ML12339A509

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Official Exhibit - ENT000401-00-BD01 - EN-LI-102, Rev. 17, Corrective Action Process (Dec. 8, 2011)
ML12339A509
Person / Time
Site: Indian Point  Entergy icon.png
Issue date: 12/08/2011
From:
Entergy Corp
To:
Atomic Safety and Licensing Board Panel
SECY RAS
References
RAS 22156, 50-247-LR, 50-286-LR, ASLBP 07-858-03-LR-BD01 EN-LI-102, Rev 17
Download: ML12339A509 (67)
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Text

United States Nuclear Regulatory Commission Official Hearing Exhibit Entergy Nuclear Operations, Inc.

In the Matter of:

(Indian Point Nuclear Generating Units 2 and 3)

ASLBP #: 07-858-03-LR-BD01 Docket #: 05000247 l 05000286 Exhibit #: ENT000401-00-BD01 Identified: 10/15/2012 Admitted: 10/15/2012 Withdrawn:

Rejected: Stricken: ENT000401 Other: Submitted: March 30, 2012 NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 1 OF 67 Corrective Action Process Procedure Contains NMM REFLIB Forms: YES NO Effective Procedure Owner: J. R. Eichenberger Governance Owner: Alan Ettlinger Date

Title:

Mgr, CA&A Manager

Title:

Fleet Manager OE&CA 12/8/11 Site: ANO Site: HQN Exception Site Site Procedure Champion Title Date*

ANO J. R. Eichenberger Mgr, CA&A N/A BRP N/A N/A GGNS James Nadeau Mgr, CA&A IPEC Ed Firth Mgr, CA&A JAF Ty Hunt Mgr, CA&A PNPS James Keyes Mgr, CA&A PLP Timothy OLeary Mgr, CA&A RBS Christopher Vines Mgr, CA&A VY Jon Bengtson Mgr, CA&A W3 William McKinney Mgr, CA&A N/A NP N/A N/A HQN Richard Courtney Mgr, CA&A Projects Site and NMM Procedures Canceled or Superseded By This Revision Process Applicability Exclusion: All Sites:

Specific Sites: ANO BRP GGNS IPEC JAF PLP PNPS RBS VY W3 NP Change Statement Editorial Change - Details Below:

  • 2.1(l): corrected reference to WF3 procedure from UNT-006-101 to UNT-006-010
  • Attachment 9.1: Corrected wording in guidance for Cat B Equipment Failure Evaluations: step 2. for failures of Low Critical Equipment to match that for step 1. High Critical Equipment. A phrase from rev 15 was inadvertently left in this step in rev 16.
  • Attachment 9.7: Updated Nonconformance tag image to a higher quality image.

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 2 OF 67 Corrective Action Process TABLE OF CONTENTS Section Title Page 1.0 PURPOSE............................................................................................................................03

2.0 REFERENCES

.....................................................................................................................03 3.0 DEFINITIONS ......................................................................................................................05 4.0 RESPONSIBILITIES ............................................................................................................ 12 5.0 DETAILS..............................................................................................................................15 6.0 INTERFACES.......................................................................................................................41 7.0 RECORDS .......................................................................................................................... 42 8.0 SITE SPECIFIC COMMITMENTS........................................................................................ 42 9.0 ATTACHMENTS ................................................................................................................. 46 ATTACHMENT 9.1 .....................................................CONDITION REPORT CLASSIFICATIONS / CATEGORY 47 ATTACHMENT 9.2 ............................................................................... EXAMPLES OF ADVERSE CONDITIONS 53 ATTACHMENT 9.3 ............................................................................................................ MANUAL CR INITIATION 56 ATTACHMENT 9.4 ................................................................. CORRECTIVE ACTION PROCESSING GUIDELINES 60 ATTACHMENT 9.5 ..................................................................... ENTERGY FLEET LEARNING REVIEW PROCESS 61 ATTACHMENT 9.6 GUIDELINES FOR CLASSIFICATION OF CRS ON LOWER LEVEL EQUIPMENT ISSUES 63 ATTACHMENT 9.7 ........................................................................................... TYPICAL NONCONFORMANCE TAG 64 ATTACHMENT 9.8 .............................................................................. CR INTERIM AND PERIODIC REVIEW FORM 65 ATTACHMENT 9.9 ..................................................................................................... LTCA CLASSIFICATION FORM 66 ATTAHCMENT 9.10 CR ASSIGNMENT AND LIFE CYCLE PROCESS MAP 67

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 3 OF 67 Corrective Action Process 1.0 PURPOSE

[1] This procedure provides instructions for the administration of Entergy (EN) Corrective Action process, including the identification, reporting, evaluation, and correction of a broad range of problems and areas for improvements. Issues addressed in the corrective action process must include Adverse Conditions and Conditions Adverse to Quality, and can include minor problems that may be precursors to more significant events, and areas for improvement identified during assessments and other activities. [10 CFR 50], [JAFP-91-0834],

[P32648], [P33542]

[2] This procedure provides management expectations and guidance for the implementation of the EN Condition Reporting Process.

NOTE Throughout the procedure, position titles are used but are not procedural obligations. The intent is to identify functional responsibilities only. Each site will implement the intended function according to its organizational structure and position titles.

2.0 REFERENCES

2.1 References (a) Title 10, Code Of Federal Regulation, Part 50, Appendix B (b) ANSI N18.7-1976, Administrative Controls and Quality Assurance for the Operational Phase of Nuclear Power Plants (c) NRC Inspection Manual, Chapter 9900, Operability Determinations & Functionality Assessments for Resolution of Degraded or Nonconforming Conditions adverse to Quality or Safety (d) ANSI 45.2.10, Quality Assurance Terms and Definitions (e) Entergy Quality Assurance Program Manual (QAPM)

(f) SOER 02-4 Rec 3, Rx Press Vessel Head Degradation at Davis-Besse (g) Nuclear Management Manual Procedure, EN-LI-104, Self-Assessment and Benchmark Process (h) Nuclear Management Manual Procedure, EN-OE-100, Operating Experience Program (i) North American Electrical Reliability Corporation (NERC) Standards

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 4 OF 67 Corrective Action Process 2.1 cont (j) GGNS Procedure: 01-S-06-5, Reportable Events or Conditions (k) RBS Procedure: RBNP-026, Reporting of Defects and Non-compliances (l) WF3 Procedures: UNT-006-010, Event Notification and Reporting (m) Nuclear Management Manual Procedure, EN-MA-123, Identification and Trending of Rework (n) Program Section CEP-R&R-001, ASME Section XI, Division 1- Repairs and Replacements (o) Program Section CEP-CII-001, ASME Section XI Repairs and Replacements of Containment Items (p) NRC Administrative Letter 98-10, Dispositioning of Technical Specifications that are insufficient to Assure Plant Safety (q) NRC Inspection Manual, Chapter 0609, Significance Determination Process (r) NRC Information Notice 97-78, Crediting Of Operator Actions In Place Of Automatic Actions And Modifications Of Operator Actions, Including Response Times (s) SOER 10-2, "Engaged, Thinking Organizations", Rec 1 (t) CAPR CR-PLP-2009-05938 2.2 Obligations and Industry Standards Implemented Overall (a) 10CFR50 (b) CR-HQN-2009-1107, NRC Order EA-09-060 (c) QAPM A.1.d (Overall procedure implements)

(d) ANSI N18.7 5.2.11 (Overall procedure implements)

(e) ANSI N18.7 5.2.15 (Overall procedure implements)

(f) ANSI N18.7 5.3.2 (Overall procedure implements)

(g) ANSI N45.2.2 5.5 (Overall procedure implements)

(h) ANSI N45.2.12 4.4.5 (Overall procedure implements) 2.3 Obligations and Industry Standards Section Specific (a) Quality Assurance Program Manual (QAPM)

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 5 OF 67 Corrective Action Process 2.3 cont.

(b) ANSI N18.7 (c) ANSI N45.2.4 (d) ANSI N45.2.11 (e) ANSI N45.2.12 (f) ANSI N45.2.13 (g) 10 CFR 50.72 (h) 10 CFR 50.73 (i) 10 CFR 73.71 3.0 DEFINITIONS

[1] Administrative Corrective Action - A Corrective Action (CA) issued to facilitate moving the CR response and CA plan through the processes identified in LI-102. These actions typically have no direct impact on actions necessary to correct the identified condition, rather they document administrative steps involved in the process (i.e., an action issued by CA&A to direct closure review of a CR, an action issued to re-evaluate closure of a CR based upon issues identified by a CA&A closure review, etc.).

[2] Adverse Condition - An event, defect, characteristic, state or activity that prohibits or detracts from safe, efficient nuclear plant operation or a condition that could credibly impact nuclear safety, personnel safety, plant reliability or non-compliance with federal, state, or local regulations. Adverse conditions include non-conformances, conditions adverse to quality and plant reliability concerns. Examples of adverse conditions are contained in Attachment 9.2. [P3098]

[3] Adverse Trend - A grouping of non-significant adverse conditions by commonality such as cause, equipment, or activity, occurring at an unacceptable rate which provides indication of the possibility or likelihood of a more significant event. The Adverse Trend classification is determined by the CRG. Adverse trends are a prediction tool used to address issues while still considered non-significant in nature prior to the escalation to a significant event.

[4] Apparent Cause - A likely cause for a condition that is determined by less rigorous means of evaluation than a root cause.

[5] ASME Section XI Boundary - For purposes of this procedure, this includes those portions of systems, components, and their supports required to be classified for ISI purposes as ASME Class 1 (Quality Group A), ASME Class 2 (Quality Group B), ASME Class 3 (Quality Group C), ASME NE (Metal Containment), and ASME Class CC (Concrete Containment).

Quality group classifications are in accordance with NRC Regulatory Guide 1.26.

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 6 OF 67 Corrective Action Process 3.0 cont.

[6] CAR (Corrective Action Request) Condition Report - A type of Learning Organization document that can be written by the Supplier Quality Assurance group to document and track evaluations of vendor issues.

[7] Condition - An issue or discrete occurrence that warrants documentation using a Condition Report (CR).

[8] Condition Adverse to Quality - As described in 10CFR50 Appendix B, Criterion XVI, such conditions include failures, malfunctions, deficiencies, deviations, defects, and non-conformances. This is a condition of a System, Structure, Component or Software (SSC) that could potentially render the SSC degraded or inoperable.

[9] Condition Report (CR) - A computer generated or paper form used to document issues into the corrective action process.

[10] Condition Review Group (CRG) - A management group responsible for CR review, categorization and assignment of responsibilities. [P2993]

[11] Conditional Release - A controlled release of materials, parts, or components that have not been fully accepted under the Quality Assurance program. This type of release serves to identify and track an item until it becomes accepted or other disposition action is completed.

[12] Contributing Cause - An identified cause that if corrected would not by itself have prevented the event. This type of cause may have facilitated the events occurrence, increased its severity, or lengthened the time to discovery..

[13] Corrective Action - Corrective Actions (CAs) include actions intended to preclude repetition of significant conditions (see CAPRs) and those intended to correct adverse conditions.

[14] Corrective Actions to Preclude Repetition (CAPRs) - A type of Corrective Action (CA) intended to correct the root cause(s) of a condition and thereby preclude repetition.

[15] Corrective Action Review Board (CARB) - A group, consisting of a cross section of personnel familiar with a particular Condition Report, assembled for the purpose of review and approval of root cause evaluations and corrective action plans. The CARB chairman ensures that adequate representation is in attendance at meetings in accordance with CARB quorum requirements. [P23035]

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 7 OF 67 Corrective Action Process 3.0 cont.

[16] Degraded Condition - A degraded condition is one in which the qualification of a structure, system or component or its functional capability is reduced. Examples of degraded conditions are failures, malfunctions, deficiencies, deviations, and defective material and equipment. Examples of conditions that can reduce the capability of a system are aging, erosion, corrosion, improper operation, and maintenance

[17] Department Performance Improvement Coordinators (DPIC) - departmental personnel as defined in ENOS/GOES to functionally perform and/or implement continuous improvement programs, including the Corrective Action Program (CAP), for their organizations.

[Chemistry, Engineering, Maintenance, Materials Purchasing & Contracts, Operations, Planning & Scheduling, Radiation Protection, Security, and Training]

[18] Deviation - A nonconformance or departure of a characteristic from specified requirements.

[19] Disposition - CR Disposition is the outcome of the evaluation of a reported problem by the CR Owner, as designated by the CRG. The disposition includes (as appropriate) the cause of the condition as determined by the CA to perform an evaluation, the extent of condition, actions to address causes, and a plan for implementing those actions that is commensurate with the significance of the problem. Completion of CR Disposition does not require the completion of all corrective actions.

[20] Effectiveness Reviews - Performance based reviews undertaken to verify that an intended result was achieved. Effectiveness Reviews are normally assigned by CARB to the Responsible Manager, but may be assigned to another group for evaluation. [P23038]

[21] Employee Concerns Program (ECP) - A program implemented to support a Safety Conscious Work Environment (SCWE). The ECP provides an alternate means for any employee to report any type of problem or concern.

[22] Enhancements - Improvement items or actions that address conditions, which meet minimum acceptable criteria, or performance standards but may be less than optimum.

Enhancements should be identified in the CR response because they add value, but may or may not be tracked to completion by the CR process. The enhancement designation is not appropriate if the action is needed to correct the originally identified adverse condition or if the action is needed to address an identified cause.

[23] Extent of Condition - An evaluation/review to identify the total population of items that have or may have the same problem as identified in the original CR problem statement. The intent of the Extent of Condition review focuses on a determination of any potential impact to the operability/functionality of the similar components, equipment, systems, human performance traps/issues, or organizational processes/programs.

[24] Inadequate Technical Specification - A specific Technical Specifications requirement (parameter value or action) that may not support safety assumptions or conclusions.

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 8 OF 67 Corrective Action Process 3.0 cont.

[25] Industrial Safety Incident - An incident that results in either an OSHA Recordable or OSHA Reportable condition.

[26] Learning Organization (LO) - An organizational culture that embraces a never-ending drive for continuous improvement, as highlighted by people at every level in the organization continually increasing their capacity to produce good results and constantly learning from others as means to systematically and deliberately realize operational excellence.

[27] Learning Organization (LO) Documents - Documents written to provide a consolidated record of assessments, benchmark trips, CAPR effectiveness reviews, and other activities.

Learning Organization documents are not processed through the Control Room, Licensing, or the CRG. LO documents are governed by EN-LI-104, Self-Assessment and Benchmark Process. (LO-WTs are NOT considered LO documents. They are ungoverned Work Tracking actions with no specific controls.)

[28] Long Term Condition Report (LTCR) - A CR that contains an approved Long Term CA.

[29] Long Term Corrective Action (LTCA) - Action(s) that cannot meet the timeframes established and approved in accordance with the Corrective Action Processing Guidelines (Attachment 9.4).

[30] Management - Defined as Supervisor and above (Supv, Supt., Manager, GMPO, V.P. etc.)

or as personnel recognized as having direct reports.

[31] A Nonconforming Condition is a condition of a System, Structure or Component (SSC) that involves a failure to meet the Current Licensing Basis (CLB) or a situation in which quality has been reduced because of factors such as improper design, testing, construction, or modification. The following are examples of nonconforming conditions:

  • An SSC fails to conform to one or more applicable codes or standards (e.g., the CFR, operating license, TSs, UFSAR, and/or licensee commitments).
  • An as-built or as-modified SSC does not meet the CLB.
  • Operating experience or engineering reviews identify a design inadequacy.
  • Documentation required by NRC requirements such as 10CFR50.49 is not available or deficient

[32] Non-Significant - A classification for condition reports (typically, B, C, D categories) that document problems or corrective actions for which a repeat occurrence, while always undesirable, can be tolerated.

[33] OPERABLE-Degraded or Nonconforming (Operable-DNC) - A condition where a TS SSC is OPERABLE but a Degraded or Nonconforming Condition exists that does not require Compensatory Measures.

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 9 OF 67 Corrective Action Process 3.0 cont.

[34] Owner - (Responsible Manager) The management position within the PCRS management group that was designated by the CRG to ensure the condition is corrected in accordance with the requirements of this procedure. The Owner may be a Superintendent or above position and is equal to the term Responsible Manager as used in this procedure.

[35] Paperless Condition Reporting System (PCRS) - A computer program that tracks actions resulting from the processes described within this procedure.

[36] Repair - The process of restoring a nonconforming characteristic to a condition such that the capability of an item to function reliably and safely is unimpaired, even though that item still may not conform to the original requirement.

[37] Repetitive Event - any significant condition adverse to quality that resulted from the same identified root cause as a previous event or nonconformance. This doesnt apply to conditions classified as significant due to the frequency of the event/condition (i.e., adverse trend).

[38] Responsible Manager (RM) - (Owner) The management position within the PCRS management group that is designated by the CRG to ensure the condition is corrected in accordance with the requirements of this procedure. The RM may be a Superintendent or above position and is equal to the term Owner as used in this procedure.

[39] Rework - From a plant maintenance efficiency perspective, rework is the re-performance of an assigned activity, in whole or in part, because the original problem/issue was not corrected the first time resulting in a loss of time, money or quality. From a quality perspective, rework is the process by which a nonconforming item is made to conform to a prior specified requirement by completion, re-machining, reassembling, or other corrective means.

[40] Root Cause - The most basic cause(s) for a failure or a condition that, if corrected or eliminated, will preclude repetition of the event or condition.

[41] Root Cause Analysis (RCA) - Structured, formatted process that documents the root cause(s) of a condition or event. The root cause is determined using recognized methodologies. RCAs are performed in accordance LI-118, Root Cause Analysis Process.

RCAs are used for complex issues or those where the cause is not understood or readily known.

[42] Routine Report - NRC reports that are generated at a fixed frequency or as required by regulations except for 10CFR50.55, 50.72, and 50.73. For example, 10CFR50.46 reports of ECCS performance modeling errors of insufficient magnitude to trigger a report under other regulations are considered routine.

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 10 OF 67 Corrective Action Process 3.0 cont

[43] Safeguards Condition Report - A Condition Report documenting a Safeguard condition.

The condition description contains as much information as possible to ensure proper prioritization within the corrective action program by the CRG without providing any safeguards information. Where additional (safeguards) information is required to describe the condition, the additional information shall be contained in a uniquely identified and referenced safeguards document. The uniquely identified safeguards document shall be maintained in a safeguards file in accordance with Safeguards requirements. [CR-HQN-2009-1107, NRC Order EA-09-060]

[44] Significance Determination Process (SDP) - A process by which a condition documented on a CR can be assessed in terms of its risk significance relative to objectives of reactor safety, radiation program effectiveness, emergency planning, & physical security program effectiveness.

[45] Significant Conditions Adverse to Quality - Conditions such as failures, malfunctions, deficiencies, deviations, defective material & equipment, and non-conformances which have resulted in, or could result in, a significant degradation or challenge to nuclear safety.

[46] Significant - A classification for CRs determined to meet one or more of the following:

[P5431]

  • Any Significant Condition Adverse to Quality. Conditions such as failures, malfunctions, deficiencies, deviations, defective material and equipment, and non-conformances which have resulted in, or could result in, a significant degradation or challenge to nuclear safety.
  • A problem recognized as having a greater than acceptable recurrence rate as determined by the CRG.
  • Any event or nonconformance that meets the definition of repetitive event.
  • A serious industrial safety incident as determined by CRG or a near miss occurred that in the judgment of the CRG could have resulted in a serious industrial safety incident.
  • A major breakdown in processes that implement QA Program Requirements as determined by the CRG.
  • Events or conditions designated as significant or considered important by management for reasons other than those that fall into the above categories.

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 11 OF 67 Corrective Action Process 3.0 cont

[47] Site -The term site is used when referring to a specific Entergy nuclear plant or Headquarters (HQN).

[48] Structures, Systems or Components (SSC) - Structures, Systems or Components, for Operability Determinations:

  • Are those SSCs that are required to be operable by Technical Specifications (TSs).

These SSCs may perform required support functions for other SSCs required to be operable by TSs (e.g., emergency diesel generators and service water).

  • Are those SSCs that are not explicitly required to be operable by TSs, but that perform required support functions (as specified by the TSs definition of operability) for SSCs that are required to be operable by TSs.

[49] Structures, Systems or Components (SSC) - Structures, Systems or Components, for Functionality Assessments are those that are not described in TSs, but which warrant programmatic controls to ensure that SSC availability and reliability are maintained.

[50] Suitability Evaluation - For purpose of this procedure, an evaluation performed to determine the cause of failure of a non-conforming item within the ASME Section XI boundary in order to ensure that the proposed repair or rework activity appropriately corrects the nonconforming condition in a manner consistent with the code of record. Suitability evaluations are applicable to components or component supports within the ASME Section XI boundary.

[51] Trip Sensitive System - Any system or component that upon actuation or failure could cause a reactor trip. Trip Sensitive Systems may be specifically identified for each site.

[52] Use-As-Is - A disposition which may be imposed for a nonconformance when it can be established that the discrepancy will result in no adverse conditions and that the item under consideration meets all engineering functional requirements (performance, maintainability, fit and safety) originally specified or as otherwise determined to be acceptable under engineering evaluation.

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 12 OF 67 Corrective Action Process 4.0 RESPONSIBILITIES

[1] All personnel working at EN facilities are responsible for: [QAPM A.6.a]

(a) Identifying and reporting problems. [P22828]

(b) Documenting problems by initiating CRs in accordance with this procedure.

[2] EN Management (Supervisor and above) is responsible for: [QAPM A.6.a], [QAPM A.6.c]

(a) Ensuring that personnel are familiar with the requirements of this procedure.

(b) Ensuring that problems are reported.

(c) Ensuring recommendations on trend codes are provided for CRs assigned to their department prior to CRG. [QAPM A.6.e]

(d) Ensuring that required actions for Condition Reports are determined, implemented, and adequate to resolve the condition.

(e) Ensuring performance of Effectiveness Reviews when assigned.

(f) Ensuring that non-conforming items are segregated as appropriate and controlled as needed until dispositioning the item to be conforming or it is otherwise discarded after removal for testing/maintenance and through disposal or reinstallation (g) Ensuring keywords and problem codes are appropriate based on investigation results.

(h) (For Responsible Managers) Approving RCAs, ACEs and Analysis assigned to their Department. This responsibility should only be delegated when the Responsible Manager is not available and then it should be performed by the individual that is Acting for their position in their absence.

[3] Each Sites Manager, Corrective Actions and Assessment and the Manager CA&A Projects is responsible for: [QAPM A.2.G.7], [QAPM A.6.c]

(a) Administering the Corrective Action Program.

(b) Administering the Root Cause investigation and review process and performing effectiveness reviews for CAPRs when assigned by CARB.

[4] Each Sites Manager, Security and the Manager Security Operations is responsible for: [CR-HQN-2009-1107, NRC Order EA-09-060]

(a) Safeguards Condition Report requirements as follows:

(1) Ensuring when a uniquely identified safeguards document is needed that the CR references the uniquely identified safeguards document and that the safeguards document references the CR (2) Maintaining and controlling the uniquely identified safeguards document in a safeguards file in accordance with Safeguards procedural requirements

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 13 OF 67 Corrective Action Process 4.0 [4] cont (3) Retaining the uniquely identified safeguards document in accordance with the retention requirements of the Corrective Action Process at the individual site.

(4) Ensuring a representative of the Security Department, with Safeguards authorization is present at the CR Pre-Screening, if applicable, and at Condition Review Group (CRG).

(5) Determining when CRG and CARB members are required to be Safeguards qualified based on the nature of the CR being reviewed

[5] Each Safeguards Custodian is responsible for: [CR-HQN-2009-1107, NRC Order EA-09-060]

(a) Safeguards Condition Report requirements as follows:

(1) Maintaining and controlling the uniquely identified safeguards document in a safeguards file in accordance with Safeguards procedural requirements

[6] Each sites Manager, Licensing, or as assigned by management at off-site locations, is responsible for: [P21440]

(a) Reviewing CRs and administering the SDP in accordance with Section 5.5.

(b) Performing Reportability Reviews and documenting the results in PCRS.

(c) Issuing CAs to address NRC violations or findings and performing closure reviews of responses to such CAs.

[7] Each sites Manager, Planning and Scheduling / Outages is responsible for:

(a) Monitoring and reporting to CRG the status of WOs that have CRs/CAs closed to them.

[8] The Condition Review Group (CRG),is responsible for: [P2993], [P21440], [P21439]

(a) Reviewing CRs to classify, categorize, and assign responsibility. Categories are classified as per Attachment 9.1.

(b) Approving closure of CRs to other processes.

(c) Determining when to apply Attachment 9.5 Entergy Fleet Learning Review Process.

(d) Ensures appropriate operability/ functionality reviews are performed per EN-OP-104.

(e) Oversight of Operable-Degraded or Nonconforming (Operable-DNC) or Operable-Comp Measures conditions (f) Determining when to apply CARB oversight responsibilities to Apparent Cause evaluations.

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 14 OF 67 Corrective Action Process 4.0 cont

[9] The Corrective Action Review Board (CARB) is responsible for: [P23035]

(a) Reviewing and approving Root & selected Apparent Cause evaluations including their proposed corrective action plans.

(b) Assigning Effectiveness Reviews to the Responsible Manager, or appropriate group, for Category A CRs and management selected Category B CRs.

(c) Reviewing, and approving or disapproving Due Date Extension Requests for CARB approved CAPRs. The CARB Chairperson may approve Due Date Extension Requests for CARB approved CAPRs rather than convening the full board.

(d) Determining when to apply Attachment 9.5 Entergy Fleet Learning review process if not already applied by CRG

[10] The Fleet Manager OE & CA is responsible for maintenance of this procedure.

[11] The Site NSA Director (or GM Fleet Operations Support for Headquarters) is responsible to evaluate Anonymous CRs for SCWE issues.

[12] Where assigned / used, Department Performance Improvement Coordinators (DPIC) are responsible for:

(a) Being the point of contact for the Corrective Action Program (CAP) and assisting with implementation of the requirements of EN-LI-102.

(b) Providing recommendations on CR assignment and significance classification prior to CRG.

(c) Providing recommendations on trend codes (system, equipment & component, reference items, etc.) for CRs assigned to their department prior to CRG. [QAPM A.6.e]

(d) Ensuring CRs involving human performance issues are properly identified and human performance trend data is entered into PCRS (e) Maintaining an awareness of the status of CRs & CAs owned by their department to ensure actions are completed by the due date or extended appropriately.

(f) Performing Responsible Manager closure reviews for Category C CRs when designated by the Responsible Manager.

(g) Performing a final CR Quality check prior to electronic CR closure review for CRs assigned to their department as allowed by EN-LI-102 after all CR closure reviews are complete and documented. Ensure trend codes are accurately assigned including causal codes, PO&C, HU, Failure modes, etc.

(h) Acting as the cause analysis point of contact for their department.

(i) Assisting others with PCRS and Corrective action program issues.

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 15 OF 67 Corrective Action Process 5.0 DETAILS 5.1 PRECAUTIONS AND LIMITATIONS

[1] Safeguards information related to Safeguards CRs shall be handled in accordance with EN-NS-204; Protection of Unclassified Safeguards Information, requirements. .

5.2 CONDITION REPORT INITIATION [INPO93OE21TP3], [INS938OTP2], [QAPM A.6.b]

[1] General Instructions (a) Notification to management prior to, or concurrent with, initiation of a Condition Report is encouraged but not required. However, due to the potential implications of safety related issues, all conditions involving personnel and/or plant safety issues are expected to be communicated to management verbally to support timely resolution of the safety issue. These notification expectations are captured in 5.2 [1] (f) of this procedure.

(b) When documenting conditions on a Condition Report, do not use names of personnel if at all possible. If necessary for clarity of the condition, use of titles is acceptable.

(c) Safeguards Information and proprietary documents are not to be placed in Condition Reports. Contact Security for guidance on safeguards information and contact Administrative Services or CA&A for guidance on proprietary documents.

(d) Employees and contractors are encouraged to write CRs for a broad range of problems.

Problems reported must include, but are not limited to, Adverse Conditions. Examples of Adverse Conditions requiring initiation of a CR are provided in Attachment 9.2.

If an employee is not satisfied with classification of a CR or if the actions are inadequate to alleviate their concern, the employee may choose to utilize Entergys Open Door Policy and discuss the concern with higher levels of management. Employees may also choose to report their concern through the Employee Concerns Program (ECP). While the Corrective Action Process is the preferred method of reporting problems, the ECP may be utilized at any time. Neither this nor any other company policy alters an individuals right to address their concerns directly to the NRC per 10CFR19 Identifying problems within the CA Program is a Protected Activity as defined in EN-EC-100, Guidelines for Implementation of the Employee Concerns Program. [CR-PLP-2007-1243]

(e) Employees are required to initiate CRs for adverse conditions, and are encouraged to write CRs whenever conditions warrant.

(1) If there is any doubt about the decision to initiate a condition report, then employees are encouraged to discuss the condition with appropriate management.

(2) If doubt remains, employees should initiate the CR.

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 16 OF 67 Corrective Action Process 5.2[1] cont (f) Any individual, including corporate, shared resource, or contracted personnel, who discovers an Adverse Condition, is expected to ensure the following actions are taken.

[P5110], [P23978]

(1) Immediate actions are taken as necessary to minimize the consequence of the condition. Expected actions are commensurate with level of training, knowledge and expertise (e.g., extinguishing a fire, eliminating a safety hazard or correcting an adverse radiological condition).

(2) Appropriate site personnel are notified of the identified condition. If immediate action should be taken by Operations to ensure the safety of the plant or personnel, contact the Shift Manager/designee. The following information should be provided:

  • Originators name, telephone number, and supervisor,
  • Brief description of the condition,
  • Equipment identification and location, and
  • Immediate corrective action taken, if any.

(3) The condition is promptly documented on a Condition Report.

(g) Non-conforming items are properly controlled to prevent their inadvertent test, installation, or use. When items are controlled by tagging, the tag is equivalent or similar to Attachment 9.7. [QAPM A.6.d S1], [QAPM Table 1.c.22], [QAPM B.13.b], [ANSI N18.7 5.2.14], [ANSI N45.2.4 2.6 S1 S2]

(1) Uninstalled quality-related nonconforming items outside of warehouse control (i.e., cannibalized components, items removed from the plant and found to be nonconforming or awaiting evaluation or refurbishment, warehouse items known to be nonconforming and conditionally released, etc.) shall be tagged where feasible. Segregation of the items should also be considered and may be an alternative when tagging is not feasible.

a. The organization responsible for the nonconforming items shall ensure they are documented on a CR [P22362]. The responsible organization shall also ensure the nonconforming items are tagged.
b. Nonconforming items shall be documented on a condition report and tagged/segregated until the item has been accepted through evaluation, rework, repair, or scrap. Tagging/segregation shall stay in place until disposition activity has been completed (2) Nonconforming items within warehouse control are addressed in EN-MP-120.

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 17 OF 67 Corrective Action Process 5.2 [1] cont.

(h) All Safeguard conditions will be identified as a Safeguard condition report. The condition description should clearly identify the CR as being a Safeguards CR. The condition description shall contain as much information as possible to ensure proper prioritization within the corrective action program by the CRG without providing any safeguards information subject to the following: [CR-HQN-2009-1107, NRC Order EA-09-060]

(1) Where additional (safeguards) information is required to describe the condition, the additional information shall be contained in a uniquely identified safeguards document (2) The Condition Report shall reference the uniquely identified safeguards document and the uniquely identified safeguards document shall reference the Condition report. It shall be the responsibility of the Security Department to ensure this cross reference is made.

(3) The uniquely identified safeguards document shall be maintained in a safeguards file in accordance with Safeguards requirements. The Security Department (Security Manager and Safeguards Custodian) shall be responsible for maintaining this safeguards file and for developing and maintaining procedures to control this file.

(4) The safeguards file shall be auditable and must meet retention requirements equivalent to those of the Corrective Action Process at the individual site.

[2] Preparation (a) When initiating a CR, with potential operability/functionality or reportability issues, promptly contact the Shift Manager/designee to inform Operations of the condition.

[COMM-93-04786], [P22829]

(1) Direct notification of Operations personnel (via phone or face-to-face) is important to ensure details of the condition are sufficient and understood for the operability/functionality/immediate reportability determination. This notification is not performed using voicemail or e-mail because timeliness cannot be assured.

(b) Determine the applicable Site:

(1) A Site CR should be initiated for the Site impacted by the Adverse Condition.

(2) Consider initiating as a Headquarters (HQN) CR instead of a Site CR if there is no Site impact, an Operability or Reportability Review is not required, AND if the Adverse Condition is related to a corporate program or fleet procedure.

(3) Where both steps (1) and (2) apply initiation of both a Site CR and a HQN CR may be indicated.

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 18 OF 67 Corrective Action Process 5.2 [2] cont (c) Prepare the Condition Report using the PCRS application through normal user log on or PCRS EZ login.

(d) In the unlikely event of a PCRS system outage, follow the instructions provided in Attachment 9.3 (Manual CR Initiation).

(e) The condition description and any supporting documentation should be in sufficient detail to provide a clear understanding of the condition. This information is used to perform operability/functionality/immediate reportability and reportability determinations.

It is expected that the condition description identify any outside agency that identified the condition, when applicable. [P23978]

(1) The condition description field should provide a brief, factual statement of what the deficiency, issue, or problem is and its impact to reliability and safety, and any additional information needed to provide complete and accurate identification of the problem. The additional information should include a summary of the facts with statements detailing what happened, when and where it happened, and if known, why the event occurred.

(f) The date and time of the occurrence are included in the Condition Description, if pertinent.

(g) Attach electronic copies of any documents needed to understand or clarify the condition (i.e., computer printouts, operating logs, survey records, etc.) in MS Word or PDF format. [P22829] [P23977]

(h) Save the Condition Report in PCRS using the Init CR button. It is then automatically routed to the appropriate departments (Operations, Licensing, and CA&A) for operability/functionality, reportability, and processing as applicable.

(i) For equipment related CRs, ensure applicable equipment information is filled out in the "Equipment" tab of the CR in PCRS after CR initiation.

(j) Information regarding subsequent CR category classification, assignment, status, and proposed corrective actions is readily available in PCRS. CR initiators can review PCRS to maintain awareness of the status of CRs they have initiated.

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 19 OF 67 Corrective Action Process 5.2 cont

[3] Original Condition Report Modification (a) If the language in a condition report is deemed abusive by CA&A, it may be administratively removed without the initiators concurrence. This includes the language is offensive, distasteful or inappropriate in nature. The original unedited version should be provided to Employee Concerns (b) In addition, if the name of an individual is provided in the CR, CA&A may substitute the individuals title or position for the individuals name without the initiators concurrence. Confidential information (SSNs, medical details, disciplinary actions, etc.) and safeguards information may also be removed and substituted with appropriate wording without the initiators concurrence.

(c) Changes should be noted inside brackets [ ] or an explanation of change provided.

(d) For changes made without the initiators concurrence the original unedited copy of the CR should be attached to the ADMIN Tab of the CR.

5.3 OPERABILITY, FUNCTIONALITY, AND IMMEDIATE REPORTABILITY [NL-98-066-C024],

[ER20031761_02], [ANSI N18.7 Section 5.2.6 S20], [10 CFR 50.72(b)],, [10 CFR 73.71(a)(1) (b)(1) S1], [ANSI N18.7, Section 4.1]

[1] For Entergy Nuclear: [ER970230]

(a) When a CR is initiated, the CR initiator is tasked with screening the condition to determine if a potential operability/functionality and/or immediate reportability concern exists. The CR initiation screen has a checklist to assist in the screening. If a CR is checked as Potential Operability - Yes, the CR is automatically routed to the site Operations Department for Operability/Functionality Determination and Immediate Reportability screening. If a CR initiator is unsure if a condition involves a Potential Operability/Functionality and/or Immediate Reportability concern, the Potential Operability button should be checked as Yes.

(b) Those CRs flagged as Potential Operability - No by the CR initiator are reviewed by the CRG to verify that Operability Determination is not required. If the CRG determines that Operability/Functionality Determination is required, Operations is notified to perform the operability/functionality.

(c) Operability/ Functionality and Immediate Reportability reviews for CRs requiring review are performed in accordance with NMM EN-OP-104. The results of the reviews are entered into PCRS on the Operability/ Functionality screen. [Gentletr9118R1], [NL-98-066-C024], [INS9620004]

[2] For Corporate:

(a) If a CR, initiated at Headquarters locations, is screened as having a Potential Operability/Functionality and/or Immediate Reportability concern, a CR is written at the affected site(s) so that an Operability/Functionality Determination can be performed.

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 20 OF 67 Corrective Action Process 5.4 REPORTABILITY [10 CFR 50.72(b)], [10 CFR 50.73(a)(2)], [10 CFR 73.71(a)(1) (b)(1) S1], [ANSI N18.7, Section 4.1], [10 CFR 21, 21 A and C]

[1] When a CR is initiated where the PCRS Reportability Bypass feature is enabled, the CR initiator is tasked with screening the condition to determine if a condition is potentially reportable. The CR initiation screen has a checklist to assist in the screening. If a CR is checked as "Potential Reportability Yes", the CR is automatically routed to the site Licensing Department for a reportability review. If a CR initiator is unsure if a condition involves a Potential Reportability concern, the "Potential Reportability" button should be checked as "Yes"."

[2] The designated personnel for completing the reportability review will enter the appropriate information in PCRS within 5 working days of CR initiation.

[3] Those CRs flagged as "Potential Reportability No" by the CR initiator are reviewed by the site Licensing Department in a timely manner to verify that a reportability review is not required. This may be performed by a Licensing Department representative during a CRG meeting where newly initiated CRs are reviewed. If the Licensing Department determines that reportability review is required, Licensing will perform the reportability review and enter the appropriate information in PCRS.

[4] Reportability Reviews are performed in accordance with EN-LI-108, Event Notification and Reportability.

5.5 SIGNIFICANCE DETERMINATION PROCESS (SDP) [Gentletr9118R1], [INS9620004]

[1] The Plant Licensing Group (or other group as assigned by plant management) reviews CRs to determine if a Significance Determination Process (SDP) review should be done to characterize the risk significance of the issue relative to the Reactor Oversight Program strategic areas (Reactor Safety, Public Radiation Safety, Occupational Radiation Safety, Physical Protection, Emergency Preparedness). The criteria used for this selection are:

  • CRs associated with NRC Findings which have been classified as potentially being more significant than green
  • CRs for which CRG has requested Risk Significance Determination
  • Other CRs as Plant Licensing deems necessary

[2] CAs are assigned in PCRS to the responsible groups to complete the SDP. If further review of the condition or event necessitates additional responsibilities to complete the SDP for all affected SDP cornerstones, additional CAs are assigned in PCRS.

[3] SDP screening is performed and the results are entered into PCRS.

[4] SDP results are made available to the CRG.

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 21 OF 67 Corrective Action Process 5.6 CONDITION REVIEW GROUP (CRG) [NL-97-084-C17]. [P2993], [P13307], [P16529], [P20277], [P21439]

[P13363], [QAPM B.13.a]

[1] Corrective Action & Assessment (CA&A) or the initiating department provides recommendations to the CRG regarding the categorization and assignment of CRs per Attachment 9.1. [P9849]

[2] The Chairperson for the CRG at the sites is the GMPO or designee. The Chairperson for the CRG at Headquarters is determined by the VP - Operations Support. The Chairperson ensures that appropriate management representation is present.

[3] CRG quorum, at a minimum, should consist of management representing CA&A, Maintenance, Operations, and Engineering. The chairperson can be counted as one of the members for the purpose of meeting minimum quorum requirements.

[4] Condition Reports are reviewed by the CRG in a timely manner.

[5] When a Condition Report includes Safeguards information a representative of the Security Department, with Safeguards authorization shall be present at the CR Pre-Screening if applicable and at Condition Review Group (CRG). [CR-HQN-2009-1107, NRC Order EA-09-060]

(a) This Security Department representative shall provide any information to the CRG that is required to classify the condition report, subject to the requirements of 10CFR73.21 Protection of Safeguards Information and EN-NS-204; Protection of Unclassified Safeguards Information.

(b) For some Safeguards CRs, CRG members may be required to be Safeguards qualified based on the nature of the CR being reviewed. Security shall make this determination (c) These requirements shall be applicable to each site and headquarters

[6] The CRG provides oversight of CR Operability/Functionality Determinations, Operable-Degraded or Nonconforming (Operable-DNC) or Operable-Comp Measures conditions.

(a) The primary responsibility for completeness and accuracy of the Operability/Functionality determinations lies with the Operations department.

(b) Operations ensures appropriate flags / codes are applied in PCRS to facilitate tracking of Operable-DNC or Operable-Comp Measures conditions.[NL-98-066-C024], [ER970230]

(c) Operations ensures that open Operable but Degraded or Nonconforming or Operable-Comp Measures conditions are tracked at the Site and presented through either the CRG or the Ops Focus meeting to meet timeliness expectations for resolution per EN-OP-104.

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 22 OF 67 Corrective Action Process 5.6 cont

[7] The CRG reviews newly initiated CRs and determines/confirms the appropriate category assignments as identified in Attachment 9.1. [P5431]

[8] The CRG determines Responsible Manager assignments. Changes to the Responsible Manager assignment can be made without CRG approval as long as the previous Owner and new Owner both agree on the assignment change.

[9] The CRG assigns due dates for disposition and corrective action determination based on the CR category (see Attachment 9.4). The CRG may assign different due dates based on their deliberations.

[10] CRG members are encouraged to provide feedback to CR initiators from their respective technical disciplines regarding CR status, ownership, and proposed corrective actions.

[11] Feedback on Category D closed CRs is provided to the initiating employee and their supervisor, when names are entered as recorded in PCRS, via the automatic e-mail extracted from PCRS. The email includes the closure description, closure date and individual performing the CR closure in PCRS. This informs the employee and supervisor that the CR has been closed so that if desired the originator/supervisor can review closure and if necessary request reconsideration based on new information or insight by initiation of a new CR.

[12] If additional information becomes available during CR processing then the CR may be presented to the CRG for re-categorization. All changes in significance or category are approved by the CRG. If the CR is re-categorized, then a new due date may be assigned based on significance of the condition.

[13] The CRG assigns any immediate or interim actions that may be required to minimize the consequences of a condition and/or to determine extent of a condition.

[14] In order to ensure appropriate oversight and independence, the Quality Assurance (QA) organization has the right to determine if a QA identified condition is a Condition Adverse to Quality or a Significant Condition Adverse to Quality. In cases where the CRG does not concur that a QA identified condition is a Significant Condition Adverse to Quality, the Director, Oversight has authority to overrule the CRG.

[15] The CRG determines if new CRs meet the criteria for application of Attachment 9.5 Entergy Fleet Learning Review Process.

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 23 OF 67 Corrective Action Process 5.7 CORRECTIVE ACTION REVIEW BOARD (CARB)

[1] The purpose of the Corrective Action Review Board (CARB) is to review and approve the root cause and the proposed Corrective Action Plan for significant CRs.

[2] The Headquarters CARB membership will consist of manager- and director-level individuals as designated by the VP, Operations Support.

[3] The Site CARB membership will consist of the following personnel or their alternates:

  • Chairperson - Director level (or higher) member of site staff
  • Director, Engineering
  • Director, Nuclear Safety Assurance
  • Manager, Corrective Action & Assessment
  • Manager, Operations
  • Manager, Maintenance
  • Manager, Training

[4] CARB quorum consists of:

(a) A Chairperson and:

  • At least one position designated member and
  • At least two additional position designated members or their alternates.

Alternates will be designated by the Chairperson

[5] For any CARB voting process each representative of the quorum shall have one vote.

[6] For some Safeguards CRs, the CARB members may be required to be Safeguards qualified based on the nature of the CR being reviewed. Security shall make this determination. [CR-HQN-2009-1107, NRC Order EA-09-060]

[7] In the event a previously CARB approved root cause report requires a revision and follow-up CARB review, the CARB (with CAA assistance) ensures follow-up actions are assigned to appropriate organizations to review the revision. This review is to ensure that if a report was made to an outside agency (or other departments) based on the original root cause, the original outside agency report remains valid, or requires a revision. Examples of reports to external agencies (or other impacted departments) include LER to NRC, reports to INPO, etc.

(a) Examples of reports to other departments include departments developing modifications, tracking materials being purchased, tracking vendor destructing testing, etc.

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 24 OF 67 Corrective Action Process 5.7 cont

[8] For CRs assigned for CARB review, the CARB assigns Effectiveness Review actions to the CR Owner, or other groups as appropriate. This assignment is made based on significance, importance, or complexity of the documented event or condition. Effectiveness reviews may be tracked and documented through the initiation of a Learning Organization document.

5.8 CR DISPOSITION [NL-97-084-C07], [NL-97-084-C13], [ANSI N18/7, Section 5.2.7.1 S14, S15, S16], [ANSI N45.2.12, Section 4.5.1 S1-S5 (QAPM Table 1N.10)], [QAPM B.13.a], [ANSI N45.2.13 9.2 S1a, b, c, d]

[1] General Instructions Caution New or revised Operability determinations / evaluations may indicate that the Reportability Review needs to be updated.

(a) Personnel involved with the investigation and disposition of CRs are responsible for:

[Gentletr9118R1], [INS9620004]

  • Informing the Shift Manager/designee immediately if a SSC previously evaluated as operable may be inoperable as determined from new information from the disposition investigation.
  • Informing the Shift Manager and Licensing Manager immediately if a condition previously thought to be not reportable is in fact reportable as determined from new information from the disposition investigation.
  • Initiating a new CR if new information or insight makes the current Operability and/or Reportability questionable or if a previous CRs identified cause is found to be incorrect.
  • Contacting CA&A if the condition or event should be reevaluated by the CRG (b) If at any time after a CR has been initiated and screened, information becomes available that may change previous conclusions regarding present or past operability, notify the shift manager immediately and initiate a new condition report.

(c) If a CR that had Potential Operability checked as No is later determined to need an Operability/Functionality Determination, the Shift Manager (SM) / designee and CA&A should be informed immediately. The SM/designee can perform an Operability/Functionality Determination even though it was originally indicated as not required.

(d) If a CR that had Potential Reportability checked as No is later determined to need a Reportability Review, the Licensing Manager / designee and CA&A should be informed immediately. The Licensing Manager /designee can perform a Reportability Review even though it was originally indicated as not required.

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 25 OF 67 Corrective Action Process 5.8[1] cont (e) During the course of investigations or completion of corrective actions for open condition reports, a new condition report shall be initiated:

(1) If additional issues beyond the scope of the initial problem description are identified during the problem evaluation of an event, an additional CR shall be initiated for these new issues.

(2) If additional issues beyond the scope of the initial problem description are identified during the initiation of a proposed correction action or the completion of an actual corrective action of an event, an additional CR shall be initiated for these new issues.

(3) A separate CR may be required for the following even if an initial CR was written to perform the maintenance when:

a. Unexpected condition (signs of overheating, damage from overstress, etc.) are identified during maintenance on safety-related SSCs; non safety-related SSCs ranked as High Critical components
b. An abnormal or unexpected condition on an SSC that needs further evaluation (e.g., deviations (trends) in operating parameters from normal)

(f) For Safeguards CRs, the assigned Department shall be responsible for performing or overseeing the required Condition Report response to meet the requirements of the Corrective Action Program. Note that this may or may not be the Security Department (i.e., Modifications, Licensing, Engineering, etc.) This would include: [CR-HQN-2009-1107, NRC Order EA-09-060]

(1) Maintaining Root Cause Analysis and Apparent Cause Evaluation qualified individuals to perform such evaluations on CRs that are Safeguards related.

Such evaluations shall be performed in accordance with existing corrective action procedures.

(2) Maintaining qualified Department Performance Improvement Coordinators (DPICs) to perform close-out reviews of Condition Reports that are Safeguards related. These reviews shall be performed in accordance with existing Entergy corrective action procedures.

(3) Individuals will obtain Safeguards qualifications in accordance with applicable Security procedures as needed to meet these requirements.

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 26 OF 67 Corrective Action Process 5.8[1] cont (g) Corrective Action plans are reviewed / approved by management. [QAPM A.6.d S2], [QAPM A.7.a.1 S2]

(1) If an assignee or reviewer recognizes that a change in the intent of a Corrective Action plan is necessary, the change should be coordinated with the Responsible Manager (and CARB Chairperson, if CARB is applicable) and documented. Changes to Corrective Action plan due dates are controlled through the normal extension process described in this procedure. However, Due Date Extension Requests must be reviewed and approved/disapproved by the CARB chairperson for CAPRs that were generated as part of a CARB approved corrective action plan.

(2) For material related CRs, non-conforming items are reviewed for the need to classify as use-as-is, reject, repair, or rework. Items that are classified as use-as-is or repair are required to have a formal engineering evaluation with technical justification, augmented inspection and/or test requirements, and design reviews as appropriate. [QAPM B.13.b], [ANSI N18.7 5.2.14], [ANSI N45.2.4 2.6 S1 S2]

(3) Suitability Evaluations are performed for the rework of items within the ASME Section XI boundary.

(h) Effectiveness Reviews are conducted per the guidance of EN-LI-118. An Effectiveness Review that reaches a conclusion that Corrective Actions / CAPRs were ineffective should result in the initiation of a new CR to determine the need to revise the cause determination, corrective action plan, effectiveness review plan and the need for additional CARB reviews. Also, consider an additional CR to explore the potential Corrective Action Program failure.

[2] Category A- Evaluation and Corrective Action Plan [P24458], [P24500], [P32520], [P17726],

[P21887], [P21896]

All Significant Conditions are subjected to an evaluation to determine Root Cause. A Root Cause evaluation is performed and reviewed by qualified Root Cause Evaluators. Root Cause evaluations are performed in accordance with fleet Root Cause Analysis process procedures and guidance documents. In most cases, CAPRs are assigned for each Root Cause identified. The purpose of the action described in the CAPR is to preclude repetition. CAPRs receive an Effectiveness Review.

(a) Responsible Manager must:

(1) Ensure that a Root Cause Analysis is performed for Category A CRs utilizing NMM EN-LI-118, Root Cause Analysis Process, and that appropriate CAPRs are issued. [P21896], [P21887]

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 27 OF 67 Corrective Action Process 5.8[2 ](a) cont (2) Ensure formulation of a proposed CA Plan to correct the condition and to preclude repetition. The corrective action plan specifies the responsible departments and relevant due dates for completion of the corrective actions.

The Corrective Action Plan includes an action to perform an Effectiveness Review of the CAPRs.

(3) Approve the cause and corrective action plan that is submitted for CARB review/approval.

(4) Ensure the completed root cause and proposed corrective action plan are submitted to CA&A for review and for scheduling of CARB review/approval (as appropriate).

(5) Ensure implementation of Attachment 9.5 guidance for Entergy Fleet Learning Review Process specified by CRG/CARB.

(6) Ensure keywords and problem codes are appropriate based on investigation results

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 28 OF 67 Corrective Action Process 5.8 cont

[3] Category B - Evaluation and corrective action plan:

Category B CRs are assigned to the Responsible Manager for an Apparent Cause Evaluation as determined by the CRG. [P21886], [P21895]

(a) Apparent Cause Evaluations (ACEs) are performed as either a Higher Tier or Lower Tier type, as assigned by CRG. Also, the CRG may direct a specific type of supporting cause analysis technique be performed in addition to ACE.

(b) Responsible Manager must:

(1) Ensure an Apparent Cause Evaluation is performed utilizing NMM EN-LI-119, Apparent Cause Evaluation (ACE) Process, AND when directed by the CRG, utilizing the specific type of supporting cause analysis process indicated.

(2) Ensure formulation of a CA Plan to both correct the condition and to address the causes that were identified.

(3) Approve the cause and corrective action plan.

(4) Ensure keywords and problem codes are appropriate based on investigation results (c) Effectiveness Reviews may be performed as determined by management for this category of CR. Effectiveness Review report format and performance guidance are contained in EN-LI-118.

(d) For Category B CRs the CRG may determine if a CARB review/approval is warranted.

CRG guidance on CARB assignment is provided in Attachment 9.1.

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 29 OF 67 Corrective Action Process 5.8 cont

[4] Category C - Corrective action:

Category C condition reports are assigned to a Responsible Manager for resolution of problem assigned by the CRG. A Root Cause or an Apparent Cause Evaluation is not required.

(a) Responsible Manager must:

(1) Ensure actions are assigned as appropriate to correct the problem.

(2) Ensure the assigned corrective actions are appropriately completed within the prescribed time frame.

(3) If the disposition review determines that the problem is broader or more severe than initially assigned, present the information to the CRG for review and potential re-categorization.

(4) Obtain CRG approval before closing a CR or CA to a Work Order. This requirement is not applicable if the CA was issued to track an enhancement and documented as such.

(5) Ensure keywords and problem codes are appropriate based on investigation results (b) Effectiveness Reviews may be performed as determined by management for this category of Condition Report. Effectiveness Review report format and performance guidance are contained in EN-LI-118.

[5] Category D - CRs are administratively closed as directed by the CRG. [P6919]

(a) When a CR is closed to an existing CR:

(1) The existing CR must have been reviewed by the appropriate CRG and assigned to a responsible manager.

(2) The CR being closed is the same or lower Category level than the existing CR..

(3) A corrective action is assigned by CA&A to the Owner of the existing CR stating that a new CR has been closed to the existing CR and must be addressed within the existing CR.

(4) If the Operability/Functionality or Reportability of the existing CR is impacted by the new condition information being added, the CR Owner must take action to ensure the Operability/Functionality or Reportability as applicable is re-evaluated.

(5) In case of a duplicate issue, a new CA is not required.

(b) For any CR closed as a Cat D based on actions already taken, a description of the actions taken is included within the CR or in the CR Closure Description field.

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 30 OF 67 Corrective Action Process 5.8 [5] cont.

(c) CRs that identify conditions that do not rise to the level of an Adverse Condition as defined in 3.0[2] or did not identify a problem may be classified as follows:

(1) These CRs may be classified by the CRG as Close Reference referencing another processs tracking identifier (i.e. WR#, TEAR #, etc.), Review Emerging Trend, or Below Threshold as appropriate.

(2) In some instances the CRG instead may choose to close these CRs to Actions Taken or Condition Corrected when supporting documentation is available or the CRG may choose to assign them for correction per their discretion.

[6] CR/CA Closure to Work Orders.

(a) CAPRs, Operable-DNC or Operable-Comp Measures conditions, and Category A CR actions (except Enhancements), may not be closed to other processes and must remain open in the corrective action process until resolved.

(b) With CRG approval, CAs or CRs to correct Adverse Conditions, other than CAPRs and Operable-DNC or Operable-Comp Measures conditions and Category A CR actions (except Enhancements) may be closed to Work Orders.

(1) Additional guidance concerning classification of CRs on lower level equipment issues can be found in Attachment 9.6.

(c) To close a CR/CA to a Work Order the following must be completed:

(1) A Work Order (WO) has been generated and the WO number is listed in the CR using a site standardized format to support retrieval and tracking.

(2) Work Order scope or description is verified to adequately describe the issue identified in the CR/CA.

(3) The CR number is identified in the Work Order using a site standardized format to support retrieval and tracking.

(d) Responsibility for monitoring and reporting on the status of WOs that have CRs/CAs closed to them resides with the Planning and Scheduling/Outage organization (P&S/O).

This monitoring is to ensure timely correction of the originally identified condition.

(1) Periodically, typically at least monthly, P&S/O will report to the CRG the status of WOs with CRs/CAs closed to them. The focus of this report should be the monitoring for timely resolution of those WOs per EN WM-100. The CRG may require additional details for any WOs not completed in a timely manner.

(2) If the work originally scheduled to correct the condition is transferred to another WO, P&S/O will ensure the CR reference is added to the new WO.

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 31 OF 67 Corrective Action Process 5.8 [6] (d) cont.

(3) Before a WO which had a CR or CA closed to it can be canceled or closed with no work to be performed, the organization requesting cancellation will present the CR and WO to the CRG for discussion. If necessary, another CR may be generated to track the issue. CRG approval is not required for canceling a WO if the work is to be performed under another WO and both WOs contain the appropriate reference to the CR.

5.9 CORRECTIVE ACTIONS [ANSI N45.2.12, Section 4.5.1 S1-S5 (QAPM Table 1N.10)]

[1] General Instructions (a) Corrective Actions are assigned a CA type code (including CAPR) in PCRS.

(b) Each corrective action should specify whether or not it is tracked as an operational constraint and which unit or Outage is affected.

(c) Any Operable-DNC or Operable-Comp Measures conditions not resolved prior to the completion of the next outage of sufficient duration shall be evaluated for continued operability into the next cycle of operation. This evaluation is reviewed and approved by the Onsite Safety Review Committee (OSRC) prior to startup from the outage.

[Gentletr9118R1], [INS9620004]

(d) For CAPRs that are credited as being implemented by procedure actions or requirements the applicable steps in the associated procedure should be annotated or flagged as commitments in accordance with EN-AD-101 and applicable site procedures.

(e) Long Term Corrective Action (LTCA) designation is approved by GMPO/Director or Site VP.

(1) Once approved, the CR/CA is appropriately flagged as long term.

(2) CAs are eligible for LTCA designation if they cannot meet the timeframes established/approved in accordance with the Corrective Action Processing Guidelines (Attachment 9.4) AND if they meet any of the following criteria:

a. Includes work requiring a plant refueling outage, plant forced outage or planned long system/train/component outage to complete. This includes CAs, such as training or meetings, which cannot be completed until pre-outage staffing is complete.
b. Requires development of a modification and/or modification of an approved modification/design change.
c. Requires training that will take multiple requalification or training cycles to complete.
d. Includes initiatives dependent upon a Licensing submittal which requires NRC (or other state or governmental regulatory organization) response/approval.

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 32 OF 67 Corrective Action Process 5.9 [1] cont.

(3) Attachment 9.9 is provided to facilitate the LTCA review and approval process. It can be used if desired. The expectation is to capture the discussion points of that form in a CA, DDE request or initial CA assignment as appropriate. The form itself need not be used, but all points applicable must be addressed and the guidance of 5.9[1] (d), (e), & (f) must be followed.

(4) The specific restriction preventing the timely completion of the item, resulting in the need to use the Long Term CA classification, must be documented in the CA. Long Term CA classifications are normally assigned at time of CA initiation (vice changing to Long Term at the due date).

(f) CAs issued to track Enhancements as defined in 3.0[22], and documented as such in PCRS, may be closed referencing other processes without CRG approval.

(g) For each Corrective Action that contains safeguards information: [CR-HQN-2009-1107, NRC Order EA-09-060]

(1) Where additional safeguards information is required to describe information in the Corrective Action, the additional information shall be contained in a uniquely identified safeguards document (2) The Corrective Action shall reference the uniquely identified safeguards document and the uniquely identified safeguards document shall reference the Condition Report and Corrective Action. It shall be the responsibility of the Security Department to ensure this cross reference is made.

(3) The uniquely identified safeguards document shall be maintained in a safeguards file in accordance with Safeguards requirements. The Security department shall be responsible for maintaining this safeguards file and for developing and maintaining procedures to control this file.

(4) The safeguards file shall be auditable and must meet retention requirements equivalent to those of the Corrective Action Process at the individual site.

(h) The Change Management Process, EN-PL-155, should be used as appropriate for corrective actions that meet the complexity and risk outlined in the policy.

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 33 OF 67 Corrective Action Process 5.9 cont

[2] Corrective Action Initiation (a) Corrective Actions are initiated using PCRS for all actions identified in the action plan, not documented as complete.

(b) Corrective Action Due Dates should be selected with consideration given toward:

  • The next potential occurrence of the problem and should ensure the action is complete prior to the next potential occurrence of the problem, if possible.
  • The potential impact to plant operation while the action completion is pending.
  • How much time is needed to complete the action
  • What are the resource availability issues that challenge the completion of the action?

(c) Corrective Action Due Dates should be assigned utilizing the guidance contained in Attachment 9.4.

(d) Typically CA assignments to another department should be made at the management level in PCRS.

(e) Typically CA assigners should notify assignees prior to assignment of an action.

(f) The corrective action content should be specific, actionable, measurable, timely, necessary, cost effective, and compatible, within the capability of management to implement and address the issue. Further guidance on each of these criteria can be found in EN-LI-118.

(g) Corrective Actions must address the cause or resolve the deficiency. Corrective action descriptions must be worded to ensure that the corrective action is tracked to completion. Cross references to other precursor or successor CAs may help ensure successful corrective action.

(h) Corrective Actions directing consideration or evaluation to resolve conditions, issues, or causes should be avoided where possible. If needed, then these corrective actions must also include the expectation for follow-up actions to be issued depending on the outcome of the review.

(i) Corrective Actions that require training or briefing, or that direct communicating expectations, requirements and information must specify the required audience for corrective actions.

(j) The CRG/CARB/OSRC or senior management or above may issue CAs for a CR without the concurrence of assigned or Responsible Manager.

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 34 OF 67 Corrective Action Process 5.9 [2] cont (k) The Operations Shift Manager/SRO may issue corrective actions on a CR, for support of Operability/Functionality Determinations or Evaluations, without the concurrence of assigned or Responsible Manager.

(l) The CA&A group issues CAs at the direction of the CRG/CARB/OSRC or senior management or above and as required by this procedure.

(m) Plant Licensing may issue CAs to have past Operability/Functionality Determinations or Evaluations performed on identified conditions. These determinations and evaluations may be used for determining reportability.

(n) Plant Licensing issues CAs to the assigned or Responsible Managers to ensure that potential or actual NRC violations or findings are adequately addressed in corrective actions. Licensing also performs a closure review of these corrective actions to ensure the finding was adequately addressed.

(o) The CA assigner has the option to review the Corrective Action response for closure, or to allow the CA assignee to close the action. The CA Assigner indicates that a required review is assigned by checking the Concurrence Reqd for Closure check box.

(p) The CA assigner has the option to oversee due date extensions for a given action or to allow the CA assignee the oversight to extend the due date. The CA Assigner indicates that due date extension approval oversight is required by CA Assigner by checking the Require Extension Approval check box (see 5.9 [3] for due date extension approval).

(q) For site CRs initiated in response to an Industry Operating Experience notification, a CA is issued for the Operating Experience organization to perform a closeout on the CR.

[3] CA Due Date Extensions (DDEs) [NL-81-A01-C15], [NL-98-025-C02], [ER960265_02]

(a) Corrective Action Due Dates are met. When needed, due date extension requests include a basis for why the extension is acceptable (i.e., interim controls are in place, the procedure will not be used until next refueling outage, etc.) and a basis for why the extension is necessary.

(b) Corrective Action DDE Approval for all corrective action types should be in accordance with the guidance contained in Attachment 9.4. If the individual approving the extension in PCRS is not at the authority level designated in Attachment 9.4 for approval, then an additional discussion to document how approval was obtained should be recorded in the DDE Request. For example, approval obtained from Director Eng or approval obtained from General Manager, etc.

(c) When approving DDEs, impact to overall corrective action plan should be considered.

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 35 OF 67 Corrective Action Process 5.9 cont

[4] CA Closure (a) Upon completion of an action item, the CA assignee documents the response in PCRS.

CRG approval is required before closing the CR or a CA from the CR to a Work Order.

This requirement is not applicable if the CA was issued to track an Enhancement that was not needed to correct the original condition or was not needed to address an identified cause (b) The only process that a CA or (CR) can be closed to is a Work Order (with CRG concurrence - reference 5.8[6]). The following additional guidance is provided concerning Training Evaluation Action Requests TEARs)

(1) When training performance or modification to training material is identified as corrective action in a condition report to address a cause or correct the identified condition, then the completion of the training or modification of training material must be documented in the condition report.

(2) When a CR/CA identifies training or training material modification as corrective action and a TEAR is written to accomplish the activity; if the TEAR process determines no training or modification is required, THEN the condition report action plan approval authority (CRG, CARB, or Responsible Manager) must approve the change to intent of the associated action plan. A new corrective action directing an alternate strategy to address the associated cause or correct the identified condition may be required.

(3) Performance of Training or modification to training material properly identified as an Enhancement, as defined in 3.0[22], may be addressed by referencing a TEAR and not followed to completion through the corrective action process. The Enhancement justification and TEAR number should be referenced in the closure to ensure traceability (c) CA Assigner or CA Assignee, when permitted as described in Step 5.9 [2] (o), reviews each completed action and verifies that the required action is complete and any additional actions are planned. This includes: [ANSI N45.2.12 Section 4.5.2.4], [ANSI N45.2.12, Section 3.3.7], [P7239], [CR-HQN-2009-1107, NRC Order EA-09-060]

  • Ensuring that the response is adequate, answers all aspects of the assigned action, and the intent of the action is met.
  • If a change in intent of a Corrective Action plan is necessary, the change should be coordinated with the Responsible Manager (and CARB, if CARB is applicable) and documented.
  • Evaluation of the adequacy of the response to a CA shall be performed by safeguard qualified personnel when additional safeguards information is required to describe information in the CA.

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 36 OF 67 Corrective Action Process 5.9[4] (c) cont

  • Ensuring all the requirements of step 5.9[1] (g) are met when additional safeguards information is required to describe information in the CA.
  • Issuing, in PCRS, any follow-up or additional actions that are documented in the response or documenting why the recommendation is not needed.
  • Ensuring that CA closure is timely commensurate with safety significance of the identified issue
  • Ensuring that the CA is not closed to a promise of future action.
  • Ensuring that the CA is not closed to an unapproved process.

o CRG approval is required before closing a CA to a Work Order.

o This requirement is not applicable if the CA was issued to track an Enhancement that was not needed to correct the original condition or was not needed to address an identified cause.

o CAPRs, actions to correct Operable-DNC or Operable-Comp Measures conditions, and Category A CR actions (except Enhancements), may not be closed to other processes and must remain in the corrective action process until resolved.

  • Ensuring any Effectiveness Review Learning Organization documents are initiated when applicable
  • Ensuring that electronic copies of any documents needed to understand, clarify, or validate completion of the corrective action responses are attached to the response. (Those attachments must be in either MS Word or PDF format.)

(d) If the action taken is adequate, the CA is closed in PCRS.

(1) If the action taken is inadequate the response is revised until considered adequate for approval, or additional CAs are issued.

(2) Changes to actions should have the same level of review as the original actions (e.g., approval by CARB). If additional CAs are issued, the original CA may be closed with a notation that additional CAs were issued.

(3) If additional corrective actions are identified, appropriate CAs are generated in PCRS.

(e) Closing an open CA in one CR to another CR should be handled as described in Step 5.10 [1] (g).

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 37 OF 67 Corrective Action Process 5.9 cont

[5] CR Interim and Periodic Reviews [SOER 10-2 Rec 1]

(a) Each open CR associated with Safety Related equipment will be reviewed at approximately six months from initial assignment date. This review will be documented in a CA assigned to the CR owner and will include at least the following items:

(1) Verification that the action plan documented in PCRS will correct the condition (2) Document expected CR Closure date based on remaining needed actions, (3) Verification, for equipment related CRs that the documented operability/functionality position remains valid for the current condition of the equipment and is expected to remain valid for the duration of the action plan.

Initiate a new CR if the current operability/functionality position is questionable.

(4) Verification that administrative performance within the corrective action process has been acceptable to date. (Appropriate approval levels and justifications for DDEs are documented; LTCAs are appropriately flagged, etc.)

(5) Verification that the risk of not correcting the condition is acceptable for the duration of the action plan, (6) Approval of these reviews and approval for the CR to remain open beyond six months has been obtained and documented from a director level or above.

(7) Attachment 9.8 is provided to facilitate the review and approval process. It can be used if desired. The expectation is to capture the discussion points of that form in a CA, DDE request or initial CA assignment as appropriate. The form itself need not be used, but all points applicable must be addressed and the guidance of 5.9[5] (a) and (b) must be followed as applicable.

(b) At least once per year, following the initial review, each open CR associated with Safety Related equipment will be reviewed. This review will be documented in a corrective action and will include as a minimum the same items as the interim review above, and may be accomplished by a documented verification of the previous review.

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 38 OF 67 Corrective Action Process 5.10 CONDITION REPORT CLOSURE [P15552], [P4669] [CAPR 00734434.01], [CAPR CR-PLP-2009-05938],

[ANSI N45.2.13 9.2 S1a, b, c, d]

[1] Condition Report Closure - Responsible Manager [P9849]

(a) When all CR actions are complete the Responsible Manager shall approve the closure of all Category A and B CRs assigned to their department. While the department manager is ultimately accountable to ensure this closure activity is satisfactorily completed, he/she can delegate necessary tasks as required to support this closure to staff within their department. Accountability for proper and complete closure always remains with that Responsible Manager.

(b) The Responsible Manager or designee should perform CR closure review for Category C CRs.

(c) For Safeguards CRs, the Responsible Manager closure review shall be performed by safeguard qualified personnel. [CR-HQN-2009-1107, NRC Order EA-09-060]

(d) The closure review by the Responsible Manager (or designee for Category C CRs),

may be documented in the last CA closed from a CR. If the closure is not readily apparent and documented, then CA&A may notify the Responsible Manager that a closure review is necessary. This notification may be in the form of a CR Closure Review CA in PCRS. The Responsible Manager, or designee, reviews the CR to make a recommendation for closure using the following criteria as applicable: [P9849]

  • The root cause or apparent cause is valid.
  • The specific condition is corrected or resolved.
  • Overall plant safety is not inadvertently degraded.
  • Generic implications of the identified condition are considered, as appropriate, including generic applicability to other departments and Entergy Sites.
  • Actions were taken to preclude repetition, as appropriate.
  • Any potential operability/functionality or reportability issue(s) identified during the resolution of the condition has been appropriately addressed.
  • All corrective action items are completed.
  • No safeguards information or proprietary documents are contained in the CR documentation.
  • Effectiveness Review actions have been initiated, when applicable.

(e) If the CR is not adequate for closure, the Responsible Manager will issue any additional actions to complete the corrective action. The issuance of additional actions will take the CR out of the closure process.

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 39 OF 67 Corrective Action Process 5.10 [1] cont (f) If the condition report is adequate for closure the Responsible Manager recommends and documents final closure of the condition report.

(g) When an open CR is closed to another existing CR, the following requirements should be met:

  • The CR being closed is the same or lower Category level than the existing CR.

Otherwise CRG concurrence is required.

  • The owner of the CR to be closed will obtain concurrence from the owner (Responsible Manager) of the CR to remain open that the open CR will be allowed to resolve the condition identified in the CR that will be closed.
  • The owner of the CR to be closed should ensure a CA is assigned to the owner of the CR remaining open stating that the CR has been closed to the CR remaining open and that the CR being closed must be addressed within the CR remaining open.

(h) Closing an open CA in one CR to another CR should be done as described in 5.10[1]

(g).

(i) An independent closure review is performed for all significant CRs prior to the CA&A closeout review (Quality Check) and CR closure. CA&A normally performs this independent closure review to the same standards/requirements applicable for the RM closure review, but a subject matter expert from a department (or Site) other than the Responsible Managers may be assigned to complete this review if warranted (j) An independent closure review is not required for non-significant CRs prior to the DPIC /

CA&A closeout review (Quality Check) and CR closure. The documented RM closure review is adequate authorization for processing and closure of the CR by DPIC / CA&A as allowed per the requirements of this section

[2] Condition Report Closure (a) DPICs are allowed to perform the CR closeout review (CR Quality check) and close Non-CARB B - Lower Tier and C level CRs. Otherwise CA&A performs this function (e.g. A and B-Higher Tier level CRs as well as B-Lower Tier CRs that were approved by CARB). Also, CA&A may perform this function as a backup for DPICs as required.

(b) General requirements for CR closeout review and CR closure (1) For Safeguards CRs, closure / closeout reviews shall be performed by safeguard qualified personnel. [CR-HQN-2009-1107, NRC Order EA-09-060]

(2) Upon receipt of response from the Responsible Manager stating that the CR is ready for closure the Manager, CA&A (or Manager CA&A Projects at headquarters) or designee, or DPIC ensures any applicable independent review and closure reviews of the CR are performed as appropriate.

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 40 OF 67 Corrective Action Process 5.10[2] (d) cont (3) If the CR closeout review determines that the condition report is adequate for closure, then the CR is closed in PCRS.

(4) If the CR closeout review determines that the report is not adequate for closure, then a CA is issued using the UNSAT RESPONSE CA&A" action type, with specific recommendations or identified discrepancies that need further review

a. Due dates for UNSAT RESPONSE CA&A" actions are usually 30 days from the date of issuance. UNSAT RESPONSE CA&A" actions do not require the concurrence of the manager being assigned the action
b. UNSAT RESPONSE CA&A" actions are issued to the Responsible Manager of the CR to evaluate the specific recommendations or identified discrepancies. Based on the evaluation results, additional actions are issued or a documented response is provided as to why no additional actions are necessary.
c. If a satisfactory response cannot be obtained for adequate closure of the CR then the issue is resolved at the appropriate level of management (c) During the closeout review process, the results of the root cause or apparent cause evaluation is reviewed and the associated trend codes are adjusted if necessary (d) If the CR was assigned to a Responsible Manager for correction of a condition, CRG approval is required before closing the CR or a CA in the CR to a Work Order. This requirement is not applicable if the CA was issued to track an Enhancement that was not needed to correct the original condition or was not needed to address an identified cause.

(1) CAPRs, actions to correct Operable-DNC or Operable-Comp Measures conditions, and Category A CR actions (except Enhancements), may not be closed to other processes and must remain in the corrective action process until resolved.

[3] EN-LI-102-02, CR Closure Quality, is available as a closure review tool for Responsible Managers, CA&A, and DPICs.

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 41 OF 67 Corrective Action Process 5.11 PROGRAM OVERSIGHT [NL-88-062-C02], [NL-97-134-C04], [NL-98-025-C02]

[1] CA&A reports status of the condition reporting process (e.g., the number of open condition reports, open corrective actions, late corrective actions) monthly. [P5085]

[2] A computerized reporting tool is provided with PCRS. This reporting tool provides up to date reports and queries that allow plant personnel to stay abreast of the status of their condition reports and corrective actions.

[3] The corrective action program is periodically evaluated through audit & assessment processes. A focused self-assessment is performed on Corrective Action Process approximately every two years. [P7237]

6.0 INTERFACES

[1] NMM EN-DC-153, Preventive Maintenance Component Classification

[2] NMM EN-EC-100, Guidelines for Implementation of the Employee Concerns Program

[3] NMM EN-HU-101, Human Performance Procedure

[4] NMM EN-LI-102-02, CR Closure Quality

[5] NMM EN-LI-108, Event Notification and Reportability

[6] NMM EN-LI-118, Root Cause Analysis Process [SOER 83-07, Recommendation 2], [SOER 92-01 Recommended CA 4A]

[7] NMM EN-LI-119, Apparent Cause Evaluation (ACE) Process [SOER 83-07, Recommendation 2],

[SOER 92-01 Recommended CA 4A]

[8] NMM EN-LI-119-01, Equipment Failure Evaluation

[9] NMM EN-LI-121, Entergy Trending Process

[10] NMM EN-MP-120, Material Receipt

[11] NMM EN-OP-104, Operability Determination Process

[12] NMM EN-FAP-OP-009, Tagging Performance Indicator Program

[13] NMM EN-NS-204: Protection of Unclassified Safeguards Information

[14] NMM EN-QV-109, Audit Process

[15] NMM EN-AD-101: Procedure Process

[16] EN-PL-155, Entergy Nuclear Change Management

[17] Significance Determination Process (SDP)

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 42 OF 67 Corrective Action Process 7.0 RECORDS

[1] CA&A transmits closed CRs for retention in accordance with applicable site procedures.

After CRs are closed and entered into the permanent document management system, they should not be re-opened. However, a CR may be administratively re-opened in PCRS to add non Quality record related information for ease of future research, in the trend section, reference section, equipment section, or Administrative section. Only trend coding, reference items or equipment identification information can be updated / corrected. Then the CR will be immediately re-closed. Otherwise, if information becomes available that indicates additional work is required for a CR in the permanent document storage system, a new CR should be initiated. [QAPM B.15.a], [10 CFR 73.71 A.5], [P15297], [P757], [ANSI N45.2.12], [P14653]

8.0 SITE SPECIFIC COMMITMENTS Step Site Document Commitment Number or Reference

[1] ANO Commitment P4997

[2] ANO Commitment P7531

[3] ANO Commitment P15552

[4] ANO Commitment P2993

[5] ANO Commitment P5431

[6] ANO Commitment P3098

[7] ANO Commitment P5085

[8] ANO Commitment P9849

[9] ANO Commitment P7239

[10] ANO Commitment P6919

[11] ANO Commitment P7237

[12] ANO Commitment P15414

[13] GGNS UFSAR 13.1.2.2 S3 P22828

[14] GGNS UFSAR 13.1.2.2 S4 P22829

[15] GGNS UFSAR 12.5.3.7 S5 P22638

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 43 OF 67 Corrective Action Process 8.0 cont.

[16] GGNS UFSAR 12.5.3.7 S6 P22639

[17] GGNS AECM 89/0162 P24458 89-17-02. Att I.IV.3

[18] GGNS AECM 90/0004 VII.A.1 P24500

[19] GGNS AECM 84/0062 83-43-03. P23977 Att I.IV. (1)

[20] GGNS AECM 84/0062 83-43-03. P23978 Att I.IV. (2)

[21] GGNS QDR 46-95 P32520

[22] GGNS ANSI-ANS 13.6/66 4.9.1 P24842 S1

[23] GGNS ANSI-ANS 13.6/66 4.9.2 P24843 S2

[24] GGNS 10CFR21.21.A.1 P17819

[25] GGNS 10CFR21.21.A.2 P17820

[26] GGNS UFSAR 8.3.1.1.4.1.2.S14, P21886, P21887, P21888 S15, S16

[27] GGNS UFSAR 8.3.1.1.4.2.13.S3, P21895, P21896, P21897 S4

[28] GGNS GIN92/03494 5.6 P33542

[29] GGNS GNRO 96/0056 96-06 P32648

[30] IP2 Commitment NL-81-A01-C15

[31] IP2 Commitment NL-88-062-C02

[32] IP2 Commitment NL-97-084-C07

[33] IP2 Commitment NL-97-084-C13

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 44 OF 67 Corrective Action Process 8.0 cont.

[34] IP2 Commitment NL-97-137-C04

[35] IP2 Commitment NL-98-025-C02

[36] IP2 Commitment NL-98-066-C024

[37] IP2 Commitment NL-98-066-C040

[38] IP2 Commitment NL-98-066-C041

[39] IP2 Commitment PD-77-234-C02

[40] IP2 Commitment PD-88-028-C21

[41] IP2 Commitment PD-97-037-C03

[42] IP2 Commitment RA-78-A05-C06

[43] IP3 Commitment COMM-93-04786

[44] JAF Commitment JAFP-91-0834

[45] JAF SOER 83-07 Recommendation 2

[46] JAF SOER 92-01 Recommended Corrective Action 4A

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 45 OF 67 Corrective Action Process 8.0 cont.

[47] PLP Commitment CAPR 00734434.01

[48] PLP Commitment CR-PLP-2007-1243

[49] RBS Commitment P13307

[50] VY Commitment AUDIT RPT 9617-01

[51] VY Commitment ER960078_02

[52] VY Commitment ER960265_02

[53] VY Commitment ER970230

[54] VY Commitment ER20032022_01

[55] VY Commitment ER20031761_02

[56] VY Commitment ER20031910_12

[57] VY Commitment Gentletr9118R1

[58] VY Commitment INPO93OE21TP3

[59] VY Commitment INS938OTP2

[60] VY Commitment INS9620004

[61] VY Commitment TREND92TP4

[62] VY Commitment ER20031637_01

[63] VY Commitment INF9607_01

[64] WF3 Commitment P5110

[65] WF3 Commitment P15297

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 46 OF 67 Corrective Action Process 8.0 cont.

[66] WF3 Commitment P16529

[67] WF3 ANSI N13.6.1.7 P15005

[68] WF3 Commitment P17707

[69] WF3 Commitment P17726

[70] WF3 Commitment P20277

[71] WF3 Commitment P21439

[72] WF3 Commitment P21440

[73] WF3 10 CFR 21.21 A P21693

[74] WF3 10 CFR 21.21 C P21700

[75] WF3 Commitment P22593

[76] WF3 Commitment P23035

[77] WF3 Commitment P23038

[78] WF3 10 CFR 21.51 A P757

[79] WF3 Commitment P4669

[80] WF3 Commitment P22362 9.0 ATTACHMENTS 9.1 CONDITION REPORT CLASSIFICATION/CATEGORY 9.2 EXAMPLES OF ADVERSE CONDITIONS 9.3 MANUAL CR INITIATION 9.4 CORRECTIVE ACTION PROCESSING GUIDELINES 9.5 ENTERGY FLEET LEARNING REVIEW PROCESS 9.6 GUIDELINES FOR CLASSIFICATION OF CRs ON LOWER LEVEL EQUIPMENT ISSUES 9.7 TYPICAL NONCONFORMANCE TAG 9.8 CR INTERIM AND PERIODIC REVIEW FORM 9.9 LTCA CLASSIFICATION FORM 9.10 CR ASSIGNMENT AND LIFE CYCLE PROCESS MAP

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 47 OF 67 Corrective Action Process ATTACHMENT 9.1 CONDITION REPORT CLASSIFICATIONS / CATEGORY Sheet 1 of 6 [P5431], [P6919], [QAPM A.6.e], [ANSI N45.2.13 9.2 S1a, b, c, d]

Corrective Action Review Board (CARB):

The Condition Review Group (CRG) is responsible for determining that a condition report contains an issue that warrants CARB oversight. The purpose of CARB oversight is to ensure the condition reports are evaluated in-depth and well documented. CARB oversight includes approval of the final cause determination and the corrective action plan. CARB oversight is assigned for all Category A, Significant condition reports and may be assigned for Category B, Non-significant condition reports. The following guidance is provided to assist CRG in the determination of CARB assignment:

s Condition reports with cross-disciplinary (across more than one department) aspects to them.

s Condition reports with cross human performance aspects.

s Condition reports with cross organizational aspects.

s Condition reports important to nuclear, public, or personnel safety s Condition reports important to generation capability s Condition report events with generic implications s Condition reports on equipment reliability applicability items impacting:

  • Capability factor
  • Forced loss rate
  • Unplanned LCO entry
  • Dose
  • Maintenance rule functional failure
  • Chronic system or component failure s CRs on training programs which are determined to meet the criteria for a Finding per the Measures for Judgment contained in ACAD 02-001. Note: A Fleet Training Assessment Challenge Board will be convened at the Training Directors discretion to review ACE or RCE results related to training assessment findings prior to their presentation to CARB.

The following classification guidance is subject to CRG discretion. The CRG maintains the authority to deviate from this guidance, as warranted, so long as resolutions of Adverse Conditions are documented in the Corrective Action program. .

Significant classification is the highest and most important. In most cases, significant events are the result of multiple barrier failures or programmatic breakdowns. There is considerably more investigation into the cause of the identified condition.

  • Category A - An adverse condition classified as significant and requires a Root Cause and actions to preclude repetition.

Condition meets one of the significant definitions. Typically, the condition is viewed as applicable to 10CFR50, requiring cause determination, correction of adverse condition and corrective actions to preclude repetition. Root Cause Evaluations should be completed within 30 days.

-For Human Performance/Process issues:

1. Does the identified problem meet the Human Performance Event Criteria? (see HU-101,Attachment 9.1) If yes then the CRG should consider classifying the CR as Significant.

-For Tagging Issues (Tagging error classification is defined in EN-FAP-OP-009)

2. Level I Tagging issue - Where no barriers were present and event is significant a Cat. A CR RCA may be applicable the CRG should consider classifying the CR as Significant.

-For Training issues:

1. Condition reports for Training Assessment Areas for Improvement (AFI as defined by EN LI-104) which are determined to meet the criteria for a Finding per the Measures for Judgment contained in ACAD 02-001 should be evaluated through a root cause process.

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 48 OF 67 Corrective Action Process ATTACHMENT 9.1 CONDITION REPORT CLASSIFICATIONS / CATEGORY Sheet 2 of 6 Non-Significant condition reports document problems for which a repeat occurrence (while always undesirable) can be tolerated.

  • Category B - An adverse condition classified as non-significant and assigned to a Responsible Manager for documentation of apparent cause, corrective actions taken to correct the condition and to address the apparent cause(s). This CR may require an Apparent Cause Evaluation / Equipment Failure Evaluation, or a Root Cause Analysis and are performed as either Higher Tier or Lower Tier type as determined by the CRG.

Condition does not meet the significant definition. Usually, Category B conditions are Conditions Adverse to Quality and 10CFR50 applicable. However, since they are not significant, 10CFR50 only requires prompt identification and correction. Notwithstanding, the CRG views a Category B condition to be more than a broke-fix issue. In addition to correcting the identified deficiency, the Category B Condition Report should:

1. Determine and document the apparent cause of deficiency.
2. Determine and document the action plan to eliminate identified causes of the condition thereby reducing likelihood of condition repetition.

Category B designation should be prudently used to ensure a value added resource expenditure. Apparent Cause Evaluations / Equipment Failure Evaluations should be done within 30 days.

The following guidance (for both Equipment Failure Evaluations and Human Performance/Process issues) is provided as a tool to further help differentiate B level CRs from C level CRs after a determination is made that the condition does not meet the criteria to be designated as a Significant CR (A). This information is only a tool and does not override the authority of the CRG to make a final decision on the classification of a CRs category.

- For Tagging Issues (Tagging error classification is defined in EN-FAP-OP-009)

1. Level I Tagging issue - Where no barriers were present requires a minimum Cat. B CR, Higher Tier ACE, based on significance of the event a Cat. A CR RCA may be applicable.
2. Level II tagging issue - Where one barrier was present requires a minimum a Cat. B CR, Lower Tier ACE based on significance of the event a Higher Tier ACE may be applicable.

-For Equipment Failure Evaluations:

1. For failures of High Critical equipment (Classification in accordance with EN-DC-153) a minimum Category B High Tier apparent cause and an EN-LI-119-01, Attachment 9.1 Equipment Failure Evaluation is recommended.
2. For failures of Low Critical equipment (Classification in accordance with EN-DC-153) a minimum Category B Lower Tier apparent cause and an EN-LI-119-01, Attachment 9.1 Equipment Failure Evaluation is recommended.
3. For equipment failure where there was an unexpected failure of safety related or important equipment

[ER20031910_12]

4. If the equipment failure is of a repeated occurrence such that it is prudent to determine why it failed and take action to preclude repetition.
5. Additional Significance classification guidance is provided in Attachment 9.6 for equipment related CRs that do not screen as Category A or B level CRs.

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 49 OF 67 Corrective Action Process ATTACHMENT 9.1 CONDITION REPORT CLASSIFICATIONS / CATEGORY Sheet 3 of 6

-For Human Performance/Process issues:

1. Does the identified problem meet the Human Error threshold? (see HU-101, Attachment 9.2)
2. Is the identified problem a repetitive issue that demands a more aggressive approach to eliminate the issue? Is continuing to treat a repetitive problem as a broke/fix still prudent?
3. Is it prudent to not only fix the identified problem, but also to determine/document cause(s) of the problem and determine/document an action plan to fix cause(s)?

-For Quality Assurance Issues:

1. Condition Reports for Quality Assurance (QA) Findings (as defined by EN-QV-109).
  • Category C - An adverse condition classified as non-significant or a non-adverse condition assigned to a Responsible Manager for investigation and correction. A condition that has or would have minimal effect on the safe or reliable operation of the plant or personnel. The safety significance of the occurrence is sufficiently minor that an apparent cause determination is not required. Required action need only return the equipment or process to an acceptable status. Conditions in this category are frequently referred to as broke/fix. See Attachment 9.6.

A Category C condition does not meet definition of significant. However, it may be a Condition Adverse to Quality and 10CFR50 applicable (prompt identification and correction). The desired resolution is correction of the identified problem. While determination of cause is often required to fix a problem, no formal documentation of cause is required. Repeat occurrence of the problem is viewed as acceptable.

-For Equipment Failure Evaluations:

Additional Significance classification guidance is provided in Attachment 9.6 for equipment related CRs that do not screen as Category A or B level CRs.

  • Category D - No tracking of corrective actions is required and the CR may be closed. For example the condition has been corrected, closed to a Work Order, closed to an existing CR, or is below CR threshold.

Adverse Conditions (and Non-Adverse conditions at the discretion of the CRG) which would not exceed the criteria for a category C CR may be closed in one of the three following ways:

Category D Close to WMS Category D Close to CR Category D Condition Corrected (when supporting documentation is provided)

CRs identifying conditions which are below the level of Adverse Conditions as defined in 3.0[2] may be classified as Category D and closed in the following ways:

Category D-- Actions Taken Category D -- Close Reference Category D -- Review for Emerging Trend Category D - Below Threshold Note: In order to ensure appropriate oversight and independence, the Quality Assurance (QA) organization has the right to determine if a QA identified condition is a Condition Adverse to Quality or a Significant Condition Adverse to Quality. In cases where the CRG does not concur that a QA identified condition is a Significant Condition Adverse to Quality, the Director, Oversight has the authority to overrule the CRG.

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 50 OF 67 Corrective Action Process ATTACHMENT 9.1 CONDITION REPORT CLASSIFICATIONS / CATEGORY Sheet 4 of 6 Standardize Significance Level and Classification Codes for CR Assignment Tab Sig CLASSIFICATION_CODE CLASSIFICATION_DESC A RCA CRG Directs a Root Cause Analysis B HT-ACE CARB CRG Directs CARB Review B HT-ACE CRG Directs a Higher Tier ACE B LT-ACE CARB CRG Directs CARB Review B LT-ACE CRG Directs a Lower Tier ACE C CORRECT/ADDRESS CRG Directs Correct/Address Identified Conditions D CLOSE TO CR CRG Directs CR to Close to Another CR D CLOSE TO WMS CRG Directs CR to Close to An Open Work Order D CONDITION CORRECTED CRG Directs CR - Condition Corrected / Documented D ACTIONS TAKEN CRG Directs CR to Close - Sufficient Actions Taken / Documented D REVIEW EMERG TREND CRG Directs CR to Close - Still Reviewed As Part of Trending Process D CLOSE REFERENCE CRG Directs CR to Close - Listing # to Address the item D BELOW THRESHOLD CRG Directs CR to Close - No Condition Identified/Exists or Below Threshold D VOID/DUPLICATE CR CRG Directs CR to Close - Void (Cancel) or Duplicate of Another CR The following is a guidance tool for determining the CR Categorization. It allows for more consistency in Categorization of Condition Reports. To use this tool, first select the closest fit under Severity Levels, then choose the best fit under Frequency Levels. If more than one level fits select the higher level. Finally, use the matrix to find the recommended CR categorization, recognizing that CRG discretion may be needed in final determination.

Severity Levels

1. Condition that:
  • Is classified as a Significant (Level 1 or 2) Reactivity Management Event,
  • Results in E-Plan declaration, regulatory intervention or significant public interest,
  • Results in an industrial related fatality, severe injury requiring transportation off site,
  • Results in major system, component, or structure damage or loss,
  • Affects more than one department,
  • Is deemed a near miss to catastrophic consequences,
  • Results in a loss of production (>10%),
  • Identifies a problem that meets the Human Performance Event Criteria (see EN-HU-101 Attachment 9.1).

When a CR identifies a Human Performance Event the CRG should consider classifying the CR as Significant.

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 51 OF 67 Corrective Action Process ATTACHMENT 9.1 CONDITION REPORT CLASSIFICATIONS / CATEGORY Sheet 5 of 6

2. Condition that does not meet Severity Level 1 criteria, but does:
  • Result in a reportable event pursuant to 10CFR21, 50.72, 50.73, or other NRC reporting criteria
  • Identify a Operable-DNC or Operable-Comp Measures condition
  • Result in unplanned events or failure impacting the function of a structure, system, or component
  • Identify errors that demonstrate fundamental misunderstandings of, or noncompliance with, procedural or regulatory requirements
  • Result in the loss of a High Risk Maintenance Rule function or a failure of a High Critical component (see EN-DC-153)
  • Result in > 1 day delay of planned LCO,
  • Identify an equipment deficiency that adversely impacts NRC or WANO Performance Indicators
  • Result in a reportable event pursuant to NERC Standard EOP-004-1, Attachment 2 Table 1, Item 5

[consequential physical sabotage, terrorism, or vandalism to major electrical systems].

  • Result in a reportable event pursuant to NERC Standard EOP-004-1, Attachment 2 Table 1, Item 6

[consequential cyber sabotage, terrorism, or vandalism.].

  • Result in an injury that is classified as a lost time accident,
  • Result in a Human Performance Clock reset (see EN-HU-101)
  • Result in an Adverse Trend designation by the CRG
  • Identify an equipment failure of repetitive nature such that it is prudent to determine why
  • Identify a Corporate or External AFI,
  • May affect more than one department.
3. Condition that does not meet Severity Level 1 or 2 criteria, but does:
  • Result in minor system damage, minor injury, or other event generally confined to one department,
  • Identify a Corporate or External Negative Observation, or an Internal Self-Assessment AFI,
  • Result in a reportable event pursuant to NERC Standard EOP-004-1, Attachment 2 Table 1, Item 5 [non consequential physical sabotage, terrorism, or vandalism to major electrical systems].
  • Result in a reportable event pursuant to NERC Standard EOP-004-1, Attachment 2 Table 1, Item 5 [non consequential cyber sabotage, terrorism, or vandalism].
  • Identify a problem that meets the Human Error threshold (see EN-HU-101 Attachment 9.2).
  • Abnormal and/or long term unexplained plant conditions [SOER 2-04 Rec 3]
4. Less than the above.

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 52 OF 67 Corrective Action Process ATTACHMENT 9.1 CONDITION REPORT CLASSIFICATIONS / CATEGORY Sheet 6 of6 Frequency Levels Consider fleet implications that could indicate an Extent of Condition or Generic Implication review is needed when selecting the appropriate Frequency Level.

I. Likely to occur often or has occurred often during the life of an individual item, system, process or very often in operation of a large number of similar items.

II. Likely to occur several times or has occurred several times in the life of an individual item, system, process, or often in operation of a large number of similar items.

III. Likely or possible to occur sometime in the life of an individual item, system, process, or will likely or reasonably be expected to occur in the life of a large number of similar components.

IV. So unlikely to occur in the life of an individual item, system, or process, that it may be assumed not to be experienced, or it may be possible, but unlikely, to occur in the life of a large number of similar components.

CR Category Matrix Guideline CR Grade Freq. I Freq. II Freq. III Freq. IV Severity 1 A A A A Severity 2 A B B C Severity 3 B C* C* C*

Severity 4 C* D D D

  • Category D is chosen if the condition is corrected and documented, and no further analysis or corrective actions are warranted.
  • Category D is chosen for relatively straightforward conditions when it is appropriate to close them to a work order or another open condition report.
  • Attachment 9.6 contains additional guidance on when it is appropriate to close relatively straightforward equipment relate CRs to a work order OR when it is appropriate to just reference the work order.

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 53 OF 67 Corrective Action Process ATTACHMENT 9.2 EXAMPLES OF ADVERSE CONDITIONS Sheet 1 of 3 [P3098], [ANSI N45.2.11, Section 9.2], [P7531], [P15005], [P21693], [P21700] [P22638] [P22639]

[P24842] [P24843] [P17819] [P17820], [ANSI N45.2.11 9 S1-S4]

Examples of Adverse Conditions Employees are encouraged to report a broad range of problems and potential problems. However, adverse conditions are required to be documented on CRs. The conditions described in this attachment are examples of adverse conditions. This list is not necessarily all-inclusive. Any adverse condition as defined in Section 3.0 should be documented on a Condition Report.

1. Operational Conditions
  • Unplanned actuation of RPS, ESF, or Emergency Power Systems
  • Potentially reportable conditions
  • Events or conditions that could negatively impact reliability or availability
  • Unplanned conditions or events that affect reactivity
  • Unplanned entry or failure to enter a LCO (includes performance outside acceptance criteria)
  • Grid Disturbance including protective relay or equipment failures, or mis-operations
2. Radiological Conditions
  • Any exposures that exceed allowable administrative or regulatory limits.
  • Lost or missing licensed radioactive material
  • Unplanned radioactive release
  • Violations of procedures or policies or regulations that are intended to satisfy 10CFR19, 10CFR20 or other applicable federal regulations
  • Abnormally high radiation or airborne radioactivity levels
3. Security Conditions
  • Potentially Reportable events (one hour report) per 10CFR73.71
  • Programmatic failure(s), recurring events or human errors that require further management attention
  • Other security events that could reduce the overall effectiveness of the security program
  • Adverse trends in the number of Security events
  • Potential or confirmed tampering, terrorism, vandalism or sabotage.
4. Industrial Safety Conditions
  • Lost time accident
  • Near miss Incident
  • OSHA Recordable event
  • Recurring minor injuries of similar cause judged to need further evaluation
  • Conditions which could create a significant personnel safety hazard
5. Material Conditions (not installed)
  • Deficient components issued or ready-for-issue for which elements of the QA program have been applied.

Deficient components are those that have not met design or procurement specifications.

  • Deficiency reported by vendor bulletin when confirmed that the product has been issued or is ready for issue at the station.
  • Conditional release of materials, parts, or components, for installation and testing, which have not been fully accepted under the Quality Assurance program.

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 54 OF 67 Corrective Action Process ATTACHMENT 9.2 EXAMPLES OF ADVERSE CONDITIONS Sheet 2 of 3

6. Structures, Systems or Components Conditions (Installed) [ER20031637_01], [QDR 200-95/RCDL 95-20, Long Term Action 2.a.1]

Conditions affecting a safety related, quality-related or trip sensitive system caused by a deficiency in characteristic, documentation or procedure that renders the quality of an item unacceptable or indeterminate.

Examples include, but may not be limited to:

  • Recurring or generic failure
  • Item has a defect as a result of design or manufacturing process that prevents or could have prevented the component from performing its intended function
  • Item fails testing performed to prove environmental or seismic design conformance
  • Deviation from prescribed processing or inspection
  • Documentation not available to confirm required inspections or tests
  • Deficiency reported by vendor bulletin
  • M&TE: A condition report is required when the non-conforming condition is related to the calibration of M&TE and the following conditions exist:

- The condition cannot be resolved through a record search.

- It cannot be verified that plant hardware or system performance is not affected and no further action is required.

  • Oil leaks or spills that could increase the potential for a plant fire or adversely affect equipment operation.

The Fire Prevention Coordinator, Fire Protection Engineer, or System Engineer should be consulted to evaluate the potential impact. This includes events such as, but not limited to: oil wetted/fouled insulation or equipment, and leaks and spills involving liquids such as fuel oil, lube oil, fluid, etc. [P15414]

  • Chemical or other leaks that could potentially impact plant operations or the environment.
  • Missed or late preventive maintenance task required to satisfy technical specifications, environmental qualification or station commitments.
  • Any code repairs on failed components that are performed to repair a component to operable status.
  • Conditions where nuclear fuel defects exist or are suspected.
  • Maintenance Rule Category A1 items
  • Conditions that degrade the ability of a Regulatory required installed fire protection system or component to perform its intended function. This includes degraded fire barriers and their sub components (penetration seals, fire doors and dampers), and fire detection and suppression systems. Additional components include Appendix R fire wrap and emergency lighting, and any Reactor Coolant Pump (PWR) oil collection system. [P15414]
7. Welding Related Conditions
  • Welds not made in accordance with applicable procedures
  • Welds made by unqualified welders
  • Welds made with improper or undocumented filler material
  • Welds on which specified hold points are bypassed
  • Welds which do not meet applicable code or job specific requirements and on which the final weld inspection and NDE have been completed/accepted

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 55 OF 67 Corrective Action Process ATTACHMENT 9.2 EXAMPLES OF ADVERSE CONDITIONS Sheet 3 of 3

8. Deviations From Design/Licensing Basis Conditions
  • Functional inaccuracies in safety-related documents (procedures, technical manuals, work plans, drawings, etc.) which could degrade plant safety [P4997], [P22593]
  • Failure to comply with design or license basis commitments as described in the SAR, TS, TRM, etc.
  • Inadequate Technical Specifications
  • Conditions that may require written or telephone notifications to the NRC, excluding routine reports.
  • SSCs or physical conditions that deviate from Design / License basis assumptions
9. Administrative or Work Practice Conditions
  • Performance of activities on the wrong equipment
  • Mispositioned equipment
  • Errors or deficiency in the design process, including computer programs.
  • Tagging errors
10. Engineering Related Conditions An error or omission in an engineering product which, if uncorrected could result in any of the following. These criteria apply even if the error was discovered before the product was finalized or issued for use.
  • significantly reduces the margin to safety as defined by Technical Specifications or the FSAR,
  • renders equipment important to safety inoperable or incapable of performing intended safety functions
  • reflects a significant procedural non-compliance or programmatic breakdown.
11. Regulatory Issues
  • potential or actual NRC violations
  • potential or actual INPO Areas for Improvement (AFIs)
12. Training Issues
  • Any condition which adversely impacts training related regulatory compliance.
  • Any condition which has the potential to adversely impact training program accreditation.
  • Areas for Improvement, Findings, or other weaknesses identified in self-assessments, QA audits, NRC inspections, or INPO evaluations.
  • Training procedure non-compliance.
  • Any adverse trends identified through routine monitoring of training-related data, condition reports, assessment findings, etc.
  • Loss of electrical power to the Training Center that impacts training.
  • Unplanned fire system actuations that impact training.
  • Simulator downtime results in greater than 15 minutes of lost scheduled training time.
  • Training facilities in disrepair for extended periods.
  • A human performance event or error that results in a reset of the Training Department Human Performance Clock, or the reset of another departments clock for training-related events (for example, student absence or tardiness).
  • Any condition that requires that commitments be made to an outside organization.
  • Any condition or event which adversely impacts the personnel safety of the training staff or students.
  • Work performed by an unqualified worker.
13. Other Issues
  • Abnormal plant conditions or indications that cannot be readily explained [SOER 2-04 Rec 3]
  • Long-term unexplained plant conditions [SOER 2-04 Rec 3]

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 56 OF 67 Corrective Action Process ATTACHMENT 9.3 MANUAL CR I NITIATION Sheet 1 of 4 NOTE Sample forms used to implement this procedure are included in this attachment. It is not mandatory that the exact forms be used. Equivalent forms may be used, but they must contain the same or additional information. Any deletion of information must be accomplished by procedure revision.

This attachment provides a contingency method for generating, performing operability/functionality and immediate reportability determinations, and tracking Condition Reports when PCRS is not available. The Entergy Help Desk and CA&A staff should be called if a PCRS outage is experienced.

Manual operation of the Condition Reporting System is limited to the generation of Condition Reports and the documentation of operability/functionality and immediate reportability determinations/evaluations. Issuing and responding to Condition Report Corrective Actions will be postponed until PCRS is available. However, any actions required to place the plant in a safe condition, or any other emergency actions, can proceed.

1.0 Condition Report Generation (Form 1):

1.1 Any individual, who discovers a Condition, when PCRS is not available, should follow the steps of section 5.2 with the exception of writing the Condition report with PCRS.

1.2 The attached form should be used to document a Condition when PCRS is unavailable.

1.3 Take the completed form and any supporting documentation to the Control Room/Work Control Center, as appropriate. (Not applicable when generating Headquarters CRs. When generating Headquarters CRs manually, contact the Headquarters Corrective Action Coordinator).

2.0 Operability and Immediate Reportability Determinations (Form 3): (This section does not apply when generating CRs for offsite locations such as Headquarters. Results of Impact Applicability Reviews for CRs generated for offsite locations are documented on the Manual CR Continuation Form (Form 2)).

2.1 The Shift Manager/designee ensures that the manual CRs are maintained in the Control Room for periodic retrieval by CA&A and that CA&A is informed when manual CRs are ready for CA&A to pick up.

2.2 The Shift Manager/designee will perform the operability and immediate reportability.

2.3 Following the completion of the operability/functionality and immediate reportability determinations the Shift Manager/designee retains the Condition Report package for CA&A pick up.

3.0 Conversion of manual Condition Reports to PCRS:

3.1 CA&A picks up manual Condition Report packages and presents them to the CRG. CA&A communicates any immediate management actions to the affected parties.

3.2 When the PCRS becomes available, CA&A informs the Control Room and then CA&A enters the manual Condition Reports into PCRS. PCRS automatically assigns the next sequential CR number to each manual CR. The original forms are then scanned into PCRS.

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 57 OF 67 Corrective Action Process ATTACHMENT 9.3 MANUAL CR I NITIATION Sheet 2 of 4 CONDITION REPORT Manual CR NO._____________

FORM 1 PAGE _______ OF ___________

CONDITION IDENTIFICATION FORM (PRINT/TYPE, USE BLACK INK ONLY)

IDENTIFICATION OF PROBLEM For Operations Use Only (Please Print)

Originator: __________________________ Ext.: __________ Date Recd Organization: __________________________________ Time Recd Supervisor: ____________________________________

Date of Discovery: _________ Time of Discovery: ___________

CONDITION DESCRIPTION:

[Include information pertinent to operability/functionality determination.]

Work Document # (i.e., WR/WO, OD, etc.) _____________________ Other: _____________________

IMMEDIATE ACTION DESCRIPTION:

AFFECTED EQUIPMENT/DOCUMENTS/MATERIAL:

Number/Description(s)

SUGGESTED CORRECTIVE ACTION (S):

Operability/Functionality in question? Potentially reportable?

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 58 OF 67 Corrective Action Process ATTACHMENT 9.3 MANUAL CR I NITIATION Sheet 3 of 4 CONDITION REPORT CR NO.____________________

FORM 2 PAGE _______ OF __________

CONDITION REPORT CONTINUATION FORM (PRINT/TYPE, USE BLACK INK ONLY)

CONTINUATION FORM:

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 59 OF 67 Corrective Action Process ATTACHMENT 9.3 MANUAL CR I NITIATION Sheet 4 of 4 Note: This section replaces the electronic PCRS operability/functionality section of the CR only. The operability/functionality determination process (EN-OP-104) is expected to be performed & attached to this manual CR form as needed.

OPERABILITY/FUNCTIONALITY REVIEW & IMMEDIATE REPORTABILITY DETERMINATION - FORM 3 I. OPERABILITY/FUNCTIONALITY REVIEW OPERABILITY/FUNCTIONALITY EVALUATION REQUIRED NO YES IF NO - EXPLAIN WHY:

(IF NO THEN LEAVE OPERABILITY/FUNCTIONALITY EVALUATION SECTION BLANK - COMPLETE REPORTABILITY SECTION AND SIGN AS APPROVER)

II. OPERABILITY DETERMINATION OPERABILITY CODE PLANT CONDITION/MODE:

EFFECT OF THIS CONDITION ON EQUIPMENT/SYSTEM/TRAIN OPERABILITY/FUNCTIONALITY:

ADMIN - NA OPERABLE - OP EVAL EQUIPMENT FUNCTIONAL NOT REQUIRED OPERABLE-DNC EQUIPMENT NON- FUNCTIONAL OPERABLE OPERABLE-COMP MEASURES INOPERABLE INOPERABLE - OP EVAL Time Entered Operability Desc: enter or attach the required documentation per EN-OP-104 LCO ENTERED NO YES LCO NO. LCO ACTION TIME TECH SPEC/TRM ACTION STATEMENT # DATE ENTERED TIME ENTERED IMMEDIATE ACTIONS TAKEN:

III. IMMEDIATE REPORTABILITY DETERMINATION IS IMMEDIATE NRC NOTIFICATION REQUIRED? NO YES IF YES (Mark appropriate time requirement and complete this section) 1-HR RPT 4-HR RPT 8-HR RPT 24-HR RPT DATE: AND TIME: OF REPORT.

NAME OF PERSON REPORT MADE TO:

CFR REQUIREMENT: NAME OF PERSON MAKING REPORT:

NRC EVENT NO.

REACTOR POWER:  % REACTOR PRESSURE: RX / RX COOLANT TEMP 6

[(BWR ONLY) CORE FLOW X 10 lbm/HR REACTOR LEVEL in]

III. PERFORMANCE/APPROVAL PERFORMED BY: DATE/TIME:

OPERATIONS REPRESENTATIVE APPROVAL: DATE/TIME:

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 60 OF 67 CORRECTIVE ACTION PROCESS ATTACHMENT 9.4 CORRECTIVE ACTION PROCESSING GUIDELINES SHEET 1 OF 1 [AUDIT RPT 9617-01], [ER960078_02], [ER960265_02], [P16529]

NOTES:

1. These guidelines should be used when setting corrective action due dates and extension requests. The target for completion of all corrective actions and closure of the CR associated with an A, B or C Condition Report is 6 months (except for those with Long Term CAs).
2. Corrective Action Due Dates should be selected with consideration given toward:
a. The risk to plant imposed as a result of the action not being complete.
b. Due Date(s) should ensure the action is complete prior to the next potential occurrence of the problem, if possible.
3. Document GMPO, Director Site VP, or CARB Chair Person approval in DDE request when that approval is required per this attachment & that position is not the authority level for approval in PCRS.
4. The 30 day clock for Root Cause Analysis stops when the final Cat A Evaluation has been approved by CARB and the CAs have been issued.
a. When CARB approves with comments, the 30 day clock can stop IF the comments do not require bring back to CARB, CAs from the RCA have been issued AND a CA is initiated, not to exceed 4 working days, to track the comment incorporation and approval by the CARB Chairperson..
b. Extension of the action to incorporate comments and obtain approval by the CARB Chairman beyond 4 working days requires initiation of a specific Condition Report documenting the lack of timely incorporation of the comments.

Corrective Action Type Corrective Action Due Date Guideline Due Date Extension (DDE) Approval

  • For Cat A: < 30 days from CR categorization (including CARB approval of RCE)

The following DDE escalation requirements apply to any action issued in a CR Disposition

  • For Cat B: < 30 days from CR categorization (all CA Types). Document appropriate concurrence in the DDE request st (not including CARB approval of ACE) 1 : Supervisor nd 2 : Responsible Manager/Superintendent rd For Cat C: < 30 days from CR categorization 3 : GMPO/Director
  • For Cat A & B: 180 days from CR Note: Site VP approval is required for extensions that allow disposition of categorization Significant Root Causes including CARB approval to extend beyond 30 days.

Corrective Action

  • For Cat C: 180 days from CA categorization Note: CARB Chairperson approval required for ANY CARB approved CAPR related extensions Long Term Actions
  • As approved by GMPO/Director/Site VP Note: LTCA extensions require GMPO/Director or Site VP approval Human Performance * < 7 days (Outage < 3 days) from CRG assignment Error Review (HPER) or from error classification

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 61 OF 67 CORRECTIVE ACTION PROCESS ATTACHMENT 9.5 ENTERGY FLEET LEARNING REVIEW PROCESS Sheet 1 of 2

Purpose:

The Entergy Fleet Learning process enables the sharing of condition reports (CR) identifying internal significant conditions, events or issues that warrant focused sharing with other Entergy Nuclear Fleet stations using the Internal Fleet Learning Operating Experience (OE) process.

This attachment provides the Condition Review Group (CRG) and Corrective Action Review Board (CARB) the criteria and guidance for the identification of an internal significant condition, event, or issue for processing through the Internal Fleet Learning OE process.

The CRG or CARB may identify the CR for:

a. Immediate Sharing - CRs which need to be shared in a timely manner. There should be sufficient information provided in the CR to allow other sites to understand, and if necessary, act on the condition.
b. Site Sharing - condition for which the causal analysis needs to be shared
c. Fleet Learning - condition for which the causal analysis is significant enough to assign a Responsible Manager to review and to determine fleet impact.

This may be done by CRG during CR classification/assignment or CARB during approval review of RCAs or ACEs.

2.0 Scope

2.1 The Fleet Learning process should include, as a minimum, the following issues identified at a Entergy Nuclear Station:

  • Each Area for Improvement (AFI) from INPO Evaluations or WANO Peer Reviews.
  • All Nuclear Regulatory Commission (NRC) Substantive Cross-Cutting Issues.
  • All NRC violations characterized as greater then GREEN.
  • Significant events, typically Category A CRs, as deemed appropriate by CRG or CARB. Not all Category A CRs are expected to be shared using this process, however those with particularly significant consequences should be shared.
  • Other issues identified by CRG or CARB of significance. Each Training program FINDING level issue identified by an INPO Accreditation Team, or by an Entergy Self-Assessment Team.

2.2 Entergys Condition Review Group (CRG) screens and classifies all condition reports and may select condition reports identifying internal significant condition, events or issues for internal fleet learning OE processing as immediate sharing and/or evaluation results sharing.

2.3 Corrective Action Review Board (CARB) reviews/approvals all Root Cause Reports and selected Apparent Cause Evaluations and may also identify one of these condition reports not previously identified by CRG for internal fleet learning OE processing as evaluation results sharing.

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 62 OF 67 CORRECTIVE ACTION PROCESS ATTACHMENT 9.5 ENTERGY FLEET LEARNING REVIEW PROCESS Sheet 2 of 2

3.0 Details

3.1 Internal Fleet OE Initiation for Fleet Learning 3.1.1 Once CRG or CARB has determined that a condition report (CR) should be processed through the internal fleet learning OE process, CA&A ensures a corrective action is issued within the identified CR, to the site OE Coordinator(s) as follows:

3.1.1.1 For CRs that require Immediate Sharing (at CR initiation) a corrective action is issued to the OE Coordinator with a due date of <14 days, unless otherwise directed by CRG. The OE Coordinator will normally process in accordance with EN OE-100 as Code B - Useful for Site Awareness.

3.1.1.2 For CRs that require SITE SHARING a corrective action is issued to the OE Coordinator with a due date of <60 days, unless otherwise directed by CRG or CARB. The OE Coordinator will process in accordance with EN OE-100.

3.1.1.3 For CRs that require FLEET LEARNING a corrective action is issued to the OE Coordinator with a due date of <60 days, unless otherwise directed by CRG or CARB. The OE Coordinator will process in accordance with EN OE-100 as Code A-Evaluation Required A2. When closed the CA will contain the following information (provided by CRG/CARB):

s Site subject matter expert.

s Identity of the Responsible Manager that will support the Internal Fleet OE through issuing review actions, performing closure review and determination of aggregate impact to the fleet..

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 63 OF 67 CORRECTIVE ACTION PROCESS ATTACHMENT 9.6 GUIDELINES FOR CLASSIFICATION OF CRS ON L OWER LEVEL EQUIPMENT ISSUES SHEET 1 OF 1 NOTE: This guidance reflects typical classification for equipment conditions that do not screen as category A or B level CRs.

However, it does not override the CRGs authority to apply management discretion when classifying these CRs.

Is the equipment issue an Adverse Condition? Yes No Is the issue affecting Operability, Functionality, or Full Qualification of Safety/Quality Related Equipment OR is it a high or low critical component failure?

Yes No Does the issue constitute a risk to generation or an unplanned shutdown LCO? LCO?

Yes No Is the failure related to equipment needed for emergency plan or site security or negatively affects an NRC PI? Yes No Is the failure an operations aggregate issue or corrective maintenance? Yes No Does the issue constitute a credible Industrial Safety threat?

Yes No The identified problem is an Adverse Condition and should be screened as higher than CAT C when other The identified problem is not an Adverse significance guidance in this procedure is applicable.

Condition. The condition report may be Otherwise, it should be screened as Cat C. Critical screened as CAT D Close Reference the equipment failures should not be closed to the Work Order Work Request number and/or Work Order (WO) until after the EFE is completed. However, if number generated for repair. Additional completion of the Work Order (WO) is the only action tracking per this procedure is not required. needed, then the CR may be screened as CAT D subject to the requirements of Section 5.8[6] of this procedure.

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 64 OF 67 CORRECTIVE ACTION PROCESS ATTACHMENT 9.7 TYPICAL NONCONFORMANCE T AG Sheet 1 of 1

[ANSI N18.7 5.2.14] [ANSI N45.2.4 2.6 S1 S2]

Typical Nonconformance Tag

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 65 OF 67 CORRECTIVE ACTION PROCESS ATTACHMENT 9.8 CR INTERIM AND PERIODIC REVIEW F ORM SHEET 1 OF 1 [SOER 10-2 REC 1]

CR Interim and Periodic Review CR Number: _______________________ Category Level ___ A ___ B ___ C CR Owner Group: _______________________________________

CR

Description:

CR Review: (All No responses require explanation be included.)

1. Will the Interim actions taken to date adequately address the issue until all corrective actions are complete? Yes ____/ No ____
2. Will the existing corrective actions documented in the condition report, when completed, correct the condition report issue? Yes ______ / No _______
3. What is the expected CR Closure date based on remaining needed actions? DATE: ________
4. Determine if a new condition currently exists that potentially requires a re-evaluation of operability/functionality? Yes ______ / No _______ /N/A __________

If the answer is Yes, then initiate a new CR to document the concern; CR # ___________

5. Are all LI-102 requirements for corrective action administration and control being met, i.e.

justifications for Due Date Extensions valid, Long Term Corrective Actions identified, CARB approved CAPRs identified, and appropriate approvals obtained for all?

Yes _________/ No _________

6. What activity is "preventing" the condition report from being resolved and closed?
7. What risk to plant operation is imposed by the condition identified and how is risk reduced to an acceptable level for the duration of the action plan?

Review / Approval Required:

Director/GM

Title:

__________________________________ Date: ____________

(Print name & Position title)

NOTE: The expectation is to capture the discussion points of this form in a CA. The form itself need not be used, but all points applicable must be addressed.

NUCLEAR QUALITY RELATED EN-LI-102 REV. 17 MANAGEMENT MANUAL INFORMATIONAL USE PAGE 66 OF 67 CORRECTIVE ACTION PROCESS ATTACHMENT 9.9 LTCA CLASSIFICATION F ORM SHEET 1 OF 1 LTCA Classification Form Long Term CA Classification:

CR Number: _______________

CR Owner Group: ____________________________________________

CA Number: ________________ LTCA Assigned to Group: _______________________________

LTCA Classification (check ONLY one):

___ RFO/FO Reqd ____ Mod/Design Change Reqd

____ NRC Resp. Reqd ____ Multi-cycle Training Reqd Provide specific details for LTCA classification selected above.

What risk to plant operation is imposed by the condition identified and how is risk reduced to an acceptable level for the duration of the action plan?

Explain impact to condition report timeliness.

Review / Approval Required:

Director/GM

Title:

___________________________________ Date: ____________

(Print name & Position title)

NOTE: The expectation is to capture the discussion points of this form in a CA, DDE request or initial CA assignment as appropriate. The form itself need not be used, but all points applicable must be addressed.

  • -= Entergy NUCLEAR MANAGEMENT MANUAL QUALITY RELATED INFORMATIONAL USE CORRECTIVE ACTION PROCESS EN-LI-102 I

PAGE 67 OF 67 REV. 17 ATTACHMENT 9.10 CR ASSIGNMENT AND LIFE CYCLE PROCESS MAP SHEET 1 OF 1 6/24/2010 CR Assignment and Life Cycle e-=- Entergy Adverse Initiate CR in Condition PCRS Discovered Initiate CR in CR Initiator PCRSw/o CR Reviewed by CA&A and DPICs CR Screened by CRG ~ _ _...J (EN-FAP-U-001)

CR Classified and assigned to a Department for Resolution per CRG CA&AIDPIC completion and ensures Trend approves Codes entered Extensions CR Owner w/DPIC CA&A/DPIC all CAs closed and assistance reviews reviews Dept may assign CR, documents approval to close closure review to and approves CR a nd closes CR per Dept owning CR Closure EN-U-102-02 DPIC assists CR Owner w/monthly Trend Review & ......-------------------------1 Quarterly Trend Report

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