ML11269A149

2010 End-of-Cycle Plant Safety Performance Summary, Assessment Period; Jan 1 10 Thru Dec 31, 10, Exemption 4 and Exemption 5

ML11269A149
Person / Time
Site:	San Onofre
Issue date:	09/23/2011
From:	- No Known Affiliation
To:	Office of Information Services
References
FOIA/PA-2011-0159
Download: ML11269A149 (26)

Text

SAN ONOFRE NUCLEAR GENERATING STATION Units 2 and 3 2010 End-of-Cycle Plant Performance Summary/Agenda Assessment Period: January I to December 31, 2010

1. PERFORMANCE OVERVIEW A. Assessment Period Results - SONGS Unit 2 remained in the Regulatory Response Column for most of the assessment period due to a white violation identified in IR 2008013. The Notice of Violation was closed in IR2010011, returning Unit 2 to the Licensee Response Column on December 22, 2010. Unit 3 remained in the Licensee Response Column for the entire assessment period.

ý(b)(5)

A Chilling Effect Letter was issued to SONGS in March 2010. Region IVreceived an approved deviation to the Action Matrix from the EDO in April 2010 for increased oversight due to the significant number of cross cutting issues, high number of allegations, and the issuance of the chilling effect letter. The inspection (IR 2010005) to close the Deviation Memo was completed on December 10, 2010. The Deviation Memo was closed on December 31, 2010.

Informallon intwL reCuif' in accordance with the F~. 1 San Onofre Nuclear Generating Station Act. exemptions - M.~j FO IA-.... kW -/-- -/ll

,,qfýe ý týýOc_ýro n MITOR 1 "tQuarter 2nd Quarter 3rd Quarter 4th Quarter 2010 2010 2010 2010 Action Matrix Unit 2: Unit 2: Unit 2: Unit 2:

Column Regulatory Regulatory Regulatory Regulatory Response Response Response Response*

Unit 3: Unit 3: Unit 3: Unit 3:

Licensee Licensee Licensee Licensee Response Response Response Response Unit 2: 1 White Unit 2: 1 White Unit 2: 1 White Unit 2: 1 White Basis finding finding finding finding Unit 3: All Unit 3: All Unit 3: All Unit 3: All findings and findings and findings and findings and Pl's were Pl's were Pl's were Pl's were Green. Green. Green. Green.

• White Violation 05000361/2008013-05 Closed in IR 20100011 on Dec 22, 2010.

B. Signature Authority The signature authority for the end of cycle assessment letter is the Division of Reactor Projects Director.

C. Summary of Previous Assessment Letters Summary of Results from Previous Mid-Cycle Letter Plant performance for Unit 2 was in the Regulatory Response Column of NRC's Action Matrix, based on one inspection finding being classified as having low to moderate safety significance (White). Plant performance for the Unit 3 was within the Licensee Response Column of NRC's Action Matrix.

The branch kept open all previously open substantive cross-cutting issues in the human performance area associated with the components of decision making, resources and work practices; and in the problem identification and resolution area, corrective action program component. The branch opened one new substantive cross-cutting issue in the Human performance area associated with the procedural compliance and communication aspect of the work practices component (H4B).

The branch observed a continuing high number of allegations.

2 San Onofre Nuclear Generating Station

Summary of Interim Assessment Letter (inspection report 2010011)

On November 15 through November 19, 2010, the U.S. Nuclear Regulatory Commission staff performed the on-site portion of a supplemental inspection pursuant to Inspection Procedure 95001, "Inspection for One or Two White Inputs in a Strategic Performance Area," at the San Onofre Nuclear Generating Station, Unit 2 facility.

The NRC determined that the corrective actions implemented to address the deficiencies leading to the White finding and to prevent recurrence were adequate to address the technical as well as organizational performance issues. Therefore, the White finding (05000361/2008013-05), "Failure to Establish Appropriate Instructions" is closed. This finding will continue to be considered for evaluation of NRC Action Matrix column status until December 31, 2010, in accordance with NRC Manual Chapter 0305, "Operating Reactor Assessment Program." As a result, the NRC determined the performance at San Onofre Nuclear Generating Station, Unit 2, to be in the Licensee Response Column (Column 1) of the Reactor Oversight Process Action Matrix as of the date of this letter. San Onofre Nuclear Generating Station, Unit 3 remains in the Licensee Response Column.

D. Public Outreach Efforts 03/24/10, Doubletree Suites, Doheney Beach, CA, Category 1 Public Meeting

" NRC held an End-of-Cycle meeting to discuss performance results for San Onofre Units 2 and 3 for calendar year 2009. (Open house and public meeting)

• Approximately 154 attended including NRC, members of public, SONGS representatives, local government, and media.

09/16/10 Doubletree Suites, Doheney Beach, CA, Category 1 Public Meetinq

• Discuss San Onofre Nuclear Generation Station's progress in addressing Safety Conscious Work Environment concerns.

• Approximately 161 attended including NRC, members of public, SONGS representatives, local government, and media.

12/14/10 Doubletree Suites, Doheney Beach, CA, Cate-gory 1 Public Meeting

• Discuss San Onofre Nuclear Generating Station's progress in addressing safety

.culture aspects in human performance, problem identification and resolution, and safety conscious work environment,

• Approximately 140 attended including NRC, members of public, SONGS representatives, local government, and media.

3 San Onofre Nuclear Generating Station Pre ei ioa

reeeits="-

2. OPERATING

SUMMARY

A. Power Operations During this assessment period, Unit 2 operated at essentially 100 percent power with the exceptions noted below:

April 9 Startup from Steam Generator replacement outage.

April 18 Hold at 98% power for AMAG (feed flow measurement) repairs.

May 1 Reduce power to 85% for waterbox cleaning. Back to 98% on May 3.

May 18 100% power after AMAG repaired.

September 28 Reduce to 94% for feed heater drain pump repairs. Back to full power October 17.

During this assessment period, Unit 3 operated at essentially 100 percent power with the exceptions noted below:

March 5 Begin Decreasing power 7% per day for fuel management. Reach 50% power on March 11, hold at 50% until April 23.

April 23 Begin raising power from 50% to 100%. Reach 100% on May 10.

July 22 Reduce power to 94% due to sea grass. Back to 100% July 23.

September 20 Begin coasting down to outage.

October 9 Shutdown for S/G replacement outage.

B. Scheduled and Forced Outages The following occurred at Unit 2 during the assessment period:

Sept 26, 2009 Shutdown for a planned refueling and S/G replacement outage.

Start-up April 9. 100% power reached on May 10.

The following occurred at Unit 3 during the assessment period:

October 9, 2010 Shutdown for a planned refueling and S/G replacement outage.

Shutdown as of 12/31/2010.

3. SAFETY-SIGNIFICANT INSPECTION AND PI RESULTS There was one low to moderate finding during the assessment period and all performance indicators were Green throughout the assessment period.

A. Mitigating Systems There was 1 White finding during the assessment period:

4 San Onofre Nuclear Generating Station

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1. GREATER THAN GREEN FINDINGS

a. PIM Entry Data The team identified a White violation of 10 CFR Part 50, Appendix B, Criterion V, "Instructions, Procedures, and Drawings," involving the failure to establish appropriate instructions for performing maintenance activities on safety-related 125 Vdc station battery Breaker 2D201. As a result, during replacement of the breaker in March 2004 electrical connection integrity was not adequate to ensure that the equipment would be able to perform its safety function. This condition existed for approximately four years. This issue was entered into the licensee's corrective action program as Root Cause Evaluation 800121216.

The finding is greater than minor because it is associated with the equipment performance attribute of the mitigating systems cornerstone and affects the associated cornerstone objective to ensure the availability, reliability, and capability of systems that respond to initiating events to prevent undesirable consequences. The final significance determination performed by the senior reactor analyst and approved by the NRC significance and enforcement review panel determined the finding was of low to moderate safety significance (White).

This finding has a crosscutting aspect in the area of human performance associated with resources because the licensee failed to establish adequate procedures and programs related to electrical connection integrity H.2(c)

(Sections 2.1.5 and 3.5)

This violation is discussed in Inspection Report 2009003 in Section 4OA2.3.

On December 4, 2009, the U.S. Nuclear Regulatory Commission staff performed a supplemental inspection pursuant to Inspection Procedure 95001, documented in IR 2009008. During this supplemental inspection, the inspectors determined that the your staff performed a comprehensive evaluation of the events associated with inadequate standards and inadequate enforcement of station policies and procedures as they related to the loose bolts on the Battery 2B008 output breaker, and for the human performance deficiencies associated with the events which occurred on March 25, 2008, in efforts associated with recovery from the loose breaker bolts event. However, many of the corrective actions associated with the root and contributing causes, including cultural issues, were broadly defined and not fully developed. Several of the corrective actions had been revised or developed just prior to the inspection, and at least one of the supporting root cause evaluations was being revised due to an NRC evaluation that the root cause was too narrowly focused. The NRC lacks assurance that the corrective actions are fully developed and that their implementation will be effective. Therefore, the White finding will remain open until performance improvement provides assurance that the corrective actions are fully developed and will adequately address the performance deficiencies.

On November 15 through November 19, 2010, the U.S. Nuclear Regulatory Commission staff performed the on-site portion of a supplemental inspection pursuant to Inspection Procedure 95001. The report is documented in IR 5 San Onofre Nuclear Generating Station Pedgfiefin-

2010011. The objective of this supplemental inspection was to provide assurance that objective number 3; "Corrective actions were or will be sufficient to address and preclude repetition of the root and contributing causes," of NRC Inspection Procedure 95001 was met. The inspection consisted of examination of activities conducted under your license as they related to safety, compliance with the Commission's rules and regulations, and the conditions of your license.

Based on the results of this inspection, no findings of significance were identified.

The NRC determined that the corrective actions implemented to address the deficiencies leading to the White finding and to prevent recurrence were adequate to address the technical as well as organizational performance issues.

Therefore, the White finding (05000361/2008013-05), "Failure to Establish Appropriate Instructions" is closed. This finding will continue to be considered for evaluation of NRC Action Matrix column status until December 31, 2010, in accordance with NRC Manual Chapter 0305, "Operating Reactor Assessment Program." As a result, the NRC determined the performance at San Onofre Nuclear Generating Station, Unit 2, to be in the Licensee Response Column (Column 1) of the Reactor Oversight Process Action Matrix as of the date of this letter. San Onofre Nuclear Generating Station, Unit 3 remains in the Licensee Response Column.

b. Additional findings None.

2. NEGATIVEIADVERSE PI RESULTS ANDIOR TRENDS None.

3. DESCRIBE THE NRC's AND LICENSEE'S FOLLOW-UP ACTIONS (to include planned actions) FOR FINDINGS AND PI DATA.

A supplemental inspection was completed on December 4, 2009, and documented in NRC Inspection Report 0500361; 362/2009008. The supplemental inspection concluded that objective numbers 1 and 2 of NRC Inspection Procedure 95001 were met, but that objective number 3 was not met in that the NRC lacked assurance that the corrective actions were fully developed and that their implementation would be effective. A second supplemental inspection was completed in November, 2010. The objective of this supplemental inspection was to provide assurance that objective number 3; "Corrective actions were or will be sufficient to address and preclude repetition of the root and contributing causes," of NRC Inspection Procedure 95001 was met. The inspection consisted of examination of activities as they related to safety, compliance with the Commission's rules and regulations, and the conditions of the license. The second supplemental inspection (IR 2010011) closed the white finding.

6 San Onofre Nuclear Generating Station V s~i ter o n Pre isio

4. DRS INSIGHTS Brief Background and Assessment The last CDBI team inspection at San Onofre was conducted in July 2008. Since that time, overall performance at San Onofre has deteriorated in some areas. Insights and assessment of the engineering area has been limited to the ROP inspections performed by the resident inspectors along with other ROP inspections that touch on engineering.

A detailed and extensive inspection of San Onofre engineering has not been completed since 2008. As a result, assessment of current performance in the area of engineering is based upon incomplete and indirect information.

Recommendations for Follow-Up Actions It is recommended that the upcoming CDBI at San Onofre, scheduled to be performed in June and July of this year (2011), be supplemented by adding a second mechanical contractor to the inspection team. This will allow a more extensive and in-depth inspection to be conducted in the same time frame as a normal CDBI. The NRR program office originally proposed this approach and the resources have already been allocated and scheduled. It is expected that this will result in an overall assessment of the engineering program at San Onofre based on current data.

5. ENFORCEMENT

SUMMARY

a. Chilling Effect Letter On March 2, 2010 the NRC issued a chilling effect letter to the licensee. This letter was issued in response to numerous observations including employees expressing difficulty or inability to use the corrective action program, a lack of knowledge or mistrust of the Nuclear Safety Concerns Program (NSCP), a substantiated case of a supervisor creating a chilled work environment in his/her work group, and a perceived fear of retaliation for raising safety concerns.

During calendar year 2009 the NRC received an elevated number of SCWE related allegations from SONGS. The chilling effect letter contained a number of requirements for SONGS to improve its working environment, including and action plan to address SCWE issues, a communication plan aimed at SCE and contract personnel, and a public meeting which was held in September, 2010.

NRC inspectors are performing an additional inspection in January, 2011 to assess the progress of SONGS corrective actions regarding the chilling effect letter.

b. Confirmatory Order By letter dated January 11, 2008 the NRC issued a Confirmatory Order to the licensee as part of a settlement agreement through the NRC's alternative dispute resolution process. The settlement was in regards to the falsification, by a contract fire protection specialist, of firewatch certification sheets on numerous occasions from April 2001 to December 2006 at SONGS. All items of the confirmatory order (EA 07-232) have been completed as documented in IR 7 San Onofre Nuclear Generating Station

2010005. NRC will close the Confirmatory Order by letter signed by RA in February 2011.

c. Severity Level IVNCV's Note: NRC should consider performing inspection procedure 92723 to follow up on the NCVs listed below due to 3 or more traditional enforcement violations in a 12 month period in the same area (impeding the regulatory process).

9 2010002-09 SL-IV NCV Failure to notify the NRC within 8 hours9.259259e-5 days <br />0.00222 hours <br />1.322751e-5 weeks <br />3.044e-6 months <br /> of a non-emergency event. Traditional Enforcement due to effect on NRC's ability to regulate.

• 2010002-10 SL-IV NCV Failure to a safety system functional failure.

Traditional Enforcement due to effect on NRC's ability to regulate.

• 2010002-11 SL-IV NCV Failure to obtain a license amendment for a Technical Specification Basis change. Traditional Enforcement due to effect on NRC's ability to regulate.

• 2010006-04 SL-IV NCV Failure to report condition that could have prevented fulfillment of safety function. Traditional Enforcement due to effect on NRC's ability to regulate.

d. Notices of Violation

• 2010006-08 Green NOV Failure to maintain written procedures covered in Regulatory Guide 1.33.

• 2010007-01 Green NOV Failure to ensure at least one train of equipment necessary to achieve hot shutdown conditions is free of fire damage.

6. STATUS OF OPEN ITEMS A. Unresolved Items The following unresolved items are open:

05000361;362/2008010-03 Omission of Station Black Out Profile During Battery Service Tests The following LERs are open:

05000361;362/2010-006- Breakers left in non-seismically qualified condition 00 prohibited by tech specs.

05000361 ;362/2010-005- Refueling water storage tank alignment to non-seismic 00 piping 8 San Onofre Nuclear Generating Station

Y M1 nja ýI I o PffL-ej-aýs 9% Zc-Ois-Z' a redýc' 05000361;362/2010-004- EDG vent fan nose cone corrosion results in fan damage 00 05000361;362/2010-003- Typo results in conflicting TS actions and TS violation 00 05000361/2010-001-00 Broken manual valve prevents timely condensate storage tank isolation 05000361/2010-002-00 Non qualified part in TDAFW pump 05000361/2009-003-00 Pressurizer aux spray failed inservice test 05000362/2009-001-00 Component declared inop after LCO The following violations are open:

2010006-08 Failure to maintain written procedures covered in Regulatory Guide 1.33.

2010007-01 Failure to ensure at least one train of equipment necessary to achieve hot shutdown conditions is free of fire damage 2009001-02 Failure to assess and manage risk for maintenance that could impact offsite power supply B. Performance Indicators There are no performance indicators close to crossing a significance threshold and/or open PI-related frequently asked questions.

C. Temporarv Instructions The following temporary instructions are open:

TI 2690/010 Due 6/30/11 TI 2690/008 Due 6/30/11 TI 2515/177 Due 12/31/12 TI 2515/145 Due 6/30/12 TI 2515/139 Due 6/30/12 TI 2515/120 Due 6/30/12 TI 2515/113 Due 6/30/12 TI 2515/110 Due 6/30/12 TI 2515/103 Due 6/30/12 TI 2515/101 Due 6/30/12 9 San Onofre Nuclear Generating Station aýS -iiO nsl nte~rn fIor Pecisl

Se "We1 nr~iýý=de~naa I

TI 2515/091 Due 6/30/12 TI 2515/087 Due 6/30/12 TI 2515/066 Due 6/30/12 TI 2515/065 Due 6/30/12 D. Miscellaneous None.

7. OPERATING EXPERIENCE There were no operating experiences impacting SONGS during the assessment period.

8. CROSS-CUTTING AREAS -

A. Substantive Cross-Cutting Issues

. HUMAN PERFORMANCE Conclusion

- '4 The criteria outlined in MC 0305 for a human performance substantive ._

crosscutting issue was met based on the presence of four themes.'i (b)(5)

_ _Inspection findings persist in the component of work practi-ces associated with the themes of lack of properly defining and effectively communicating expectations regarding procedural compliance resulting in personnel following procedures H.4(b) and in the theme of management oversight of work activites

.. H.4(c)j].

(b)(5)

Details '

A review of PIM entries between January 1 and December 31, 2010 revealed the following trends:

10 San Onofre Nuclear Generating Station 1 s ly title I IIn tion Prede nal

Eleven of the thirty findings in the cross-cutting area of human performance were within the decision making component. Five had the common theme of, not using a systematic process in decision making [Hj]a*)z 1 -

pix findings had the common theme of not

'using conservative assumptions and validating underlying assumptions in decision making H.1(b). Two of the supporting findings for this theme were identified in the fourth quarter, 2010.t

________ _ Also, there is an increasing trend in the number of findings in this area (5 at MC and 6 at EOC).

(b)(5)

Two of the thirty findings in the cross-cutting area of human performance were within the resources component. The mid-cycle assessment held open one substantive cross cutting issue in the area of not having complete, accurate, and up-to-date design documentation, procedures, and work packages, and correct labeling of components H.2(c). The branch recommends keeping this theme open based on a lack of improvement in the area of procedure quality. The branch would like to see results of the licensee's ongoing gap analysis and corrective actions before closing this theme.

Sixteen of the thirty findings in the cross-cutting area of human performance were within the work practices component. Of these, three were related to the aspect of not using adequate human error prevention techniques H.4(a). The branch recommends keeping open the theme in Human Performance / work practices associated with human error prevention techniques due lack of confidence in to licensee's corrective actions in this area. Nine of the findings in the work practices component were associated with the theme of not defining.

and communicating expectations regarding procedural compliance or personnel not following procedures H.4(b)./

(b)(5) _

p ism ew wht /,The other four findings in the work practices component were wihinthe work oversight component H.4(c).'

~(b)(5)

FTfiough there is-an improving trend in the numbie r of fin-dings assciated6with this theme, allegation data incomplete corrective actions associated with management field observations indicate that more corrective actions are needed.

11 San Onofre Nuclear Generating Station C, y ivoe al ati Cý ýred o nalI

[able1.0 -FCROSSCUTTING ARE k UMAN-PERFORMAN*.E Decision Making Component'-H.1 -_1 Finding Documented Contributing Cause/ Cornerstone Crosscutting Aspect Failure to properly implement OE review team did not use a Mitigating procedure requirements to ensure systematic process when making Systems that applicable risk significant afety significant decisions. H.1(a) operating experience was entered into the corrective action program for timely evaluation (IR2010002-03, PIM#79311).

Failure to report conditions that The licensee did not make safety- Miscellaneous could have prevented fulfillment of significant decision using a safety function (IR 2010006-04, systematic process, especially when PIM# 79349). faced with uncertainty. H.1(a)

Failure to establish goals and Failure to use a formal decision Mitigating monitor for Auxiliary Feedwater making process to determine how to Systems trains (IR 2010006-09, count unavailable hours for the PIM#79345) maintenance rule. [H. 1(a)]

Failure to Define Authorities and Failure to make safety-significant Initiating Events Responsibilities of Work Process decisions using a systematic Area Operator (IR 2010010-01, process, including formally defining PIM#79364) the authority and roles for decisions affecting nuclear safety [H. 1(a)].

Failure to Ensure At Least One Failure to make a risk-significant Mitigating Train of Equipment Necessary to decision using a systematic process Systems Achieve Hot Shutdown Conditions when considering the scheduling of Is Free of Fire Damage (IR corrective actions H.1(a)

2010007-01, PIM#79365)

Failure to Follow Procedure for Failure to use conservative Occupational Modifying Work Clearance assumptions and formally validate Radiation Safety Applications (IR 2010005-02, and verify plant conditions and PIM#79360) associated tagging boundaries

H.1(b)

Inadequate Control of Foreign Failure to demonstrate that nuclear Barrier Integrity Material over the Spent Fuel Pool safety is an overriding priority uring Surveillance Testing (IR through the use of conservative 2010005-03, PIM#79361) assumptions in decision making and adopting a requirement to demonstrate that the proposed action is safe in order to proceed rather than a requirement to 12 San Onofre Nuclear Generating Station

~~~Pre cis' a,'

Pde9ona I Table4.111- CROSSCUTiNG0AREA - HUMANWEREORMANGCE -. -

demonstrate that it is unsafe in order to disapprove the action [H. 1(b)]

Unavailability Time for Component Failure to demonstrate that nuclear Mitigating Cooling Water Incorrectly Counted safety was an overriding priority Systems (IR 2010003-01, PIM#79324) through the use of conservative assumptions in decision making and adopting a requirement to emonstrate that a proposed action is safe in order to proceed rather han a requirement to demonstrate that it is unsafe in order to disapprove the action H.1(b).

Inadequate Operability Failure to demonstrate that nuclear Mitigating Determination for Safety-Related safety was an overriding priority Systems Concrete Cracks (IR 2010003-06, through the use of conservative PIM#79331) assumptions in decision making and adopting a requirement to emonstrate that a proposed action is safe in order to proceed rather than a requirement to demonstrate that it is unsafe in order to disapprove the action [H. 1 (b)].

Inadequate operability Failure to demonstrate that nuclear Mitigating determination of the turbine driven safety was an overriding priority Systems auxiliary feed water pump steam through the use of conservative admission valves (IR 2010006-01, assumptions in decision making and PIM#79341). adopting a requirement to emonstrate that a proposed action is safe in order to proceed rather than a requirement to demonstrate that it is unsafe in order to disapprove the action [H. 1(b)].

Failure to identify and correct the Failure to demonstrate that nuclear Mitigating use of deficient relays (IR safety was an overriding priority Systems 2010006-10, PIM#79346) through the use of conservative assumptions in decision making and adopting a requirement to demonstrate that a proposed action is safe in order to proceed rather than a requirement to demonstrate that it is unsafe in order to 13 San Onofre Nuclear Generating Station

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disapprove the action [H. 1(b)].

.... 'Resources Comp-nent H.2 Finding Documented Contributing Cause/ Cornerstone Crosscutting Aspect Lack of preventive maintenance Failure to ensure that equipment was Mitigating results in valve failure and available and adequate to assure Systems inoperable condensate storage nuclear safety by minimization of tank (IR 2010006-03, PIM#79343) long standing equipment issues in hat the valve was not being maintained through a preventive maintenance program. H.2(a)

Improper Risk Assessment and Failure to ensure that procedures Initiating Events Management for Emergent Work were adequate to support nuclear (IR 2010003-03, PIM#79326) safety, including complete, accurate, and up-to-date work packages

H.2(c)

Work Control Com ent - H.3-. -

Finding Documented Contributing Cause/ Cornerstone Crosscutting Aspect Failure to secure loose items in the Failure to appropriately plan work Initiating Events electrical switchyard (IR 2010006- activities involving job site conditions 11, PIM#79340) which may impact plant structures, systems and components. H.3(a)

Work Practices Component - H.4 Finding Document Contributing Cause/ Cornerstone Crosscutting Aspect Licensee failed to follow Operations personnel failed to use Mitigating procedures for operating the proper human error prevention Systems component cooling water system techniques in the face of unexpected (IR 2010002-14, PIM#79323). circumstances H.4(a)

Licensee failed to follow station Licensee failed to communicate Initiating Events procedures on written instruction human error prevention techniques use and adherence while such that work activities were performing testing on a feed heater (IR 2010003-11, PIM#79336).

Failure to Properly Store C-Panels Failure to properly check the Initiating Events in the Radwaste Building (IR procedural requirements prior to 2010005-04, PIM#79362) staging C-panels near the hydrogen line H.4(a)

14 San Onofre Nuclear Generating Station Ss enPr ive nernatia d *_.rei?1i0onal"

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'able1.0c ICROSS.CurFItRGARAHUA P-ER FPRM A, Az Licensee contractors and station Licensee did not define and Initiating Events personnel failed to properly effectively communicate implement the requirements of a expectations regarding procedural station fire protection procedure for ompliance. H4(b) control of hot work activities (IR 2010002-01, PIM#79309).

Licensee operations and work Licensee did not define and Initiating Events control personnel failed to effectively communicate adequately assess and manage e=xpectations regarding procedural the increase in risk associated with compliance. HA(b) maintenance activities in the electrical switchyard (IR2010002-04, PIM#79312).

Licensee maintenance planning Licensee failed to follow procedures Mitigating personnel failed to develop and to develop adequate work Systems specify an adequate post- instructions to perform maintenance maintenance test in the work on safety related equipment. H.4(b) instructions used to perform maintenance on the backup nitrogen regulator for the component cooling water surge tank (IR 2010002-06, PIM#79315).

Licensee failed to adequately Licensee did not define and. Barrier Integrity implement foreign material effectively communicate exclusion controls (IR 2010002-07, expectations regarding procedural PIM#79316). compliance. H.4(b)

Licensee failed to assess and Licensee did not define and Mitigating manage risk associated with effectively communicate Systems maintenance on emergency diesel expectations regarding procedural generators (IR 2010003-02, compliance. H.4(b)

PIM#79325).

Licensee failed to define the Licensee did not maintain up to date Initiating Events control room as required in design documentation, procedures, technical specifications (IR and work packages. H.4(b) 2010003-04, PIM#79327).

Licensee failed to follow work Licensee did not define and Mitigating control procedures requiring effectively communicate Systems pproved work orders for work on expectations regarding procedural safety related components (HP, IR 15 San Onofre Nuclear Generating Station Irr I mation Pr deci oal

P~esior~

Tabl61.0- CROSSCUTTING AREA -.-HUMAN4PERFORMANCE 2010003-05, PIM#79330). compliance. H4(b)

Licensee failed to appropriately Licensee did not define and Mitigating identify and classify degraded effectively communicate Systems voltage on a class 1E battery (IR expectations regarding procedural 2010003-09, PIM# 79334). compliance. H.4(b)

Failure to Follow Procedures While Failure to define and effectively Mitigating Implementing a Design Change communicate expectations regarding Systems (IR 2010004-01, PIM#79354) procedural compliance, and that

personnel follow procedures H.4(b)

Licensee failed to adequately licensee failed to ensure supervisory Mitigating implement a Work Order and and management oversight of work Systems provide adequate oversight to activities, including contractors, such transmission and distribution that nuclear safety is supported personnel while performing work in the electrical switchyard (IR H.4(c)

2010002-13, PIM#79322).

Control room operators failure to Failure to ensure supervisory and Initiating Events adhere to conduct of operations management oversight of work procedural requirements (IR activities. H.4(c)

2010006-05, PIM#79338)

Failure to provide adequate Failure to ensure activities Initiating Events procedure for boron dilution associated with re-activity control activities (IR 2010006-06, were performed in a controlled PIM#79339) manner such that nuclear safety was assured. H.4(c)

Failure to meet action plan for Failure to ensure management Miscellaneous ubstantive crosscutting issues (IR oversight of work activities. H.4(c)

010006-13, PIM#79350) 16 San Onofre Nuclear Generating Station i Oni -Sen e nal a

PQ ýyn I 4e itlyeVter PreglleCisi=rol"ýý on ih 6 1111111110-1 al X a-b*

tablei-A'A-- Bas-I C clusl W. or -C 'A 7- iV( c MC 0305 Guidance on Substantive .Performance. Observations in the mo :

Met Cross-Cutting (SC) :1 ues Human Performance Area,- XYZ... Criteria Component - -

Criterion 1: Contributing Causes have a 30 findings with aspects of human

-ommon theme corroborated by more performance.

than three (3) findings and from more than H. I(a) 5 findings in Decision-Making/ ES Dne cornerstone (exception is Mitigating formal decision making process; MS and IE System) ornerstones.

H.1(b) 6 findings in Decision-Making / using YES conservative assumptions; MS, BI, and ORS cornerstones.

H.2(a) 1 finding in Resources / minimizing NO long standing plant equipment issues and preventive maintenance deferrals.

H.2( c) 1 findings in Resources / providing omplete, accurate, and up-to-date design NO documentation, procedures, and work packages.

H.3(a) 1 finding Work Control / planning work activities by incorporating risk insights, NO

• ob site conditions, and contingency plans.

H.4(a) 3 findings in Work Practices / using NO human error prevention techniques and not proceeding in the face of uncertainty. MS, IE ornerstones.

HA(b) 9 findings in Work Practices I YES defining and communicating expectations regarding procedural compliance or personnel not following procedures. MS, IE, BI Cornerstones.

H.4(c) 4 findings in the Work Practices /

ensuring adequate supervisory oversight of work activities; MS and IE cornerstones.

17 San Onofre Nuclear Generating Station m ti n bf n n tnýr

Criterion 2: The agency has a concern HA (a) Based on the licensee's NO with the licensee's scope of efforts or preemptive actions to address this new progress in addressing the cross- issue.

cutting area performance deficiency H.l(b) Based on the previous high YES number of findings in this area and 2 new findings in the 4 1h quarter.

H.2(c) Based on concerns with the YES licensee's procedural quality H.4(a) Based on concerns with the YES licensee's corrective actions to address this theme.

H.4(b) Based in the high number of YES indings covering 3 cornerstones.

H.4(c) Based on no new findings in this YES area in the 3 rd and 4th quarter resident reports.

ii. PROBLEM IDENTIFICATION AND RESOLUTION Conclusion Details A review of PIM entries between January 1 and December 31, 2009, indicated an improving trend in this area. There were 9 findings in this area during the assessment period. During the mid-cycle assessment period there were 19 findings in the PI&R crosscutting area. Four of the inspection findings in this area had a theme of not having a low threshold for raising issues and for not identifying these issues in a complete, accurate, and timely manner--

commensurate with their safety significance [P..A]i--

(b)(5) __ ___ __

SATll OrT me -TfnrIngs-;n mis aspect bccUrred during th-e-fist-hiaIf --F2010, and CA-P_ numbers point to a lower threshold for raising issues (5200 corrective actions generated in 2010 vsa 4600 in 2009). Also, the licensee has made efforts to make the CAP more accessible to more people.

Four of the inspection findings in this area had a theme of failing to thoroughly 18 San Onofre Nuclear Generating Station ic* s - sitiv er rma Pr sio

evaluate cosproblems n[d it.I o(C _.pr'..that the resolutions n )] such .......... address

. causes and extent of

• conditions .1(C4 (b)(5)

An additional theme for failure to take appropriate corrective actions to address safety issues and adverse trend in a timely manner [P. 1 (d)] was opened for the assessment cyce.J.e_,j (b)(5) 19 San Onofre Nuclear Generating Station

ly nýs!.ti OýýýP ý624nal a~r~al~Me2;~O~ - POBLtTIFPiCzAONAND RE8O LJTION Corrective Action Program Component - P.1 Finding Documented Contributing Cause/ Cornerstone Crosscutting Aspect Licensee failed to enter conditions Licensee failed to implement the Mitigating adverse to quality into the corrective corrective action program with a Systems action program (IR 2010002-12, low threshold for identifying issues.

PIM#79321). P. 1(a)

Licensee failed to follow the conduct Licensee failed to implement the Mitigating of operations procedure direction to corrective action program with a Systems

ontrol operator aids (IR 2010003-07, low threshold for identifying issues.

PIM#79332). P. 1(a)

ailure to translate design basis Licensee failed to implement the Mitigating nformation into procedures for the corrective action program with a Systems

urbine-driven auxiliary feed water low threshold for identifying issues.

Dump steam admission valves (IR P.1(a) 2010006-02, PIM#79342)

=ailure to establish component cooling Plant operators did not have a low Public Nater radiation monitoring procedures hreshold for identifying Radiation 1R 2010006-07, PIM#79348) deficiencies in procedures. P.1(a) Safety Licensee operations personnel failed Licensee failed to evaluate Mitigating to follow procedures to approve and problems such that the resolution Systems document operability determinations addressed the cause and extent of using adequate or technically correct ondition. P.1(c) information (IR2010002-05, PIM#79314).

Licensee failed to notify the NRC Licensee failed to evaluate Miscellaneous within 8 hours9.259259e-5 days <br />0.00222 hours <br />1.322751e-5 weeks <br />3.044e-6 months <br /> of a nonemergency problems such that the resolution

-vent (IR 2010002-09, PIM#79318). addressed the cause and extent of condition. P.1(c)

Licensee failed to maintain procedures Licensee failed to evaluate Mitigating such that outdated procedures with problems such that the resolution Systems known technical errors were in use in addressed the cause and extent of the plant after plant modifications ondition. P.1(c)

(IR2010006-08, PIM#79344).

20 San Onofre Nuclear Generating Station e ~vS~omt--

U ly - nsftive-1hte fo

-6.;ý -L:ý ýPr4i'e--C-Isl="V2ýý Table 2~.0 .ROSSCUfING9AREA. PROBLEM IDENTIFICATIONWAND RESOLUTIONI Failure to Appropriately Classify Failure to thoroughly evaluate Mitigating Conditions Adverse to Quality for problems such that the resolutions Systems Significance (IR 2010005-01, address causes and extent of PIM#79359) conditions, and failed to properly classify, prioritize, and evaluate for operability and reportability conditions adverse to quality

_P.I(c)]

Operating EXperience Component.- P.2 Finding Documented Contributing Cause/ Cornerstone Crosscutting Aspect Licensee failed to translate design Licensee failed to implement and Mitigating basis information into affected institutionalize operating Systems calculations and procedures (IR experience information through 2010006-12, PIM#79347). changes to plant processes, procedures, equipment, and training programs. P.2(b)

Self and Independent Assessments P.3 -. _ _ _

Finding Documented Contributing Cause/ Cornerstone Crosscutting Aspect none 21 San Onofre Nuclear Generating Station al 0 netIntrpa or n

-0Ifi 0*i de~cl oW

ýed onai6l Table 20 CRSGl AFEAPRBLM iDiT~CTy91NREQL ON.

Table 2.1-ai I'mCi~i[~(~bcdeJ MC 0305 Guidance on Substantive Performance Observations In the Met Cross-Cutting (SCC) Issues Human Performance Area - XYZ:, Criteria Component Criterion 1 Contributing Causes have a 9 findings in the area of Problem common theme corroborated by more Identification and Resolution were than three (3) findings and from more than found in this inspection cycle.

one cornerstone (exception is Mitigating System) F)P.

1(a) 4 findings in Corrective Action Program / low threshold for identifying ES issues in the MS and PRS cornerstones.

P.1(c) 4 findings in the area of YES thorough problem evaluation in the MS cornerstone.

P.2.(b) 1 finding with the aspect of NO implementing and institutionalizing OE through changes to station processes, procedures, equipment, and training programs.

Criterion 2: The agency has a concern P.1(a) Based on no new findings in NO with the licensee's scope of efforts or his area in the 3 rdand 4 quarter progress in addressing the cross-cutting resident reports and NRC inspection rea performance deficiency efforts looking into the licensee's corrective actions.

P. 1(c) Based on NRC inspection efforts to review the licensee's NO corrective actions for this issue.

22 San Onofre Nuclear Generating Station

~Prede~rsii

iii. SAFETY CONSCIOUS WORK ENVIRONMENT Conclusion The criteria outlined in MC 0305 for a safety conscious work environment substantive crosscutting issue were not met. Because the NRC has issued a Chilling Effect Letter to SONGS, a cross-cutting theme exists for the licensee in the area of safety conscious work environment. The branch does not wish to open a substantive crosscutting issue in the area of SCWE at this time because the licensee is in the process of taking action to improve their working environment such that employees feel free and unencumbered in raising safety concerns.

B. Cross-Cutting Themes There were no safety significant findings with a cross-cutting aspect in safety conscious work environment during the assessment period. However, on March 2, 2010 the NRC issued a chilling effect letter to the licensee. This letter was issued in response to numerous observations including employees expressing difficulty or inability to use the corrective action program, a lack of knowledge or mistrust of the Nuclear Safety Concerns Program (NSCP), a substantiated case of a supervisor creating a chilled work environment in his/her work group, and a perceived fear of retaliation for raising safety concerns. During calendar year 2009 the NRC received an elevated number of SCWE related allegations from SONGS. The high number of allegations continued throughout 2010. The chilling effect letter contained a number of requirements for SONGS to improve its working environment, including an action plan to address SCWE issues, a communication plan aimed at SCE and contract personnel, and a public meeting during which the licensee reviewed progress and additional planned actions to deal with the SCWE issues.

Because the NRC has issued a Chilling Effect Letter to SONGS, a cross-cutting theme exists for the licensee in the area of safety conscious work environment.

The branch does not wish to open a substantive crosscutting issue in the area of SCWE at this time because the licensee is in the process of taking action to improve their working environment such that employees feel free and unencumbered in raising safety concerns. The effectiveness of these licensee actions will be assessed in early 2011.

C. PI&R Inspection Results The last PI&R team inspection was completed in April 2010. When compared with the findings from the previous inspection conducted in September 2008, the findings from this inspection indicate that the corrective action program effectiveness has declined. As previously discussed in the past five NRC assessment letters, the licensee's ability to thoroughly evaluate problems such that the resolutions effectively address the causes and extent of conditions is of concern. The licensee's efforts to reverse the trend of substantive crosscutting 23 San Onofre Nuclear Generating Station

i i~e "" el al ln issues in both the human performance and problem identification and resolution areas have not shown to be effective.

Additionally, the inspection identified a number of issues that the licensee's staff had previous opportunities to identify. The inspectors noted that even after issues were discussed with the licensees' staff, thorough evaluations were not consistently completed. We noted examples were the evaluations for deficient components failed to fully address the component safety functions for all applicable design basis accident scenarios.

The inspectors determined that the licensee adequately evaluated industry operating experience for relevance to the facility, and entered applicable items in the corrective action program. The inspectors noted that operating experience was considered in cause evaluations. The inspectors noted that following the review of operating experience the licensee failed to consistently incorporate the knowledge into procedural guidance and design calculations.

In February 2010, the inspectors found that several work groups at San Onofre did not feel free to raise safety concerns without fear of retaliation. This was documented in NRC Inspection Report 050000361; 05000362/2009009 dated March 2, 2010, and in the NRC's Chilling Effect Letter dated March 2, 2010.

9. MISCELLANEOUS TOPICS A. Independent Assessments (e.g., INPO, IAEA, OSART. etc.)

B. Allegations and 01 investigations SONGS continues to receive a very high number of allegations. In calendar year 2010 SONGS received 75 allegations. Approximately 21 of these involved allegations concerning the absence of a safety conscious work environment.

Also, approximately 12 of these allegations involved willfulness. Currently there are 13 open cases being investigated by the office of investigations.

10. INSPECTION STATUS AND PLAN -

In 2010, in addition to the planned baseline inspection, NRC inspectors performed several additional inspections in support of evaluating issues at San Onofre, These included an expanded PI&R inspection, a steam generator replacement inspection, a follow up inspection focused just on substantive cross cutting issues, a second 95001 inspection to close out the white finding for unit 2, 24 San Onofre Nuclear Generating Station

and a confirmatory order inspection that also focused on work observations in the areas of operations and maintenance.

In 2011, major planned inspections include a Biennial EP exercise inspection, a CDBI, and two inspections to review the ongoing safety conscious work environment issues at SONGS.

The proposed inspection plan is attached.

ATTACHMENTS 1.

2, Focus Areas/Technical Issues

2. Proposed Inspection Plan

3. Previous Follow-up Assessment Letter

4. Plant Issues Matrix

5. Performance Indicator Summary 25 San Onofre Nuclear Generating Station "4YZXr-edec!=n1aýI -ation

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