available opportunity or appropriately justify a longer completion schedule (PI&R, IR 2008005-02, PIM# 79253)
14) Green NCV - Licensee failed to follow procedures after notification that Battery 2B008 terminal voltage was less than required Technical Specification value, resulting in more than a two hour delay in entering the required 2-hour technical specification action statement (HP, IR 2008013-01, PIM# 79233)
15) Green NCV - Licensee failed to follow procedures, resulting in troubleshooting activities that were performed without a maintenance order and control room authorization (HP, IR 2008013-02, PIM# 79234)
16) Green NCV - Licensee failed to follow procedures, resulting in commencing work to correct the identified degraded electrical condition prior to having the appropriately authorized maintenance order (HP, IR 2008013-03, PIM# 79235)
17) Green NCV - Licensee failed to establish measures to assure that deficient electrical connections were promptly identified and corrected (PI&R, IR 2008013-08, PIM# 79238)
18) Green NCV - Licensee failed to provide procedural guidance to operations personnel to combat and recover from a loss or degradation of a Class 1 E 125 Vdc bus (IR 2008013-09, PIM# 79239)
19) Green NCV - Licensee failed to have adequate procedures, resulting in an inadvertent electrical ground on a safety-related electrical distribution bus (HP, IR 2008012-01, PIM# 79248)
20) Green NCV - Licensee failed to properly evaluate a degraded relay that affected the operability of Unit 3 Train A emergency diesel generator (HP, IR 2008012-02, PIM#

79249)

21) Green NCV - Licensee failed to consider the impact to the auxiliary feedwater pump room's heat load design basis calculation for the most limiting scenario (IR 2008012-03, PIM# 79250)
22) Green NCV - Licensee had no procedures to verify periodic heat treatments of intake tunnel and structure was consistent with historical data, resulting in the design basis calculation and operating instructions not ensuring the capability of the heat exchangers to perform their design function during anomalous conditions (IR 2008010-01, PIM# 79241)
23) Green NCV - Licensee failed to consider and analyze the voltage drop that occurs in control circuit elements that could result in considerably lower voltage at the devices than is available at the corresponding distribution panels (IR 2008010-02, PIM# 79242)
24) Green NCV - Licensee failed to recognize, evaluate, or write an action request when the performance test for a station battery was terminated early due to test equipment issues (IR 2008010-04, PIM# 79245)
25) Green NCV - Licensee failed to follow procedures while performing battery performance tests, resulting in the performance tests for one station battery being terminated early instead of continuing the tests until reaching one of the test termination criteria (HP, IR 2008010-05, PIM# 79243)
26) Green NCV - Licensee had inadequate procedures that did not identify the deleterious effects of 480 Volt AC system grounds on connected equipment (IR 2008010-06, PIM# 79244)

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Performance Indicators: All performance indicators were Green throughout the assessment period.

Barrier Integrity Inspection Findings: Three green NCV's were evaluated by inspectors during this assessment period.

1) Green NCV - Licensee failed to follow procedures to evaluate the operability of an identified non-conformin condition associated with containment structural Tendon H-14 (PI&R, IR 2009003-05, PIM# 79274)
2) Green NCV - Licensee failed to follow procedure requirements for work on a reactor coolant system pressure retaining component, resulting in a reactor coolant system leak during the fill and vent process (HP, IR 2009002-06, PIM# 79266)
3) Green NCV - Licensee did not properly implement procedural controls to adequately evaluate or repair a degraded source handling tool used in the spent fuel, resulting in the tool being returned to service still in a degraded condition (PI&R, IR 2008005-03, PIM#

79254)

Performance Indicators: All performance indicators were Green throughout the assessment period.

Emergency Preparedness Inspection Findings: No findings were evaluated by inspectors during this assessment period.

Performance Indicators: All performance indicators were Green throughout the assessment period.

Occupational Radiation Safety Inspection Findings: No findings were evaluated by inspectors during this assessment period.

Performance Indicators: All performance indicators were Green throughout the assessment period.

Public Radiation Safety Inspection Findings: No findings were evaluated by inspectors during this assessment period.

S a Us ny-Se "tive n - isi n Hformatio Performance Indicators: All performance indicators were Green throughout the assessment period.

4. Adverse Trends in Cross-cutting areas A. SCWE- Allegations Received Between January 1, 2008 - June 30, 2009 or NRC letters to Licensee Forty-one allegations were received during the past eighteen months. The NRC has not sent any letters to Southern California Edison regarding SCWE. The following lists the twenty-one concerns associated with SCWE.
1. Alleger believes that they were discriminated against for raising safety related concerns. (2008-A-0035)
2. Two individuals separately contacted the NRC via email claiming that they had been subjected to discrimination for "raising safety concerns". (2008-A-0062)
3. Alleger states that (s)he was yelled at, intimidate, and questioned by his/her supervisor as to the reason why (s)he had raised a concern to the Nuclear Safety Concerns office (unsubstantiated). (2008-A-0083)
4. Alleger states that Bechtel contract painters do not feel safe coming forward to their supervisor or the Nuclear Concerns department with their concerns because of what happened to another individual (2008-A-0089)
5. Alleger believes that they were discriminated against for raising safety related concerns (unsubstantiated). (2008-A-0111)
6. Alleger states that another individual was retaliated against for raising safety concerns (third party discrimination). (2008-A-01 14)
7. Alleger states that the vice president has created a chilled environment (unsubstantiated). (2008-A-0128)
8. Alleger believes (s)he was retaliated against for raising safety concerns (ADR).

(2008-A-0141)

9. Alleger states that operators were intimidated to work unfit for duty (nonallegation).

(2008-A-0152)

10. Alleger believes that (s)he was black-listed due to use of sick leave (nonallegation).

(2008-A-0156)

11. Alleger states that there is a chilled environment (unsubstantiated). (2008-A-0163)
12. Alleger states that they were terminated for raising safety concerns (ADR). (2009-A-0017)
13. Alleger states that a negative perception of SCWE exists. (2009-A-0032)
14. Alleger states that they and others will not approach management about concerns.

(2009-A-0039)

15. Adverse action was taken against two individuals who opposed remote access (transferred to HQ's, NSIR-2009-A-005). (2009-A-0043)
16. Alleger believes that (s)he has been discriminated against for raising safety concerns to the NRC (ADR). (2009-A-0057)

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(b)(5)

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processes have not been effective, possibly resulting in the increased levels of concerns. The licensee is currently in the process of performing an independent safety culture assessment and other safety culture assessments specific to the contract workforce. The NRC plans to perform focused inspections to review the results of these efforts and any associated action plans developed by the licensee to address areas of concern. The licensee plans to have the results of these assessments the end of September and state they should be ready for an NRC inspection in early November.

The NRC will also perform a team PI&R inspection in February 2010. A focus area for this inspection will be placed on evaluating the SCWE at the facility in addition to the effectiveness of the employee concerns program.

B. Human Performance- PIM Entries Between July 1, 2008 - June 30, 2009 Conclusion There is an increasing trend in the number of findings with cross-cutting aspects in the area of human performance. In the end-of-cycle assessment, there were sixteen findings with cross-cutting aspects in this area. In this assessment, there are twenty-one, indicating a degrading trend in the area of human performance overall.

(b)(5)

(b)(5)

Details Three of the twenty-one findings in the cross-cutting area of human performance were within the resources component. All three had the common theme of not providing complete, accurate and up-to-date design documentation and procedures (H.2(c)), one finding was safety significant (White). This contributing cause was first noticed in the second quarter of the 12-month inspection cycle and continued throughout the period with one new finding in this aspect occurring during the most recent quarter. The branch has concern with the scope and effectiveness of the licensee's efforts in addressing this issue. Consequently, the branch recommends leaving the substantive crosscutting issue in Human Performance / Resources open.

Nine of the twenty-one findings in the cross-cutting area of human performance were within the work practices component. Of the nine, six had the common theme of not using human error prevention techniques and proceeding in the face of uncertainty (H.4(a)). The branch has concerns with the scope and effectiveness of the licensee's efforts in addressing this issue. The branch recommends leaving the substantive croscutting issue in Human Performance / Work Practices open.

Six of the twenty-one findings in the cross-cutting area of human performance were within the decision-making component. Of the six, four had the common theme of not using conservative assumptions in decision-making (H.1(b)). This contributing cause was first noticed in the second quarter of the 12 month inspection cycle and continued throughout the period with one new finding in this aspect occurring during the most recent quarter. The branch has concerns with the scope and effectiveness of the licensee's efforts in addressing human performance. The branch recommends opening a substantive crosscutting issue in Human Performance / Decision-Making.

Table 1.0 - Cross Cutting Area - Human Performance Decision-Makina Component Documented Cornerstone Finding Contributing Cause Licensee failed to follow procedures after notification Licensee did not Mitigating that Battery 2B008 terminal voltage was less than make safety- Systems required Technical Specification value, resulting in more significant decisions than a two hour delay in entering the required 2-hour using a systematic technical specification action statement (HP, IR process when faced 2008013-01, PIM# 79233) with uncertain and unexpected conditions. H.1(a)

Licensee did not Mitigating Licensee failed to follow procedures, resulting in make safety- Systems troubleshooting activities that were performed without a significant decisions maintenance order and control room authorization (HP, using a systematic IR 2008013-02, PIM# 79234) process when faced with uncertain and unexpected conditions. H. 1(a)

Licensee failed to properly evaluate a degraded relay Failure to use Mitigating that affected the operability of Unit 3 Train A emergency conservative Systems diesel generator (HP, IR 2008012-02, PIM# 79249) assumptions for operability decision-making H.1(b)

Licensee failed to follow procedures and adequately Failure to review Mitigating evaluate degraded conditions to support operability past operability Systems decision making (HP, IR 2009002-02, PIM# 79263) decisions to verify validity of underlying assumptions H.1(b)

Licensee failed to properly perform an evaluation of Failure to use Initiating reactor boric acid corrosion control program procedures conservative Events (HP, IR 2009002-05, PIM# 79265) assumptions to identify possible unintended consequences H.1(b)

Licensee failed to implement timely corrective actions to Failure to verify Mitigating preclude repetition of a significant condition adverse to safety-significant Systems quality involving the failure of a safety-related 480 volt decisions to validate circuit breaker (HP, IR 2009003-02, PIM# 79271) underlying assumptions H.1(b)

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Documented Cornerstone Finding Contributing Cause Licensee failed to consider the risk associated with the Licensee did not Initiating increased likelihood of an initiating event during have complete, Events emergent work on energized safety-related 125 Vdc accurate up-to-date battery breakers (HP, IR 2008013-04, PIM# 79232) procedure H.2(c)

Licensee failed to establish appropriate instructions for Licensee did not Mitigating performing maintenance activities on safety-related 125 have complete, Systems Vdc breaker, resulting in an electrical connection whose accurate up-to-date integrity was inadequate to ensure the equipment would procedure H.2(c) be able to perform its safety function (HP, IR 2008013-05, WHITE Violation, PIM# 79236)

Licensee failed to include maintenance activities in or Licensee did not Initiating near the electrical switchyard and offsite power have complete, Events components in the on-line risk assessment (HP, IR accurate up-to-date 2009003-04, PIM# 79273) procedure H.2(c)

Work Control Component Documented Cornerstone Finding Contributing Cause Work was not Mitigating Licensee failed to have adequate procedures, resulting planned to address Systems in an inadvertent electrical ground on a safety-related the human-system electrical distribution bus (HP, IR 2008012-01, PIM# interface 79248) H.3(a)

Licensee did not Initiating Licensee failed to follow procedures for reactivity appropriately plan Events manipulations (HP, IR 2009002-04, PIM# 79260) work activity H.3(a)

Licensee did not Barrier Licensee failed to follow procedure requirements for incorporate actions Integrity work on a reactor coolant system pressure retaining to address operation component (HP, IR 2009002-06, PIM# 79266) impact of work activities H.3(b)

Work Practices Component Documented Cornerstone Finding Contributing Cause Licensee failed to evaluate scaffolding for its impact Licensee did not use Mitigating on fire protection systems (HP, IR 2009003-01, PIM# human error Systems 79270) prevention techniques such as proper documentation H.4(a)

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Licensee failed to follow procedures while performing Licensee did not use Mitigating battery performance tests, resulting in the human error Systems performance tests for one station battery being prevention terminated early instead of continuing the tests until techniques such as reaching one of the test termination criteria (HP, IR proper 2008010-05, PIM# 79243) documentation H.4(a)

Licensee failed to follow procedures, resulting in Licensee did not use Mitigating commencing work to correct the identified degraded human error Systems electrical condition prior to having the appropriately prevention authorized maintenance order (HP, IR 2008013-03, techniques such as PIM# 79235) proper documentation H.4aa)

Licensee failed to follow procedures for nuclear fuel Licensee did not use Initiating movement in the spent fuel pool, resulting in the human error Events placement of spent fuel assemblies into storage prevention locations different from those evaluated and approved techniques such as by the procedure (HP, IR 2008004-01, PIM# 79227) proper documentation H.4aW Licensee failed to properly install and inspect Licensee did not use Mitigating scaffolding in safety-related areas in accordance with human error Systems procedure (HP, IR 2009002-03, PIM# 79264) prevention techniques such as proper documentation H.4(a)

Licensee failed to follow procedures to place an ion Licensee did not use Initiating exchanger in service, resulting in interruption of human error Events letdown flow and diversion of reactor coolant to prevention radiological waste system (HP, IR 2009002-07, PIM# techniques such as 79261) proper documentation H.4(a)

Licensee failed to provide adequate work instructions Licensee did not Mitigating to control the connection of electrical monitoring comply with Systems devices on operable plant equipment (HP, IR expectations 2009003-06, PIM# 79275) regarding procedural compliance H.4(b)

Licensee failed to follow instructions to fully remove Licensee did not Mitigating fuses from the fuse holder (HP, IR 2009002-01, PIM# comply with Systems 79262) expectations regarding procedural compliance H.4(b)

- are S Si I ma mre ýs ýf o Licensee failed to follow procedures while inspecting Licensee failed to Mitigating coating systems applied more than 20 mils think of ensure supervisory Systems saltwater cooling valve discs, resulting in defects in oversight of work the coating not being detected (HP, IR 2009003-07, activities such that PIM# 79277) nuclear safety is supported HA(c)

Table 1.1 - Basis for Conclusion on MC 0305 Criteria MC 0305 Guidance on Performance Observations in the Human Met Substantive Cross-Cutting Performance Area Criteria (SCC) Issues Criterion 1: Multiple Green or Twenty-one findings with aspects of human Yes safety significant inspection performance.

findings in the assessment period with documented aspects of human performance Four findings in the Decision-Making Criterion 2: Contributing Causes Yes have a common theme component with the common theme of not using conservative decision-making, covering corroborated by more than three (3) findings and from more than the Mitigating Systems and Initiating Events cornerstones. H.1(b) one cornerstone (exception is Mitigating System)

Three findings in Resources component with the common theme of not providing complete, accurate, and up-to-date design No documentation, procedures, and work packages, covering the Mitigating Systems and Initiating Events cornerstones. H.2(c)

Six findings in the Work Practices component with the common theme of not using human error prevention techniques and proceeding Yes in the face of uncertainty covering the Mitigating Systems and Initiating Events cornerstones. (H.4(a))

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Criterion 3: The agency has a Based on the fact that the total number of Yes concern with the licensee's scope findings with human performance cross-of efforts or progress in addressing cutting issues has increased, and that this the cross-cutting area theme had three findings in the last two performance deficiency quarters, the branch has a concern with licensee's actions and progress in addressing the cross-cutting area. The branch recommends opening a substantive cross-cutting issue in human performance /

decision-making.

Based on the fact that the theme was seen throughout the entire cycle with one new finding in this most recent quarter we Yes recommend keeping open the substantive cross-cutting issue in human performance/

resources.

Based on the fact that the theme was seen throughout the entire cycle with one new Yes finding in this most recent quarter we recommend opening a substantive cross-cutting issue in human performance / work practices.

C. PI&R - PIM Entries Between July 1, 2008- June 30, 2009 Conclusion There is an increasing trend in the number of findings with cross-cutting aspects in the area of problem identification and resolution. In the end-of-cycle assessment, there were eight findings with cross-cutting aspects in this area. In this assessment, there are nine, indicating a degrading trend in the area of problem identification and resolution overall. -_..._,.

(b)(5)

Details All of the nine findings in the cross-cutting area of Problem Identification and Resolution (PI&R) were in the corrective action program component. Seven of the nine shared the common theme of failing to thoroughly evaluate problems such that the resolutions address causes and extent of conditions.;

(b)(5)

Table 2.0- Cross Cutting-,Area -7ProblemIdentification and Resolution.:'. -

CorrectiVb Action Prog ra6m Comphienn-f --

Documented Cornerstone Finding Contributing Cause Licensee failed to perform an adequate inspection of a Licensee did not Initiating main generator stator water pump discharge check identify a degraded Events valve, resulting in an unrecognized degraded condition condition that caused a main generator trip and subsequent completely, reactor trip (PI&R, IR 2008005-01, PIM# 79252) accurately and in a timely manner P.1(a)

Licensee took ineffective corrective actions to address Licensee did not Initiating blended flow evolutions, resulting in multiple reactivity thoroughly evaluate Events excursions occurring in the plant over the past two years the problem such (PI&R, IR 2008010-07, PIM# 79246) that resolutions address causes and extent of conditions P.1(c)

Licensee failed to establish measures to assure that Licensee did not Mitigating deficient electrical connections were promptly identified thoroughly evaluate Systems and corrected (PI&R, IR 2008013-08, PIM# 79238) the problem such that resolutions address causes and extent of conditions P.1(c)

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Licensee failed to submit a required Licensee Event Licensee did not Mitigating Report within 60 days after discovering and event thoroughly evaluate Systems requiring a report, specifically safety-related 125 Vdc the problem such battery 28008, which had been inoperable for greater that resolutions than the technical specification allowed outage time address causes and (PI&R, IR 2008013-06, PIM# 79237) extent of conditions P.1(c)

Licensee failed to resolve degraded or nonconforming Licensee did not Mitigating conditions at the first available opportunity or thoroughly evaluate Systems appropriately justify a longer completion schedule (PI&R, the problem such IR 2008005-02, PIM# 79253) that resolutions address causes and extent of conditions P.1(c)

Licensee did not properly implement procedural controls Licensee did not Barrier to adequately evaluate or repair a degraded source thoroughly evaluate Integrity handling tool used in the spent fuel, resulting in the tool the problem such being returned to service still in a degraded condition that resolutions (PI&R, IR 2008005-04, PIM# 79254) address causes and extent of conditions P.1(c)

Licensee failed to follow procedures to evaluate the Licensee did not Barrier operability of an identified non-conformin condition properly classify, Integrity associated with containment structural Tendon H-14 prioritize, and (PI&R, IR 2009003-05, PIM# 79274) evaluate for operability conditions adverse to quality P.1(c)

Licensee failed to maintain written procedures covered in Licensee did not Mitigating Regulatory Guide 1.33, resulting in 54 uncontrolled thoroughly evaluate Systems procedures available for use on safety-related systems the problem such without flagging the required changes (PI&R, IR that resolutions 2009003-09, PIM# 79279) address causes and extent of conditions P.1(c)

Licensee failed to assess and manage the increase in Licensee failed to Mitigating risk associated with planned maintenance activities on take appropriate Systems an emergency chiller (PI&R, IR 2009003-03, PIM# corrective actions to 79272) address identified errors in a timely manner P.1(d)

Operating Experience Component Documented Cornerstone Finding Contributing Cause I

None.III Table 2.1 - Basis for Conclusion on MC 0305 Criteria MC 0305 Guidance on Performance Observations in the Met Substantive Cross-Cutting Problem Identification and Resolution Criteria (SCC) Issues Area Criterion 1: Multiple Green or Nine findings in the area of Problem Yes safety significant inspection Identification and Resolution were found in findings in the assessment period this inspection cycle.

with documented aspects of PI&R Criterion 2: Contributing Causes There is a common theme with seven findings Yes have a common theme sharing the same aspect of Corrective Action corroborated by more than three Program not thoroughly evaluating extent of (3) findings and from more than condition P.1(c), in the Mitigating Systems, one cornerstone (exception is Barrier Integrity, and Initiating Events Mitigating System) cornerstones.

Criterion 3: The agency has a Due to the fact that this theme is apparent Yes concern with the licensee's scope throughout the inspection cycle with two of efforts or progress in addressing findings in the most recent quarter we the cross-cutting area recommend keeping open a substantive performance deficiency cross-cutting issue in the problem identification and resolution area.

D. SummarylConclusions of PI&R inspections The PI&R inspection was completed on October 3, 2008. The inspection team determined that once problems were identified, the licensee usually entered the issues into the corrective action program but was inconsistent in ensuring that identified problems were thoroughly evaluated in a timely manner and identified several issues with the quality of cause evaluations and the completeness of corrective action documents. They also identified that operability assessments and reportability reviews were not being implemented consistent with procedural guidance and many of these assessments did not demonstrate the appropriate level of technical rigor to support conclusions made for operability or reportability. The team determined that the licensee was adequately evaluating industry operating experience for relevance to the facility, and had entered applicable items in the corrective action program in accordance with stations procedures.

All of the individuals interviewed expressed a willingness to raise safety concerns and were able to provide multiple examples of avenues available. Overall, the interviewees expressed positive experiences in raising concerns to their supervisors and through their chain of management.

During this inspection, the team reviewed the licensee's evaluations, actions, and plans to assess the progress in addressing the open substantive cross-cutting issues in human performance and problem identification and resolution. After evaluating the licensee's root cause evaluations for these substantive cross-cutting issues, the team determined that the root cause evaluations did not include appropriate information and detail to identify the reasons for the insufficient progress in addressing the substantive cross-cutting issues. Also, the team could not assess and evaluate the effectiveness of the corrective actions because the licensee was in the early stages of implementation of their improvement plans.

Part of the PI&R inspection was to follow-up on the Confirmatory Order items. During this inspection, the PI&R inspection team felt that sufficient progress had been made to close items 1, 2.d, 2.e, 2.f, 2.i, 2.j, 2.k, and 3. The inspectors did not feel that sufficient progress had been made on the other remaining Confirmatory Order items and so recommended keeping those items open.

Southern California Edison submitted a letter updating the status of these open items in January 2009. NRC performed a PI&R/Confirmatory Order inspection in June 2009 to followup on the Order actions and licensee efforts to address the open Substantive Cross-Cutting issues. Following that inspection, the inspectors felt that sufficient progress had been made to close items 2a, 2b, 2g, and 2h. The remaining open order items are 2c and 21. The inspectors reviewed the recently revised human performance and problem identification and resolution improvement plans. The inspections concluded that the root cause evaluations were adequately defined and understood, and the corrective actions resulting from the evaluations appeared reasonable. However, the inspectors could not assess and evaluate the effectiveness of the corrective actions because SONGS was in the early stages of implementation of the improvement plans.

5. Performance Indicator Verification All performance indicators are Green. No significant issues were identified during the review of licensee performance indicators.
6. Licensee and NRC action on safety significant PIs and inspection findings A. Results of any follow-up actions taken by the licensee and the NRC to current safety significant Pis and inspection findings.

A Special Inspection was performed as a result of loose electrical connection issues. The Special Inspection performed on-site inspection from August 4-8, 2008 with in-office review continuing through December 11, 2008. As a result of this special inspection, the NRC issued Southern California Edison a finding of low-to-moderate safety significance (White) for the failure to establish appropriate instructions to perform maintenance activities on safety-related 125 Vdc station

batter breaker. This violation was issued as part of the special inspection report, IR 2008013.

B. Planned NRC follow-up actions due to safety significant PIs and inspection findings.

NRC will be performing a Supplemental Inspection Procedure 95001, "Supplemental Inspection for One or Two White Inputs in a Strategic Performance Area" for the White violation that was issued as a result of the Special Inspection performed on the loose electrical connections.

7. Non-SDP Severity Level III or greater violations currently proposed or issued July 1, 2008 - June 30, 2009.

None.

8. Longstanding or emergent safety issues for possible trend problems.

None.

9. Potential Greater-than-Green PIs or inspection findings I Open Unresolved Items Potential Greater-than-Green PI/Inspection Finding The following URI is currently going through Phase 3 of the Significance Determination Process to determine if it is potentially greater-than-green:

05000361/05000362/2008013 Degraded Electrical Connections Open Unresolved Item 1)05000361/05000362/2008012 Open Confirmatory Order items.

2)05000361/05000362/2008010 Omission of Station Black-Out Profile During Battery Service Tests 3)05000361/05000362/2008013 Degraded Electrical Connections

10. Inspections planned through December 31, 2010.

All required baseline inspections were completed in CY 2008. See Proposed Inspection Plan for future inspections. NRC will be performing a Supplemental Inspection IP 95001 to address White battery breaker issue.

NRC will be performing Steam Generator replacement inspections commencing in 2009 and continuing through 2010. The NRC will be performing its triennial heat sink inspection and an EP exercise inspection in August and September 2009. The NRC will perform its triennial fire protection inspection starting in May 2010.

In November of 2009 the NRC plans to perform a focused PI&R inspection to review results and actions taken by the licensee following performance of an independent safety culture assessment. The NRC will also perform a team PI&R inspection in February 2010. Focus areas for this inspection will be evaluating the SCWE at the facility, effectiveness of the employee concerns program, status of improvements initiatives to address the substantive cross cutting areas, and status of remaining open confirmatory order items.

11. Conclusions from any independent assessment (i.e. INPO, IAEA. OSART. etc)

(b)(~4)

-Miscellaneous Topics

13. Attachments Plant Issues Matrix Performance Indicator Summary Proposed Inspection Plan
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