IR 05000313/2017010

NRC Confirmatory Action Letter (EA-16-124) Follow-Up Inspection Report 05000313/2017010 and 05000368/2017010

ML17117A696
Person / Time
Site:	Arkansas Nuclear
Issue date:	04/27/2017
From:	O'Keefe N NRC/RGN-IV/DRP/RPB-E
To:	Richard Anderson Entergy Operations
Neil O'Keefe
References
EA-14-008, EA-14-088, EA-16-124
Download: ML17117A696 (48)

Text

ril 27, 2017

SUBJECT:

ARKANSAS NUCLEAR ONE - NRC CONFIRMATORY ACTION LETTER (EA-16-124) FOLLOW-UP INSPECTION REPORT 05000313/2017010 AND 05000368/2017010

Dear Mr. Anderson:

On March 16, 2017, the U.S. Nuclear Regulatory Commission (NRC) inspection team reviewed your progress in implementing specific actions from the ANO Comprehensive Recovery Plan that were committed to in a Confirmatory Action Letter (CAL) dated June 17, 2016 (NRCs Agencywide Documents Access and Management System (ADAMS) Accession No.

ML16169A193) (EA-16-124). The team discussed the results of this inspection with you and other members of your staff. The team documented the results of this inspection in the enclosed inspection report.

The team reviewed Arkansas Nuclear Ones (ANO) progress in implementing the ANO Comprehensive Recovery Plan, focusing on 30 actions which ANO management had concluded were complete and had been determined to be effective. The inspection included a review of corrective actions to address the finding of substantial safety significance (Yellow) involving the failure to adequately approve the design and to load test a temporary lift assembly (EA-14-008)

and the finding of substantial safety significance (Yellow) involving the requirements for flood mitigation (EA-14-088). The attached report documents the basis for closing 25 of the 30 reviewed CAL actions inspected, as well as observations related to the stations progress in addressing those actions that were not sufficiently complete or effective to close at this time. An additional inspection for one closed action was performed to observe a load test on a specially designed temporary lifting device. The NRC will further review your development and implementation of corrective actions for these risk-significant findings during future inspections.

The NRC inspectors did not identify any findings or violations of more than minor significance. This letter, its enclosure, and your response (if any) will be made available for public inspection and copying at http://www.nrc.gov/reading-rm/adams.html and at the NRC Public Document Room in accordance with 10 CFR 2.390, Public Inspections, Exemptions, Requests for Withholding.

Sincerely,

/RA/

Neil OKeefe, Chief Project Branch E Division of Reactor Projects Docket Nos. 05000313, 05000368 License Nos.: DPR-51, NPF-6 Enclosure:

Inspection Report 05000313/2017010 and 05000368/2017010 w/Attachments:

1. Supplemental Information 2. Confirmatory Action Letter Item Status

SUNSI Review Non-Sensitive Publicly Available By: JLD/dll Sensitive Non-Publicly Available OFFICE DRP/RI DRP/PE DRS/PSI DIRS/ROE DRP/PE DNMS/FCDB DRP/SRI DRP/BC NAME RKumana BCorrell CJewett ZHollcraft JChoate LBrookhart BTindell NOKeefe SIGNATURE Not Avail /RA/ /RA/ /RA/ /RA/ /RA/ /RA/ /RA/

DATE 4/27/17 4/26/17 4/26/17 4/26/17 4/26/17 4/27/17 4/26/17 4/27/17 OFFICE NAME SIGNATURE DATE

U.S. NUCLEAR REGULATORY COMMISSION

REGION IV

Docket(s): 05000313; 05000368 License: DPR-51; NPF-6 Report: 05000313/2017010; 05000368/2017010 Licensee: Entergy Operations, Inc.

Facility: Arkansas Nuclear One, Units 1 and 2 Location: Junction of Highway 64 West and Highway 333 South Russellville, Arkansas Dates: February 27 through March 16, 2017 Team Lead: B. Tindell, Senior Resident Inspector Inspectors: L. Brookhart, Senior ISFSI Inspector J. Choate, Project Engineer B. Correll, Project Engineer Z. Hollcraft, Reactor Operations Engineer C. Jewett, Physical Security Inspector R. Kumana, Resident Inspector Approved By: N. OKeefe Chief, Project Branch E Division of Reactor Projects 1 Enclosure

SUMMARY

IR 05000313/2017010; 05000368/2017010; 02/17/17 - 03/16/17; Arkansas Nuclear One, Units and 2; Confirmatory Action Letter Follow-up Inspection.

The inspection activities described in this report were performed between February 17, 2017, and March 16, 2017, by inspectors from the NRCs Region IV and Headquarters offices and the resident inspector at ANO. This report documents no findings of significance. The NRCs program for overseeing the safe operation of commercial nuclear power reactors is described in NUREG-1649, Reactor Oversight Process.

The team reviewed 30 actions from the ANO Comprehensive Recovery Plan involving commitments made in a Confirmatory Action Letter (EA-16-124). The team concluded that 25 of the actions reviewed were complete and were effective in achieving the associated performance improvement objectives. The team also concluded that five actions were not sufficiently complete or effective to close at this time. Additional inspection was also performed for one closed action in order to observe a load test on a specially designed temporary lifting device.

No findings were identified.

REPORT DETAILS

4OA5 Other Activities

Confirmatory Action Letter Follow-up (IP 92702)

.1 Actions to Address Significant Performance Deficiencies

FP-5 Revise procedure EN-DC-329, Engineering Programs Control and Oversight, to include external and internal flood protection in the Engineering Program List.

Revise the flooding programmatic aspects of procedure EN-DC-150, Condition Monitoring of Maintenance Rule Structures. Revise EN-DC-136, Temporary Modifications, to incorporate external flood considerations.

(CR-ANO-C-2014-00259, CA-64 and CA-247)

During the 95003 supplemental inspection (NRC Inspection Report 05000313/

2016007 and 05000368/2016007, ADAMS ML16161B279), the NRC team determined that ANO had performed a comprehensive review and inspection of both units flood protection programs, including conducting extensive site walkdowns and assessments of the flood protection barriers, and had identified multiple degraded flood barriers and flood protection program deficiencies. The NRC team also concluded that corrective actions taken and planned enhanced the flood protection program by improving configuration control, design documentation, program ownership, preventive maintenance quality, maintenance process controls, and contractor oversight.

To evaluate the licensees corrective action effectiveness, the team reviewed:

• Condition Report (CR) CR-ANO-C-2014-00259, corrective action numbers CA-64 and CA-247

• Procedure EN-DC-329-ANO-RC, Engineering Programs Control and Oversight, Revision 00

• Procedure EN-DC-150, Condition Monitoring of Maintenance Rule Structures, Revision 11

• Procedure EN-DC-136, Temporary Modifications, Revision 11 The team performed interviews with the owners of this action as well as personnel responsible for implementing the procedures.

The NRC team concluded that the action to revise procedures to include internal and external flooding considerations was effective. The procedure changes created a flood protection program that was consistent with the treatment of other engineering programs and incorporated the flood protection into the Engineering Programs List, which allows the flooding protection program to be tracked and monitored at a frequency parallel to other engineering programs. The procedures also ensured that flood protection features are considered and are not adversely impacted by proposed temporary modifications.

Based on the actions taken by the licensee, data evaluated by the team, and observations performed on site, the team concluded that the actions taken to address FP-5 were effective. Therefore, FP-5 is closed.

VO-10 Evaluate span of control with regard to responsible oversight of vendors, and place actions to address identified weaknesses in the Corrective Action Program.

(CR-ANO-C-2015-02838, CA-10)

During the 95003 supplemental inspection, the NRC team determined that Entergy assigned a responsible manager for each project, and then implemented a qualification process to allow the use of supplemental supervisors to perform most supervisory duties. The NRC team concluded that actions to improve contractor oversight had not yet been fully effective and further action was needed because oversight plans for contract outage workers were inadequate, qualification requirements for contractors to act as supervisors did not have a consistent standard, and designated ANO oversight personnel lacked adequate guidance and training to perform their oversight role. ANO wrote CR-ANO-C-2015-03788 to enter all of these issues into the CAP.

To evaluate the licensees corrective action effectiveness, the team reviewed CR-ANO-C-2014-02318; CA-063; CA-067; CA-165; Procedure EN-OM-126-ANO-RC, Management and Oversight of Supplemental Personnel, Revision 1; Attachment 9.9, Oversight Structure and Span of Control, and 9.3, Vendor Oversight Plan. The team performed interviews with the owners of this action item as well as personnel responsible for implementing the procedure. The team also reviewed two recent contractor oversight plans and confirmed the licensee included Attachment 9.9, Span of Control.

The NRC team concluded that actions to improve span of control for contractor oversight were effective because span of control is defined and structured in Procedure EN-OM-126-ANO-RC, Revision 1, Attachment 9.9, and the licensee is effectively implementing the span of control requirements. The team concluded that this attachment outlined the organizational structure and number of workers a qualified supervisor or responsible oversight can effectively oversee for a variety of different types of activities that established reasonable span of control for each activity. Concerns addressed during the 95003 inspection are discussed in this report under VO-20.

Based on the actions taken by the licensee, data evaluated by the team, and observations performed onsite, the team concluded that the actions taken to address VO-10 were effective. Therefore, VO-10 is closed.

VO-14 Establish a fleet charter team or ANO team to address weaknesses in the procedures for contractor oversight. Specifically, identify gaps in the procedures to align with industry guide AP-930, Supplemental Personnel Process

Description.

Assign additional actions as warranted to address any gaps identified. (CR-ANO-C-2014-02318, CA-175)

During the 95003 supplemental inspection, the NRC team identified concerns with Procedure EN-OM-126. These included inadequate guidance for developing an oversight plan, required reading for workers or supervisors, ensuring adequate technical background of the supervisors, and qualification board requirements for vendor oversight supervisors. Common Cause Evaluation (CCE) CR-ANO-C-ANO-2015-04461, Misjudgment - Wrong Assumptions Trend Analysis in Maintenance and Projects Organizations, and focused self-assessment LO-ALO-2014-00094, Maintenance Services Supplemental Worker Oversight, were completed after the gap analysis of ANO vendor oversight fundamental problem was completed. The evaluations identified shortfalls in supplemental supervisor observations and field presence.

The corrective actions were not being tracked as part of ANOs Comprehensive Recovery Plan (CRP).

To evaluate the licensees corrective action effectiveness, the team reviewed CR-ANO-C-2014-02318, CA-175; Procedure EN-OM-126-ANO-RC, Management and Oversight of Supplemental Personnel, Revision 1; and Industry Guide AP-930, Supplemental Personnel Process Description, Revision 2. The team performed interviews with the owners of this action item as well as personnel responsible for implementing the procedure. The NRC team also attended the ANO Vendor Oversight Continuous Improvement Team weekly meeting and interviewed the members.

The NRC team concluded that the licensee established an ANO team to address weaknesses in the procedures for contractor oversight, and was effective in addressing oversight gaps by revising the vendor oversight procedures to align with Industry Guide AP-930. Concerns addressed during the 95003 inspection are discussed in VO-20.

Based on the actions taken by the licensee, data evaluated by the team, and observations performed on site, the team concluded that the actions taken to address VO-14 were effective. Therefore, VO-14 is closed.

VO-20 Issue a procedure for management and oversight of supplemental personnel including improvements to

(1) defined responsibilities,

(2) assessment of risk, and

(3) vendor oversight plans. (CR-ANO-C-2014-02318, CA-20, CA-30, CA-115, CA-128, CA-129, CA-154, CA-164, CA-198, and CR-ANO-C-2014-02698 CA-14)

During the 95003 supplemental inspection, in addition to the issues mentioned above in VO-14, the NRC team found that Procedure EN-OM-126 also did not contain guidance to ensure that supervisors or oversight personnel had appropriate technical expertise to be fully capable of providing oversight for the specific project or work. Interviews with ANO personnel assigned oversight roles for supplemental workers commented that they did not always feel that they had the technical expertise to provide oversight of supplemental employees assigned to them.

To evaluate the licensees corrective action effectiveness, the team reviewed:

• CR-ANO-C-2014-02318, CA-20, CA-30, CA-115, CA-128, CA-129, CA-154, CA-164, and CA-198

• CR-ANO-C-2014-02698, CA-14

• Procedures EN-OM-126 and EN-OM-126-ANO-RC, Revision 1, Management and Oversight of Supplemental Personnel

• Procedure EN-OM-126-03, Qualification of Supplemental Supervisors

• EN-OM-126-02, Qualification of Oversight Personnel The team performed interviews with the owners of this action item as well as personnel responsible for implementing the procedures. The team also attended the ANO Vendor Oversight Continuous Improvement Team weekly meeting where revisions to Procedure EN-OM-126-ANO-RC were discussed.

The team determined that VO-20 will remain open because the licensee failed to address the following items and failed to assess action effectiveness with respect to the 95003 inspection team concerns discussed above:

• Procedure EN-OM-126-ANO-RC did not contain guidance to ensure that supervisors or oversight personnel had appropriate technical expertise to be fully capable of providing oversight for the specific project or work.

Interviews with ANO personnel assigned oversight roles for supplemental workers commented that they did not always feel that they had the technical expertise to provide oversight of supplemental employees assigned to them.

• Entergy procedure EN-OM-126-03 required that each supplemental supervisor pass an oral qualification board. However, the procedure allowed two of the three board members to be filled by supplemental personnel who had achieved the same qualification, without further requirements. This did not appear to ensure that the purpose of the board, being able to recognize compliance with ANO management expectations and awareness of expected actions, would be met.

• Procedure EN-OM-126-03 allowed supplemental supervisor qualifications to transfer between Entergy sites without any additional evaluation or qualification board, at the discretion of the responsible manager. Since management expectations vary from site to site, this allowance did not appear to ensure that an individual would be aware of the management expectations at the new site.

• Procedure EN-OM-126-03 allowed conducting oral qualification boards for up to six candidates at a time. The NRC team concluded that this practice would make it difficult to recognize knowledge weaknesses in individual candidates.

Concerns initially addressed in action items VO-10 and VO-14, which were also related to procedural changes from VO-20, were evaluated by the team and found to be adequate. These items were:

• The NRC team determined that oversight plans for contract outage workers, qualification requirements for contractors to act as supervisors, and designated ANO oversight personnel obtaining guidance and training to perform their oversight role were adequate.

• The NRC team determined that the changes made in EN-OM-126-ANO-RC provided adequate guidance for developing an oversight plan and required reading for workers or supervisors. The evaluation identified adequate supplemental supervisor observations and field presence.

The team concluded that action VO-20 should remain open. This action will be reviewed in a future inspection after the licensee determines that sufficient monitoring time has passed to monitor performance and determine whether sustained improvement has occurred, the above concerns have been addressed, and pending completion of an updated effectiveness review by the licensee.

VO-24 Revise Procedure EN-MA-119, Material Handling Program, to require a documented engineering response to evaluation critical lifts if using any specially designed temporary lifting device, any lifting device that cannot be load tested per EN-MA-119 criteria, or any lifting device without a certified load rating nameplate rating affixed to it. (CR-ANO-C-2013-00888, CA-20)

To evaluate the licensees corrective action effectiveness, the team reviewed CR-ANO-C-2013-00888, CA-00020; Procedure EN-MA-119, Material Handling Program, Revision 28; Engineering Change EC-65067; and supporting vendor calculations for the upcoming lifts needed to replace two shutdown cooling heat exchangers (SDCHXs) using a temporary lift device. The inspectors also observed the load test for the temporary lift device on March 8-9, 2017, at a vendors facility in Rosharon, Texas.

ANO contracted Steam Generating Team (SGT) as the vendor to remove and replace the two SDCHXs. SGT subcontracted Mammoet Inc. and PMC Engineering Solutions Inc. to design and implement rigging and lifting evaluations to complete the replacement activities. ANO contracted LPI Inc. as a third party to independently review all calculations provided by SGT and their subcontractors.

The inspectors determined the licensee was utilizing the applicable industry codes and appropriate factors of safety to evaluate the design the temporary lift device and the below the hook lifting devices required to be used in the SDCHXs replacement operations. The inspectors determined that the design and 125 percent load test met procedural requirements and industry standards. In addition, the inspectors determined that the licensee had appropriately planned to protect mitigating systems in the vicinity of the lift.

NRC Inspection Report 05000313/2016008 and 05000368/2016008 (ML17059D000) closed this action because the licensee had adequately revised their material handling program. Due to the availability of an opportunity to conduct a performance-based observation of the effectiveness of those actions, this inspection reviewed an actual heavy lift to evaluate the effectiveness of the program changes. This inspection of a heavy load lift with a temporary lift device further demonstrated the effectiveness of the completed VO-24 actions.

.2 Actions to Address Identifying, Assessing, and Correcting Performance Deficiencies

CA-15 Revise the Operating Experience (OE) actions for selected responses to require a pre-job brief from the OE specialist. This brief should include examples of missed opportunities from past OE responses and a review of the procedure requirements for a satisfactory OE written response. (CR-ANO-C-2015-00259, CA-114)

During the 95003 supplemental inspection, the NRC team agreed with ANOs assessment that OE evaluations tended to justify why an issue was not applicable to ANO rather than finding ways to use the lessons presented in OE reports to improve performance. OE reports reviewed by the 95003 team included examples containing a lack of conservative bias or lack of information verification, which led to shallow evaluations, narrowly focused evaluations, and some production over safety behaviors.

To evaluate the licensees corrective action effectiveness, the team reviewed:

• CR-ANO-C-2014-00259, CA-114

• CR-ANO-C-2016-02679

• Procedure EN-OE-100, Operating Experience Program, Revision 27

• Procedure EN-OE-100-02, Operating Experience Evaluations, Revision 1

• Desk Guide PI-003, Operating Experience Desk Guide, Revision 0 The licensee created a new Operating Experience Desk Guide to provide guidance for OE pre-job briefs, lessons learned, requirements for becoming an ANO OE Point of Contact, and examples of OE written responses. The OE specialist prepared the desk guide using feedback from the NRC 95003 supplemental inspection and from other Entergy Fleet OE specialists. The team found the licensee had adequately incorporated requirements for pre-job briefs by the OE specialist or designee, and included examples of missed opportunities from past OE responses along with their resulting effects.

Based on the actions taken by the licensee and data evaluated by the team, the team concluded that the actions taken to address CA-15 were effective.

Therefore, CA-15 is closed.

CA-16 Train each Operating Experience (OE) point of contact on their responsibilities and skills needed to recognize the applicability of OE, elevate OE, and use search tools to locate OE for evaluation. (CR-ANO-C-2015-00259, CA-115)

During the 95003 supplemental inspection, the NRC team found that the OE Program allowed ANO to decide that no action was needed to address OE reports that were determined to be applicable to ANO if sufficient pre-existing barriers existed such that the outcome would be minimized at ANO. The NRC team concluded that although ANO appropriately evaluated whether external OE was applicable to ANO, the corrective actions developed to address OE were sometimes insufficient.

The team reviewed the computer-based training developed for this corrective action, interviewed the site OE specialist and a sample of the OE points of contact that received the training, and the cognizant Entergy Corporate Functional Area Manager. The team verified through interviews that the OE points of contact could demonstrate understanding of their roles and responsibilities, according to EN-OE-100, Operating Experience Program, Revision 27, which demonstratives effectiveness of the training.

During discussions with the Entergy Corporate Functional Area Manager, the team discovered that Entergy planned to make significant changes to the fleet OE Program, including changes that could significantly change the process for disseminating OE and consideration of eliminating the OE points of contact.

While the team concluded that the licensee had completed the action and demonstrated the effectiveness of those actions, the team determined that ANO had failed to determine whether those actions would remain effective due to the planned OE Program changes. Specifically, the team could not determine if the OE program changes would continue to reasonably assure that OE will be properly evaluated and acted upon when appropriate.

The team concluded that CA-16 should remain open until after Entergy completes planned changes to the OE Program. This action will be reviewed during a future inspection after the licensee determines that sufficient time has passed to determine whether the intent of the committed action has been fulfilled, sustained improvement has occurred, and the licensee performs an updated effectiveness review.

CA-17 Revise Operating Experience (OE) Program procedure to include an annual review of the list of vendors providing safety-related products/services to ensure new suppliers are added. (CR-ANO-C-2016-00782, CA-2)

During the 95003 supplemental inspection, the NRC team concluded that ANO had not established an effective method for evaluating vendor-related OE or vendor bulletins. The NRC team identified that the last four unplanned scrams involved the failure to effectively use OE and also found examples where the OE program credited unverified barriers.

The team reviewed the changes to Procedure EN-OE-100 Operating Experience Program, Revision 27, the actions already taken to update the OE list of vendors, and interviewed the fleet Corporate Function Area Manager regarding the process going forward for performing the new review.

The inspectors determined that the licensee updated their list of vendors, the vendors had appropriate contact information for providing bulletins to the licensee, and the licensee had proceduralized periodic reviews to update the list.

Based on the actions taken by the licensee, data evaluated by the team, and observations performed on site, the team concluded that the actions taken to address CA-17 were effective. Therefore, CA-17 is closed.

DM-5 Benchmark a nuclear facility outside the Entergy fleet for its ability to recognize risk. Incorporate the learnings and develop a risk recognition training plan to be delivered at ANO. (CR-ANO-C-2015-02832, CA-43)

During the 95003 supplemental inspection, the NRC team noted that licensed operators assigned as operations work liaisons were assigned risk management responsibilities, but nearly all of them had limited experience and no specific training to be able to implement risk recognition and risk management responsibilities. The operations work liaisons stated that procedure COPD-024, Risk Assessment Guidelines, was confusing and difficult to understand and, as a result, they tended to ask other operators how to perform some actions. The NRC 95003 team determined that actions to improve knowledge of risk were missed in the assignment of corrective actions for the Decision Making and Risk Management Fundamental Problem Area (FPA).

To evaluate the licensees corrective action effectiveness, the team reviewed CR-ANO-C-2015-02832 and CR-ANO-C-2016-01660, the benchmarking report, and conducted interviews with licensee personnel.

The licensee performed a benchmarking activity at a nuclear facility outside the Entergy fleet to incorporate learnings and develop a risk recognition training plan.

The team concluded that the licensee did develop a risk recognition training plan to be delivered at ANO, but the training was covered under actions DM-6, DM-7, and DM-9 and will be reviewed during a future inspection.

The licensee also developed corrective actions to address gaps identified during the benchmarking visit. The team reviewed the status of those actions and determined that some had not been completed. The licensee had added the items to action DM-22 involving benchmarking best practices in work management, but DM-22 was not ready for inspection. The team noted that while some objectives of the benchmarking activity were related to DM-22, the licensee had identified other issues related to risk recognition that had not been completed. Specifically, the licensee had identified three negative observations under Objective 2: Determine how Plant Hatch trains personnel on Risk Recognition, but had only completed actions to address one of them. The licensee wrote condition report CR-ANO-C-2017-00796 to ensure that DM-22 addresses the remaining two negative observations.

Although the licensee has not completed all of the corrective actions developed as a result of the benchmarking activity, the team determined that these actions could be reviewed under action DM-22 and a future inspection team would determine whether the licensee adequately corrects gaps identified as a result of the DM-5 benchmarking trip. Therefore, DM-5 is closed.

DM-23 Have a group from another plant perform a peer assist visit in work management.

(CR-ANO-C-03034, CA-27)

During the 95003 supplemental inspection, the NRC team identified that ANOs work planning process and scheduling processes were undergoing improvements to increase accountability and promote communication across work groups. However, the team also noted cases where work had been delayed or removed from the schedule because preparations were not completed prior to equipment being taken out of service. Examples included unavailable workers, required parts that were not available, or incomplete maintenance risk evaluations.

To evaluate the licensees corrective action effectiveness, the team reviewed CR-ANO-C-2015-03034 and CR-ANO-C-2016-01461. The team reviewed the results and recommendations of the peer assist visit.

The licensee hosted a peer assist visit to ANO in 2016 to address deficiencies in work management practices and wrote CR-ANO-C-2016-01461 to identify and correct gaps identified during the visit. The team determined that the peer assist visit had been effective in identifying gaps and deficiencies and the licensee had developed corrective actions. However, the licensee had not completed all of these corrective actions. The team also discovered that many of the corrective actions had been closed without action and that the licensee had not determined the effectiveness of the actions. The licensee was unable to determine whether the actions were successfully implemented and entered the teams observation into the corrective action program as CR-ANO-C-2017-00795.

Because the licensee had not closed the gaps identified from the peer assist visit, the team determined that DM-23 will remain open. This action will be reviewed during a future inspection after the licensee completes corrective actions to address identified gaps and determines that the actions were effective to close the gaps.

PH-9 Conduct a benchmark of the Plant Health Committee and Plant Health Working Group at a recognized industry leader in identifying and addressing equipment reliability issues. The intent of this action is to validate the action plan for improving our Plant Health Committee and establishing a Plant Health Working Group. (CR-ANO-C-2015-03029, CA-8)

During the 95003 supplemental inspection, the NRC team reviewed the licensees conclusion that their evaluation of the Plant Health Committee was not reviewing and resolving all of the degraded equipment issues documented in individual System Health Reports. The NRC team also identified that the Plant Health Project Plan was incomplete and lacked sufficient detail to provide assurance that identified issues would be corrected. Some of those steps did not appear to support timely improvements in equipment reliability, potentially missing opportunities to add scope to the next outage for each unit.

To evaluate the licensees corrective action effectiveness, the team reviewed CR-ANO-C-2015-02832 and CR-ANO-C-2015-03029. The team determined that the licensee had completed a benchmarking activity of the Plant Health Committee and equipment reliability programs at another site recognized as an industry leader. The licensee identified several gaps in their processes as a result and entered them into their corrective action program under CR-ANO-C-2015-03029 and CR-ANO-C-2015-05111.

The team determined that the licensee actions to address how plant health issues are identified and prioritized and how resources are aligned had not all been completed. Specifically, the licensee had not completed CR-ANO-C-2015-03029 CA-00113 and CR-ANO-C-2015-03029 CA-00115. The team determined that the licensee did not develop any actions to address methods used to maintain accountability, because accountability issues were covered in the leadership fundamentals area of the CAL. The licensee assessed the action as effective, but did not provide any justification for that assessment.

The team concluded that the licensee had not demonstrated effectiveness and had not completed actions developed as a result of the benchmark.

Although the licensee had not completed corrective actions developed as a result of the benchmarking activity, the team determined that CR-ANO-C-2015-03029 CA-00113 and CR-ANO-C-2015-03029 CA-00115 would be reviewed under related action DM-22 and a future inspection team would determine whether the licensee effectively corrected gaps identified as a result of the benchmarking trip.

Therefore, PH-9 is closed.

PM-9 Develop metrics for the number of open craft work order feedback requests.

(CR-ANO-C-2015-02834, CA-126)

During the 95003 supplemental inspection, the NRC team identified that maintenance workers were providing work order feedback informally rather than submitting a Procedure Improvement Form. The NRC team also found that work planners typically only reviewed the feedback on the last work order and not the work order feedback log when planning for the next job. In response, ANO developed actions to assess the extent of work instruction quality issues, and to conduct industry certification training for procedure writers (PQ-3 and PQ-4).

To evaluate the licensees corrective action effectiveness, the team reviewed:

• CR-ANO-C-2015-02834 CA-126

• CR-ANO-C-2016-03315

• Procedure EN-LI-123-12-ANO-RC, Comprehensive Recovery Plan and Performance Metrics, Revision 5

• Procedure EN-WM-105-ANO-RC, Planning, Revision 2 The team performed interviews with the owners of this action item as well as personnel responsible for implementing the procedures. The NRC team also reviewed the metric data as well as Planning Aggregate Indicator for open work order feedback requests.

The NRC team concluded that the action to develop a metric for the number of open craft work order feedback requests was effective. The new metric tracks the number of open craft work order feedback requests and the indicator changes color based on the oldest open request: green for less than 70 days, yellow for between 70 and 90 days, and red for greater than 90 days old. While the metric was red at the time of this inspection, indicating that there was at least one open craft work order feedback request greater than 90 days old, action PM-19 addresses the performance issues measured by this metric.

Based on the actions taken by the licensee, data evaluated by the team, and observations performed on site, the team concluded that the actions taken to address PM-9 were effective. Therefore, PM-9 is closed.

.3 Actions to Address Human Performance Issues

LF-1 Conduct leadership assessments for the senior leadership team, managers, and superintendents and establish individual development plans to support closing identified gaps in leader behaviors. (CR-ANO-C-2015-02829, CA-43)

During the 95003 supplemental inspection, the NRC team reviewed ANO corrective actions, which included ANO contracting with a vendor to perform leadership assessments focused on seven selected leadership attributes. The NRC team discussed the selected leadership attributes and overall assessment strategy with ANO management and the vendor project manager, and concluded that the strategy and actions appeared to be an effective mechanism to assess and improve ANO leader performance.

To evaluate the licensees corrective action effectiveness, the team reviewed:

• CR-ANO-C-2015-02829 CA-43 and CA-57

• Procedure EN-FAP-OM-016, Performance Management Processes and Practices, Revision 6

• reports on individual leaders from consulting firms STS and RHR International

• individual development plans for station leaders The team performed interviews with the owners of this action item, station leaders, and the Entergy Director of Organizational Effectiveness. The NRC team also reviewed the metric data related to Leadership Fundamentals.

The team determined that the licensee had hired consulting firms STS and RHR International to perform leadership assessments for the senior leadership team, managers, and superintendents. The leaders had developed individual development plans that addressed the identified gaps in leader behaviors. The team verified through interviews that leaders have been addressing gaps and updating the plans.

Based on the actions taken by the licensee, data evaluated by the team, and observations performed on site, the team concluded that the actions taken to address LF-1 were effective. Therefore, LF-1 is closed.

LF-6 Benchmark an external organization for leadership fundamentals and develop improvement actions as warranted based upon the results.

(CR-ANO-C-2015-02829, CA-57)

During the 95003 supplemental inspection, the NRC team received feedback during interviews with most management and non-supervisory personnel that benchmarking was not a common practice at ANO. If benchmarking occurred, it was typically within the Entergy fleet. Also, personnel commented that if benchmarking resulted in suggestions for improvements, improvement items typically have not received priority due to limited resources. Even though ANO identified this, the NRC found the use of benchmarking was largely absent from the ANO Comprehensive Recovery Plan. ANO subsequently documented this issue in the CAP as CR-ANO-C-2016-00630 and developed LF-6.

To evaluate the licensees corrective action effectiveness, the team reviewed:

• CR-ANO-C-2015-02829, CA-53

• the benchmarking report for leadership fundamentals

• the ANO Communication Plan

• improvement items document in LO-ALO-2016-00042 and CR-ANO-C-2016-00415 The team performed interviews with the owners of this action item, station leaders, and the Entergy Director of Organizational Effectiveness.

The team determined that the licensee had performed a benchmark trip to an external organization, identified actions to address gaps, and implemented those actions. For example, Entergy initiated an Organizational Effectiveness division, developed a communication plan, and expanded the use of cross-functional teams in decision-making as a result of recommendations from the benchmarking. The team verified through interviews that the actions had contributed to improved leadership fundamentals at the station through improved vertical alignment, strategic long-term decision-making focused on safety, and long-term investment in leadership.

Based on the actions taken by the licensee, data evaluated by the team, and observations performed on site, the team concluded that the actions taken to address LF-6 were effective. Therefore, LF-6 is closed.

PQ-1 Develop and implement a site procedure writers guide based on applicable industry standards. (CR-ANO-C-03033, CA-10, CA-11, CA-15 through 18, CA-20 through 22, CA-28, and CA-32)

During the 95003 supplemental inspection, the NRC team reviewed the licensees conclusion that procedures and work instructions have been technically inaccurate or incomplete and that ANO procedures lacked consistent structure for human factoring. These factors contributed to consequential conditions in the past due in part to the licensee not consistently applying current industry guidance for procedure content, structure, and human factoring.

To evaluate the licensees corrective action effectiveness, the team reviewed:

• CR-ANO-C-2015-03033

• Procedure CPG-001, ANO Procedure Writers Guide, Revision 0

• Procedure OP-1015.020, ANO-2 EOP/AOP Writers Guide, Revision 12

• Procedure OP-1015.029, Unit One Emergency Operating Procedure Writers Guide, Revision 7 The team also interviewed site personnel and reviewed a sample of procedures that had been revised following completion of the PQ-1 actions. The team determined that CPG-001 was applicable to all site procedures other than emergency operating procedures (EOPs) and abnormal operating procedures (AOPs). The team determined that the writers guide was based on the Procedure Professionals Association (PPA) standards PPA-AP-907-001, Procedure Process Description, Revision 1, and PPA-AP-907-005, Procedure Writers Guide, Revision 1, which are applicable industry standards. However, at the time of implementation, the PPA had implemented Revision 2 of both standards. The team determined that the licensee had not committed to incorporating updated versions of the industry standards into their writers guide.

The licensee wrote CR-ANO-C-2017-00897 to document this issue.

The team determined that the licensee had also incorporated these industry standards into Procedures OP-1015.020 and OP-1015.029. The team determined that the licensees procedures did not require procedure writers to utilize a writers guide for writing Unit 1 AOPs. The licensee stated that the licensee procedure writers would use the Unit 1 EOP writers guide because no other guidance existed. The licensee entered this into their corrective action program as CR-ANO-1-2017-00828.

The team reviewed the licensees effectiveness review. The licensee had developed a grading system and had graded new revisions of procedures to determine if their writers guide was effective. The team reviewed a sample of graded procedures and determined that the grades were consistently high on the licensees scale and that the graded procedures were consistent with the new writers guide.

Based on the actions taken by the licensee, data evaluated by the team, observations performed on site, and CR-ANO-1-2017-00828, the team concluded that the actions taken to address PQ-1 were effective. Completion of the corrective actions to address CR-ANO-1-2017-00828 will be reviewed under CAL items PQ-6 and PQ-7. Therefore, PQ-1 is closed.

PQ-2 Develop and implement a work order instruction guide based on applicable industry standards. (CR-ANO-C-2015-03033, CA-14 and CA-33)

During the 95003 supplemental inspection, the NRC team reviewed the licensees Preventive Maintenance (PM) Fundamental Problem Area root cause evaluation. ANO identified that the level of detail in work orders has not been sufficient to prevent plant events, the backlog of work order and PM feedback had increased, PM documents were not updated until the PMs are entering the work scheduling process, and insufficient resources were available to support work planning.

To evaluate the licensees corrective action effectiveness, the team reviewed CR-ANO-C-2015-03033 and Procedure EN-WM-105-ANO-RC, Planning, Revision 2. The team determined that the new procedure was applicable to work orders written at the site and that it was based on the Procedure Professionals Association (PPA) standards PPA-AP-907-001, Procedure Process Description, Revision 1, and PPA-AP-907-005, Procedure Writers Guide, Revision 1, which are applicable industry standards. However, at the time of implementation, the PPA had implemented Revision 2 of both standards. The team determined that the licensee had not committed to incorporating updated versions of the industry standards into their writers guide. The licensee wrote condition report CR-ANO-C-2017-00897 to document this issue.

The team reviewed the licensees effectiveness review. The licensee had developed a grading system and had graded new work orders to determine if their work instruction guide was effective. The team determined that some of the work orders had been graded by the same planner who made the revision. The team noted that the self-graded work orders had several attributes marked as not applicable, despite the attributes being applicable to the work order. The team found that the licensee had also independently graded an additional sample of work orders. The grades on the independently graded work orders were high on the licensees scale and none of the sampled work orders required major revisions. The team concluded that the sample of independently graded work orders sufficiently demonstrated that the new work orders were being written in accordance with the new standard. The team noted that action PQ-9 would ultimately upgrade all Critical 1-4 model work orders, and concluded that action PQ-2 could be closed, with future inspection efforts under PQ-9 to validate proper use of the new work instruction guide.

Based on the actions taken by the licensee, data evaluated by the team, and observations performed on site, the team concluded that the actions taken to address PQ-2 were effective. Therefore, PQ-2 is closed.

PQ-4 Conduct a Procedure Professionals Association certification course for selected plant personnel. (CR-ANO-C-2015-03033, CA-31)

During the 95003 supplemental inspection, the NRC team found that the licensees corrective actions as part of their Comprehensive Recovery Plan did not include providing training to the planners on writing work orders using industry standards. In response, ANO developed actions to assess the extent of work instruction quality issues, and to conduct industry certification training for procedure writers.

To evaluate the licensees corrective action effectiveness, the team reviewed CR-ANO-C-2015-03033 and the applicable industry standards, and interviewed several licensee personnel.

The team determined that the licensee conducted a PPA certification course for selected personnel. The licensee selected the contractors assigned to the licensees procedure upgrade project to attend the course, and included additional licensee employees from the planning and procedure writing groups.

The team noted that the deficiency observed during the 95003 supplemental inspection was a lack of industry standard training for planners who write work orders. The team found that of 16 planners, only three had completed the PPA certification course. The team reviewed the licensees training program for planners and determined that there was no other formal training on writing work orders using industry standards. Therefore, the team concluded that the licensee did not complete this action as intended. The licensee entered this into their corrective action program as CR-ANO-C-2017-00880.

The licensee considered the item effective based on the grading of a sample of completed procedure revisions. The team determined that the licensee had not met the intent of the action, since only three of 16 procedure writers had completed the certification course and the licensee provided no basis to support why training a small percentage of procedure writers was sufficient to ensure sustained improvement in procedure quality.

The team concluded that action PQ-4 should remain open. This action will be reviewed during a future inspection after the licensee demonstrates that enough current work planners and procedure writers have successfully completed a Procedure Professionals Association certification course and determines that the training is effective in sustained improvement in procedure quality.

.4 Actions to Address Equipment Reliability and Engineering Program Deficiencies

PH-11 Develop a job familiarization guide for Plant Health Working Group and Plant Health Committee members and alternates. Have all members and alternates complete the guide. (CR-ANO-C-2015-03029, CA-12)

During the 95003 supplemental inspection, the NRC team reviewed the licensee identification that they did not manage resources with a long-term view, and exhibited weak focus with respect to eliminating or mitigating challenges to reliable plant operations, prompt and thorough resolution of challenges, and maintaining margins. One issue in particular was that the Plant Health Committee was not reviewing and resolving all of the degraded equipment issues documented in individual System Health Reports.

The team interviewed Plant Health Committee (PHC) members, reviewed the new Job Familiarization Guide, plant health related metrics, and Plant Health Committee meeting evaluation forms for several meetings. The team also confirmed that all members of the PHC and Plant Health Working Group (PHWG)completed the reading and discussion requirements of the guide.

The Job Familiarization Guide consisted of a reading list of the documents that govern the roles and responsibilities of the PHC and PHWG. The site also developed a condensed list of precautions and guidance taken from the various governing procedures that members could reference during meetings.

From interviews with PHC members and a review of PHC meeting scorecards, the team determined that the quality of the meetings appeared to be improving.

The meeting quality scores have increased since 2016. Early score card comments include issues with lack of quorum or preparation for meetings, while later scorecards contained critical comments involving the level of critical review on specific issues while also positively recognizing overall meeting success and cultural change.

Specific system health issues are being addressed, as seen in the site Top Ten Equipment Reliability Issues which tracks specific equipment issues that had been causing low system health scores. This can also be seen in the system health metrics, which are green for both units. These metrics show that the number of systems that have been red or yellow for greater than one refueling cycle is zero for both units, showing that system health has been driving priorities.

Based on the actions taken by the licensee, data evaluated by the team, and observations performed on site, the team concluded that the actions taken to address PH-11 were effective. Therefore, PH-11 is closed.

PM-2 Create a site-specific PM program procedure that includes lessons learned from the PM FPA root cause related to critical input to PM changes.

(CR-ANO-C-2015-02834, CA-102)

As a part of their Preventive Maintenance FPA Root Cause Evaluation (CR-ANO-C-2015-02834), ANO identified weaknesses within the PM technical basis and program implementation. ANO concluded that several recent events had been a result of PM activities that were performed less frequently than recommended by the vendor. Additionally, examples were identified where the bases for the PM strategies were deficient.

During the 95003 supplemental inspection, the NRC team concluded that the licensees evaluations for PM scope changes were comprehensive. The NRC team noted that the evaluations included a sound basis for determining that the period of decline started in 2008. The decline involved non-conservative decisionmaking, inadequate organizational capacity, and ineffective reinforcement of standards by station leadership. The evaluations identified multiple conditions that contributed to the failure to identify and resolve declining performance. The NRC team concluded ANOs evaluation was sufficient and did not identify any additional consequences from PM scope reductions.

The team reviewed site recovery Procedure EN-DC-324-ANO-RC, Preventive Maintenance Program, Revision 0, interviewed Preventive Maintenance Oversight Group (PMOG) members, and reviewed metrics and evaluations related to maintenance evaluation quality. The team reviewed examples of recent Preventive Maintenance Change Requests (PMCRs) and the score sheet used by the PMOG to evaluate and approve them. The team concluded that the sample of procedure changes reviewed were completed in accordance with the proposed changes from the corrective action documents. Based on discussions with PMOG members, the team determined that meetings were being conducted in accordance with the new guidance, including the designation of a Conservative Decision Making Advocate and demonstrated more critical reviews of PMCRs.

A licensee assessment of PMOG effectiveness using interviews with PMOG members and non-Entergy observers determined that PMCRs were being submitted with the intent to improve the PM program and increase conservatism, many of them associated with recovery actions. PMOG members were prepared for meetings and had comprehensive discussions on the reviewed PMCRs. An outside observer noted that system engineers provide better quality PMCRs when they understand the context of the PMOG discussions and how they critically review them. As a result, from discussions with PMOG members, the licensee has had engineers and maintenance personnel witness PMOG meetings so they can gain this insight.

Based on the actions taken by the licensee, data evaluated by the team, and observations performed on site, the team concluded that the actions taken to address PM-2 were effective. Therefore, PM-2 is closed.

PM-4 Transfer responsibility for PM evaluations of all maintenance rule components and critical system redundancy components to engineering to ensure that appropriate expertise is brought to bear on these evaluations.

(CR-ANO-C-2015-02834, CA-122)

During the 95003 supplemental inspection, the NRC team reviewed the licensees evaluation of the differences in implementation of the Critical PM Program by engineering and Non-Critical PM Program by maintenance as part of the PM root cause evaluation. The licensee identified that station leaders made the decision to transfer responsibility for PM strategies of non-critical components to maintenance without adequate change management.

The team reviewed the changes to Procedure EN-DC-324-ANO-RC, Preventive Maintenance Program, Revision 0, pertaining to the transfer of maintenance rule and critical system redundant components to engineering; discussed the changes with the System Engineer Manager and PMOG members; and reviewed recent engineering PMCRs, related metrics, and site assessments.

The team concluded that the licensee has transferred responsibility for maintenance rule and critical system redundancy component PM evaluations to the system engineering group, which was also responsible for maintenance rule strategies and monitoring for their systems. The feedback from PMOG members was that engineering has traditionally submitted better PMCRs, with a higher quality and understanding of possible risk or unintended ramifications of changes to PM strategies. With the transfer of responsibilities, the system engineering group continues to submit more thorough evaluations. The inspectors reviewed PMCRs submitted by engineering and found that they show a high level of detail and regard for commitments, risk, and conservatism. Relaxations were justified with technical reasoning and a discussion of risk. As discussed in the PM-2 closure, the system engineers have been encouraged to sit in PMOG meetings to witness the level of rigor expected of them. This conclusion was also supported by the PMCR metric that shows a lower number of rejections since last year.

Based on the actions taken by the licensee, data evaluated by the team, and observations performed on site, the team concluded that the actions taken to address PM-4 were effective. Therefore, PM-4 is closed.

PM-11 Implement a new qualification card for maintenance personnel who perform PM evaluations. (CR-ANO-C-2015-02834, CA-124 and CA-125)

During the 95003 supplemental inspection, the NRC team reviewed the licensees identification that maintenance personnel lacked the proper training and qualification to manage the population of non-critical components. The NRC team identified that Maintenance Department PM coordinators had reduced the time spent performing PMs in order to perform other maintenance activities. This included extending PM frequencies for non-critical components without an adequate technical basis.

The team reviewed Job Familiarization Guide, Maintenance PM Program Manager, ASFAM-MNTC-PMOWN, Revision 0, which was developed to meet this action. They also interviewed the action owner and members of the PMOG who review PM evaluations performed by maintenance personnel qualified under this guide.

The licensee implemented the Job Familiarization Guide in December, 2015. All Maintenance Coordinators were required to complete it. The team verified that all personnel required to have completed the guide have done so. Interviews with PMOG members show that they have noted an increase in quality of the PMCRs submitted by maintenance personnel, which was supported by non-Entergy observers who agreed in an assessment performed in late 2016. The team reviewed a sample of non-critical PMCRs submitted by maintenance personnel and determined that non-critical maintenance deferrals requests were supported with appropriate technical rigor, consideration of risk, and appropriate justification. The metric shows a reduction in rejected PMCRs by the PMOG.

Based on the actions taken by the licensee, data evaluated by the team, and observations performed on site, the team concluded that the actions taken to address PM-11 were effective. Therefore, PM-11 is closed.

.5 Actions to Address Safety Culture Issues

Three similar actions were created in the ANO Comprehensive Recovery Plan to observe and provide feedback on safety culture behaviors at meetings: CA-2, LF-9, and SC-14. While each action was implemented by the same condition report action, each area action plan addressed slightly different problems and therefore, intended slightly different outcomes. Due to the similarity of actions, they were reviewed together.

CA-2 Establish a Nuclear Safety Culture Observer function and expectations to observe and provide feedback on leader behaviors (nuclear safety culture and safety conscience work environment) in key forums and to provide trends for review by the Nuclear Safety Culture Monitoring Panel. (CR-ANO-C-2015-2829, CA-31)

LF-9 Establish a Nuclear Safety Culture Observer function to observe and provide feedback on leader behaviors in key forums and to provide observation data for review by the Nuclear Safety Culture Monitoring Panel. (CR-ANO-C-2015-2829, CA-31)

SC-14 Establish and implement a Nuclear Safety Culture Observations process including elements of leader behaviors, nuclear safety culture, and safety conscious work environment. The observer monitors leader performance on a daily basis and provides feedback to correct adverse trends in behaviors.

(CR ANO-C-2015-2829, CA-31)

During the 95003 supplemental inspection, the NRC team noted that ANO had identified that the site did not have an adequate explicit management focus on safety culture and the associated infrastructure to support a healthy nuclear safety culture. This apparent cause allowed the specific nuclear safety culture weaknesses to exist at ANO and affected the ability of the leadership team to recognize and address the overall decline in nuclear safety culture.

During the NRCs first review of CA-2, LF-9, and SC-14, in Inspection Report 05000313/2016010 and 05000368/2016010 (ML16314C483), the team reviewed CR-ANO-2015-2829 CA-31, nuclear safety culture observation database entries between March and August 2016, and the minutes from the past four Nuclear Safety Culture Monitoring Panel meetings. The team also attended a number of ANO meetings to observe how the nuclear safety culture observer process identified issues and provided feedback, as well as how that feedback was received. The team noted that SC-14 was intended to have the observer monitor leader performance on a daily basis, but the meetings selected did not assure monitoring would be performed on a daily basis, so the team was unable to conclude that the action was sufficient to close SC-14.

The PI&R team found that the licensee had established the nuclear safety culture observer process using two external experts as observers and that the corrective action directed that ANO keep the process in place until completion of Unit 1 refueling outage 1R26 (fall of 2016) with at least one external observer. At the time of the inspection, the licensee had one external observer on site who was providing coaching and mentoring to licensee personnel who were performing the function of the nuclear safety culture observer. The licensee was transitioning to having the observations performed by licensee personnel. The team concluded that these initial observations performed by both the external observer and the licensee personnel were providing meaningful and effective feedback at meetings. Supervisors and managers have been responsive to feedback and have started to exhibit self-correcting behaviors during the meetings. However, the team concluded that there was not enough examples of using ANO managers as safety culture observers to determine the effectiveness of feedback to close these items.

The PI&R team determined that CA-2, LF-9, and SC-14 would remain open until a future inspection after the external observers/coaches have left and the licensee determined that the station personnel assigned to be safety culture monitors were providing effective feedback to be able to determine the effectiveness of the ANO nuclear safety culture observer program.

For the current inspection, the team reviewed CA-2, LF-9, and SC-14, CR-ANO-C-2015-2829, CA-31, nuclear safety culture observations, and minutes from the previous monitoring panel meeting. During the inspection, the team observed an Operational Focus meeting, a Performance Review Group meeting, a Critical Evolutions meeting, and a Nuclear Safety Culture Monitoring Panel meeting. The team observed that the licensee was performing the nuclear safety culture observations independently, without the oversight of any external observers. The team reviewed the corrective actions taken to update Procedure EN-QV-136-ANO-RC, Nuclear Safety Culture Monitoring, Revision 2, to address safety culture and feedback during the meetings. The team reviewed CR-ANO-C-2016-3774 and discussed the closure response with the licensee.

The team reviewed the completed nuclear safety culture observation forms from the observed meetings.

During the NRCs initial review of these items (Inspection Report 05000313/2016010 and 050003682016010), the team was unable to close the items because the meetings selected for requiring a nuclear safety culture observer were not the same as the initial list of meetings identified in CR-ANO-C-2015-2829, CA-31. The inspector reviewed CR-ANO-C-2016-4233, CA-2, which documented the criteria for determination of meetings that require a nuclear safety culture observer. The licensee focused on the causes identified in the CR-ANO-C-2015-2829, CA-31, action in order to define appropriate criteria for which meetings should be observed. The licensee identified four criteria for establishing meetings requiring the nuclear safety culture observation: 1) the meeting must include ANO leadership; 2) it must be strategic (decisions) in nature; 3) it must involve continuous learning; and 4) it must involve leader development and reinforcement of standards. The team determined the required meetings were adequate to conduct sufficient leadership observation for safety culture to meet the intent of this action.

The licensee wrote CR-ANO-C-2016-4233, CA-5, to specifically address the basis for not requiring meetings performed each day to meet the original corrective action wording of daily observations. The licensee concluded that leadership-type meetings do not occur every day to satisfy the daily wording. In addition to the required meetings, the licensee included steps in EN-QV-136-ANO-RC to periodically assign a nuclear safety culture observer to sixteen additional meetings to provide a broader perspective on leadership behaviors and performance with respect to nuclear safety culture. The team concluded that the required meetings, plus additional meetings, provided sufficient observation opportunity to satisfy the intent of daily observation in the corrective action.

The team observed that nuclear safety culture observers were appropriately assessing safety culture traits during meetings and providing acceptable feedback, but were not always critical in identifying negative behaviors.

However, the Nuclear Safety Culture Monitoring Panel independently identified this issue (CR-ANO-C-2017-00711), and took action, as documented in WT-WTANO-2017-00002, to provide paired observations to the nuclear safety culture observers to enforce the need to be more critical when performing the observation function.

Based on the actions taken by the licensee, data evaluated by the team, and observations performed on site, the team concluded that the actions taken to address CA-2, LF-9, and SC-14 are effective. Therefore, CA-2, LF-9, and SC-14 are closed.

CO-4 Revise procedures that govern Nuclear Oversight Performance Assessments to include nuclear safety culture trend codes. Apply relevant safety culture trend code(s) during the trending process. Based on report frequency, roll up codes to provide a perspective on NSC and include in established reporting process.

(CR-ANO-C-2015-2836, CA-23)

During the 95003 supplemental inspection, the NRC team noted that the licensee identified that some safety culture attributes were contributors to several of the root cause evaluation problem statements, but the licensee did not consider the collective significance. The NRC team concluded that identifying a safety culture attribute that contributed to multiple significant performance deficiencies was an adequate basis to conduct further evaluations, however, this was noted as a gap in the licensees approach.

The team reviewed CR-ANO-C-2015-02836, CA-23, and the corrective actions taken to update Procedures EN-FAP-QV-202, Nuclear Independent Oversight Performance Reporting, Revision 1, and EN-FAP-QV-204, Nuclear Independent Oversight Trending and Analysis, Revision 2, to ensure trend codes were incorporated into the procedures. The team also reviewed the latest Nuclear Independent Oversight roll-up report, dated October 31, 2016, to ensure trend codes were being rolled up and assessed by licensee management.

Based on the actions taken by the licensee, data evaluated by the team, and observations performed on site, the team concluded that the actions taken to address CO-4 were effective. Therefore, CO-4 is closed.

NF-4 Develop content for the NSC observation process that addresses procedure use and adherence. (CR-ANO-C-2015-04647, CA-14)

During the 95003 supplemental inspection, the NRC team noted that procedure adherence problems were identified in the root cause evaluations for the White Unplanned Scrams performance indicator and the two Yellow findings, but the licensee did not perform any cause evaluation for procedure adherence problems. Corrective actions developed by the licensee to improve procedure adherence were focused on establishing clear standards and improving procedure quality and human factoring, but initially did not include actions to monitor and coach procedure adherence.

The team reviewed CR-ANO-C-2015-4647, CA-14, and the corrective actions taken associated with NF-4. The inspector reviewed the procedure changes made to Procedure EN-QV-136-ANO-RC, Nuclear Safety Culture Monitoring, Revision 2, to address observations for procedure use and adherence during meetings involving leadership personnel. The team noted that NF-4 only addresses the nuclear safety culture aspect of procedure use and adherence for leadership personnel during meetings, while other nuclear fundamental actions, (NF-03 and NF-05) addressed field presence to ensure procedure use and adherence. The team verified that the procedure was updated to include procedure use and adherence observation guidance for the observer. The team observed three meetings where the nuclear safety culture observer function was implemented to verify that procedure use and adherence was being monitored.

The team determined the actions taken were effective.

Based on the actions taken by the licensee, data evaluated by the team, and observations performed on site, the team concluded that the actions taken to address NF-4 were effective. Therefore, NF-4 is closed.

PM-20 Track Leadership Fundamentals RCE CR-ANO-C-2015-02829 CA-022. Improve the performance review process for leadership fundamentals supportive of long term strategic improvement. (CR-ANO-C-2015-02834, CA-105)

During the 95003 supplemental inspection, the NRC team reviewed the licensees Leadership Fundamentals RCE conclusion that leaders at ANO have not maintained a strong continuous improvement organization. Specifically, a focus on short-term results sometimes took precedence over the continuous improvement activities such as performance review, benchmarking, use of OE, and self-assessment that are necessary to maintain strong station performance and achieve excellence.

To evaluate the licensees corrective action effectiveness, the team reviewed:

• CR-ANO-C-2015-02829 CA-22

• CR-ANO-C-2015-02834 CA-105

• Procedure EN-LI-121-ANO-RC, Trending and Performance Review Process, Revision 3

• department performance review meeting reports

• condition reports related to leadership fundamental improvements The team performed interviews with the owners of this action item, station leaders, and a sample of department performance improvement coordinators.

The team determined that the licensee had added guidance to the trending and review process for the departmental and station level performance assessments that addressed leadership fundamentals. Specifically, EN-LI-121-ANO-RC was revised to include qualitative guidance provided to evaluate the department or station performance in each element of leadership fundamentals. The team interviewed a sample of department performance improvement coordinators to determine how the department leaders used the guidance and found that some departments had rigorous evaluations and actions in leadership fundamentals, and other departments did not document an auditable basis to show what was evaluated or support their conclusions. The inspectors noted that the licensee had not created any quantitative measures or standardized approach, such that each department could have a different standard. The team concluded that the licensee had failed to create a rigorous and repeatable process.

The inspectors noted that the licensee had created quantitative measures of leadership behaviors in the recovery organization, which may be appropriate to apply more broadly to support PM-20. The inspectors determined that without a repeatable process for evaluation of quantitative and qualitative leadership data, the licensees actions would be unlikely to satisfy the intent of PM-20.

The team concluded that action PM-20 will remain open. This action will be reviewed in a future inspection after the licensee develops and implements additional guidance and determines whether those actions have been effective.

SC-2 Revise procedure EN-QV-136, Nuclear Safety Culture Monitoring, to define the roles and responsibilities of the ANO NSC Manager. (CR-ANO-C-2015-02829, CA-32, and CR-ANO-C-2016-00748, CA-8)

During the 95003 supplemental inspection, the NRC inspection team noted that the licensee did not create a specific improvement plan to address the findings of the safety culture assessments, choosing to address selected safety culture attributes that were associated with root cause evaluations rather than treating the findings in the context of a separate problem area. By not performing a cause evaluation for safety culture, ANO management missed the opportunity to address the full scope of safety culture weaknesses. In response, the licensee performed two cause evaluations, developed the Safety Culture Area Action Plan, and assigned a full-time Nuclear Safety Culture Manager.

The team reviewed CR-ANO-C-2015-282, CA-32, and CR-ANO-C-2016-748, CA-8, to assess the licensees corrective actions associated with establishing a new Nuclear Safety Culture Manager position. The inspectors reviewed Procedure EN-QV-136-ANO-RC, Nuclear Safety Culture Monitoring, Revision 2, to verify the roles and responsibilities of the manager position, and discussed those responsibilities with the individual fulfilling the manager role.

The inspectors observed the NSC Manager performing oversight of the organization and implementing the roles and responsibilities. The NSC Manager was observed to identify that a NSC observer was not meeting expectations to be critical in identifying negative behaviors. The manager initiated a corrective action work tracker WT-WTANO-2017-00002 to address the concern, and provided peer-to-peer training and observations to reinforce the need for critical observations.

Based on the actions taken by the licensee, data evaluated by the team, and observations performed on site, the team concluded that the actions taken to address SC-2 were effective. Therefore, SC-2 is closed.

SC-3 Revise procedure EN-QV-136, Nuclear Safety Culture Monitoring, to add NSC monitor orientation training for Nuclear Safety Culture Monitoring Panel (NSCMP)and Safety Culture Leadership Team members. (CR-ANO-C-2016-00748, CA-13)

During the 95003 supplemental inspection, the NRC team found that the NSCMP did not identify weaknesses or a declining trend in NSC until receiving the results of the external safety culture assessments (i.e., 2014 Synergy Safety Culture Survey and 2015 Third Party Nuclear Safety Culture Assessment (TPNSCA).)

The team concluded that prior to spring 2015, the NSCMP did not demonstrate a rigorous, consistent process for evaluating the available information concerning ANOs safety culture. The team concluded that a lack of specific training for NSCMP members and guidance regarding how to assess the sites safety culture, contributed to assessment results that were overly subjective.

To evaluate the licensees corrective action effectiveness, the team reviewed:

• CR-ANO-C-2016-00748, CA-13

• Procedure EN-QV-136-ANO-RC, Nuclear Safety Culture Monitoring, Revision 2

• Job Familiarization Guide ASFAM-NSC-MON, Nuclear Safety Culture Monitoring, Revision 0 The team determined that Procedure EN-QV-136-ANO-RC, Nuclear Safety Culture Monitoring, Revision 2, included requirements for members assigned to the Nuclear Safety Culture Monitoring Panel and Safety Culture Leadership Team to complete training within six months of being assigned to one of the groups. The team reviewed the training qualification material, Job Familiarization Guide ASFAM-NSC-MON, Nuclear Safety Culture Monitoring, Revision 0, to assess the quality of the training and concluded that this guide was effective in providing appropriate training to achieve a rigorous and consistent process for evaluating information for ANOs safety culture. The team verified that all personnel assigned to the monitoring panel had completed the training within the six-month procedural requirement, with the exception of two individuals. These two individuals were verified to have been in place less than six months and were on track to complete the training within the time required.

Based on the actions taken by the licensee, data evaluated by the team, and observations performed on site, the team concluded that the actions taken to address SC-3 were effective. Therefore, SC-3 is closed.

SC-4 Conduct a structured off-site meeting among the ANO Senior Leadership Team to align on what a strategic commitment to safety looks like at ANO and the leader behaviors that will demonstrate that commitment.

(CR-ANO-C-2016-00748, CA-7)

During the 95003 supplemental inspection, the NRC team identified that the licensee had not evaluated the causes for the safety culture weaknesses documented in the Synergy Safety Culture Survey and the TPNSCA reports. In response to the NRC teams concerns, the licensee performed a common cause analysis and identified that they did not have an adequate explicit management focus on safety culture and the associated infrastructure to support a healthy NSC. Leadership did not align on what a strong NSC at ANO looks like and their personal impact on the workforce through their actions or inactions.

The team reviewed CR-ANO-C-2016-00748, the off-site leadership meeting minutes, onsite posters documenting the ANO leadership teams strategic commitment to safety and desired behaviors, and interviewed a sample of leadership team members.

The ANO leadership team conducted structured off-site meetings on April 20, 2016, and January 17, 2017, to align on a strategic commitment to safety and leader behaviors that demonstrate that commitment. The leadership team created a document describing their commitment to safety and listed the desired behaviors that support safety. As a result of the meeting, the leadership team created posters and other communications that reinforce to site personnel the desired behaviors and commitment to safety. The inspectors also determined that leaders used the commitment and list of desired behaviors in meetings to support decision-making for safety.

Based on the actions taken by the licensee, data evaluated by the team, and observations performed on site, the team concluded that the actions taken to address SC-4 were effective. Therefore, SC-4 is closed.

SC-7 Establish a small group meeting schedule to facilitate face-to-face interaction between ANO senior leadership and station employees. This activity should span a minimum period through the end of 2016 and include the following attributes: 1) purpose is open dialogue on safety performance with emphasis on employee questions and feedback; and 2) schedule should be coordinated to facilitate broad exposure, with emphasis on workers on shift rotation who cannot routinely participate in other communication forums. (CR-ANO-C-2015-01445, CA-99, CA-100, CA-102 through CA-112, CA-116, and CR-ANO-C-2016-00748, CA-19)

During the 95003 supplemental inspection, the NRC team reviewed the licensees safety culture common cause analysis (also discussed above under SC-4) conclusion that leadership did not effectively engage and align the ANO workforce on individual responsibilities for nuclear safety. Leadership did not create an environment where input and feedback were consistently sought out, valued, and rewarded. The free flow of information up, down, and across the organization was not cultivated or used by leaders to positively influence the culture, to learn, and to understand organizational health.

The team inspected a sample of the groups associated with this action using individual interviews with personnel from the engineering, chemistry, and instrument maintenance departments to assess the effectiveness of Safety Conscious Work Environment (SCWE) and NSC training performed and the impact of the alignment meetings. The inspectors also verified that the licensee has continued face-to-face meetings between the senior leadership and the line workers. The team concluded that the face-to-face meetings were effective in creating open dialog up and down the organization. A review of attendance sheets for the meetings demonstrated that the meetings spanned a broad schedule to ensure shift workers were able to attend the meetings.

The inspectors noted that several newly hired engineering staff could not articulate a clear understanding of the differences between SCWE and NSC, but overall, these engineering staff members understood the overarching importance of having a strong nuclear safety culture and stated they would raise safety concerns to their supervisors. Newly hired engineering staff also recognized the different organizations available to them for raising these types of concerns. The inspectors also noted that other departments were exhibiting behaviors that the overall message was received and implemented, such as a chemistry technician describing the coach-the-coach process when discussing critical observations.

Based on the actions taken by the licensee, data evaluated by the team, and observations performed on site, the team concluded that the actions taken to address SC-7 were effective. Therefore, SC-7 is closed.

4OA6 Meetings, Including Exit

Exit Meeting Summary

On March 16, 2017, the team presented the inspection results to Mr. R. Anderson, Site Vice President, and other members of the licensee staff. The licensee acknowledged the issues presented. The licensee confirmed that any proprietary information reviewed by the inspectors had been returned or destroyed.

SUPPLEMENTAL INFORMATION

KEY POINTS OF CONTACT

Licensee Personnel

R. Anderson, Site Vice President

L. Blocker, Director, Recovery

C. Couch, Specialist, Chemistry

D. Edgel, Recovery Manager, Regulatory Assurance and Performance Improvement

M. Hall, Licensing Specialist, Regulatory Assurance

D. James, Director, Recovery

D. Marvel, Recovery Manager, Regulatory Assurance and Performance Improvement

N. Mosher, Licensing Specialist, Regulatory Assurance

E. Nicholson, Manager, Performance Improvement

E. Nietert, Senior Specialist, Performance Improvement

B. Pace, Manager, Work Management

D. Sileo, Director, Organizational Effectiveness

M. Skartvedt, Manager, System Engineering

G. Sullins, Senior Recovery Manager, Regulatory Assurance and Performance Improvement

J. Toben, Manager, Nuclear Safety Culture

LIST OF CONFIRMATORY ACTION LETTER ITEMS CLOSED AND DISCUSSED

Closed

Significant Performance Deficiency FP-5 (Section 4OA5.1)

VO-10 (Section 4OA5.1)

VO-14 (Section 4OA5.1)

Identifying, Assessing and Correcting Performance Deficiencies CA-15 (Section 4OA5.2)

CA-17 (Section 4OA5.2)

DM-5 (Section 4OA5.2)

PH-9 (Section 4OA5.2)

PM-9 (Section 4OA5.2)

Human Performance LF-1 (Section 4OA5.3)

LF-6 (Section 4OA5.3)

PQ-1 (Section 4OA5.3)

PQ-2 (Section 4OA5.3)

Equipment Reliability and Engineering Program Deficiencies PH-11 (Section 4OA5.4)

PM-2 (Section 4OA5.4)

PM-4 (Section 4OA5.4)

PM-11 (Section 4OA5.4)

Safety Culture Issues CA-2 (Section 4OA5.5)

LF-9 (Section 4OA5.5)

SC-14 (Section 4OA5.5)

CO-4 (Section 4OA5.5)

NF-4 (Section 4OA5.5)

SC-2 (Section 4OA5.5)

SC-3 (Section 4OA5.5)

SC-4 (Section 4OA5.5)

SC-7 (Section 4OA5.5)

Discussed

Significant Performance Deficiency VO-20 (Section 4OA5.1)

VO-24 (Section 4OA5.1)

Identifying, Assessing and Correcting Performance Deficiencies CA-16 (Section 4OA5.2)

DM-23 (Section 4OA5.2)

Human Performance PQ-4 (Section 4OA5.3)

Safety Culture PM-20 (Section 4OA5.5)