ML19331A275

Non-Concurrence on Monticello Nuclear Generating Plant - Follow-Up Inspection Regarding the Assessment and Management of Shutdown Risk (NCP-2019-005)

ML19331A275
Person / Time
Site:	Monticello
Issue date:	10/07/2019
From:	Antonios Zoulis NRC/NRR/DRA/APOB
To:	Hironori Peterson NRC/RGN-III
References
NCP-209-005 05000263/2019012
Download: ML19331A275 (10)

Text

NRC FORM 757 (06-2019)

NRC MD 10.156 U.S. NUCLEAR REGULATORY COMMISSION NON-CONCURRENCE PROCESS COVER PAGE NRC FORM 757 (06-2019)

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Page 1 of 10 The U.S. Nuclear Regulatory Commission (NRC) strives to establish and maintain an environment that encourages all employees to promptly raise concerns and differing views without fear of reprisal and to promote methods for raising concerns that will enhance a strong safety culture and support the agency's mission.

Employees are expected to discuss their views and concerns with their immediate supervisors on a regular, ongoing basis. If informal discussions do not resolve concerns, employees have various mechanisms for expressing and having their concerns and differing views heard and considered by management.

Management Directive, MD 10.158, NRC Non-Concurrence Process, describes the Non-Concurrence Process (NCP).

The NCP allows employees to document their differing views and concerns early in the decisionmaking process, have them responded to (if requested), and include them with proposed documents moving through the management approval chain to support the decisionmaking process.

NRC Form 757, Non-Concurrence Process," is used to document the process.

Section A of the form includes the personal opinions, views, and concerns of a non-concurring NRC employee.

Section B of the form includes the personal opinions and views of the non-concurring employee's immediate supervisor.

Section C of the form includes the agency's evaluation of the concerns and the agency's final position and outcome.

NOTE: Content in Sections A and B reflects personal opinions and views and does not represent the official agency's position of the issues, nor official rationale for the agency decision. Section C includes the agency's official position on the facts, issues, and rationale for the final decision.

1. If the process was discontinued, please indicate the reason (and skip to #3):

Non-concurring employee(s) requested that the process be discontinued Subject document was withdrawn

2. At the completion of the process, the non-concurring employee(s):

Concurred Continued to non-concur

Agreed with some of the changes to the subject document, but continued to non-concur

3. For record keeping purposes:

This record is non-public and for official use only This record has been reviewed and approved for public dissemination

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1. NCP Tracking Number NCP-2019-005 Date 10/7/2019 Section A - To Be Completed By Non-Concurring Employee

2. Title of Subject Document MONTICELLO NUCLEAR GENERATING PLANT - FOLLOW-UP INSPECTION REGARDING THE ASSESSMENT AND MANAGEMENT OF SHUTDOWN RISK

3. ADAMS Accession Number N/A

4. Document Signer Hironori Peterson

5. Document Signer's Phone Number (Enter 10 numeric digits)

(630) 829-9707

6. Title of Document Signer Chief, Branch 3, Division of Reactor Projects

7. Office (Choose from the drop down list or fill in)

RIII

8. Name of Non-Concurring Employee(s)

Antonios Zoulis

9. Employee's Telephone Number (Enter 10 numeric digits)

(301) 415-1209

10. Title of Non-Concurring Employee Chief, PRA Operations Branch, Division of Risk Assessment

11. Office (Choose from the drop down list or fill in)

NRR

12.

Document Author Document Contributor Document Reviewer On Concurrence

13. Name of Non-Concurring Employee's Supervisor Russell Felts

14. Office (Choose from the drop down list or fill in)

NRR

15. Title of Non-Concurring Employee's Supervisor Deputy Director, Division of Risk Assessment

16. Supervisor's Telephone Number (Enter 10 numeric digits)

(301) 415-2884

17.

I would like my non-concurrence considered and would like a written evaluation in Section B and C.

I would like my non-concurrence considered, but a written evaluation in Sections B and C is not necessary.

18. When the process is complete, I would like management to determine whether public release of the NCP Form (with or without redactions) is appropriate (Select No if you would like the NCP Form to be non-public):

Yes

No

19. Reasons for the Non-Concurrence, Potential Impact on Mission, and the Proposed Alternatives NRR/DRA does not agree with the attribution of the Performance Deficiency (PD) to 10CFR50.65 (a)(4). The performance deficiency establishes a new precedent for maintenance rule implementation with regards to managing and accessing risk at licensee facilities. It sets unrealistic expectations in the scope and level of assessment required and goes contrary to established NRC enforcement guidance and past practices.

The inspection report conflates the shutdown safety plan with the actual (a)(4) risk assessment implementation by the licensee.

The licensee's risk assessment is conducted using form 2270 Critical Safety System Checklist at least once per shift. The inspection report inaccurately places the proximity of the PD on the development of the shutdown safety plan and the failure of the licensee to adequately assess and manage the risk during the development of this plan. The inspectors did not identify any 50.65 (a)(4) issues until the licensee failed the surveillance test related to shutdown cooling. The inspectors would not and did not identify any issues when they reviewed the pre-outage plan. The true proximate PD (i.e. the error in developing the RHR hardening procedure) appears to be mischaracterized as a contributing cause even though the licensee was not aware of the procedural error until they performed the shutdown cooling surveillance procedure. Per the Monticello draft apparent cause evaluation, the licensee determined that RHR hardening procedure 9111-05 Rev was inadequate. Specifically, on August 5, 2018 the licensee failed to translate steps to install jumpers to enable the RHR pump permissive from procedure 8.03.04-05 to the new RHR hardening procedure 9111-05 Rev. 0. The apparent cause evaluation determined that subsequent reviews did not identify this oversight and procedure 91111-05 Rev. 0 was issued with this deficiency prior to being implemented during the refueling outage on April 13, 2019. As a result, RHR pump remote start capability was unknowingly defeated for pumps with suction aligned through valves M0-2029 and M0-2030.

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1. NCP Tracking Number NCP-2019-005 Date 10/7/2019 The condition that could have been foreseen and prevented (required for a PD) was the incorrect development of procedure 9111-05, not the shutdown risk assessment that utilized the reviewed and approved, but never-the-less incorrect, RHR hardening procedure. The precedent the proposed performance deficiency would set going forward is that compliance with 50.65(a)(4) requires that associated risk assessments include separate technical reviews of procedures, drawings calculations, etc. already approved by the station review/approval process. This is not a reasonable expectation for licensees to meet or for the NRC to use as a basis for regulatory compliance determinations in this or future findings involving 50.65(a)(4).

In addition, the pre-outage plan is not required as part of 10 CFR 50.65. The requirement is to complete the assessment prior to conducting the maintenance work window. As we know, outages are fluid and often do not match the pre-planned outage schedule. This requires the licensee to conduct a risk assessment to assess and manage the risk daily and prior to each shift.

The licensee's shutdown safety plan states as much:

to perform the risk assessment, a qualitative assessment is being performed which relies on the outage risk management model and is determined at least once per shift using form 2270. This form will be completed by the Outage Control Center (OCC} SRO and approved by the Shutdown Safety Manager (SSM) with input from the duty operating crew.

There is no indication that the licensee would have taken any additional risk management actions given their lack of knowledge to the performance deficiency related to the failure hardening procedure during completion of form 2270.

The NRC Enforcement Guidance Section 2.1.10 Actions Involving the Maintenance Rule, general enforcement guidance clearly states the following:

The Maintenance Rule does not require licensees to establish program procedures.

1.

There cannot be a procedure violation of 10 CFR Part 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings, for failing to establish, implement or to maintain Maintenance Rule process implementing procedures.

The shutdown safety plan as indicated in the inspection report was required by the licensee's station procedures. The licensee's failure to accurately develop the shutdown safety plan is not a requirement of the regulation and cannot be cited as support for this violation. Therefore, stating that development of the shutdown safety plan was inadequate and resulted in the licensee's failure to assess and manage risk is counter to NRC established enforcement guidance. It would not be within the licensee's ability to foresee and correct as part of any risk assessment, given the licensee was not aware (unknowingly degrading the shutdown safety functions) of the procedure error until the performance of the surveillance test. Furthermore, conducting a risk assessment on a procedure is unprecedented and not considered as part of the maintenance rule. The actual physical installation of the jumpers would be assessed by the licensee when the actual work was performed. In addition, as indicated in the previous comment, the actual risk assessment does not occur with the shutdown safety plan but with the completion of form 2270.

The screening of the issue is also conflating the procedure error with the (a)(4) risk assessment. The procedure error resulted in the loss of a system safety function. The failure to assess and manage the risk, if it were the true performance deficiency, would only be more than minor if the overall elevated plant risk would put the plant into a higher licensee established risk category or would require, under plant procedures, RMAs or additional RMAs, as stated in IMC 0612 Appendix E. Failing to perform a risk assessment did not render the RHR shutdown cooling pumps inoperable. The inspection report is silent on what additional risk management actions would have been performed by the licensee given the procedural error. It is certain that the facility would never have knowing entered in the configuration described in this inspection report and therefore would not have needed to take any additional risk management actions. The response of the licensee would have been to correct the procedural error, not to conduct any additional risk assessments.

The attribution of this performance deficiency to 10CFR50.65 (a)(4) establishes a new regulatory precedent and expands the scope and intent of the rule. Since this regulatory position appears to be demonstrably unreasonable and contrary to the principles of good regulation for clarity and reliability, the NRC's regulatory credibility may be challenged.

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1. NCP Tracking Number NCP-2019-005 Date 10/7/2019

20. Signature and Date of Non-Concurring Employee Antonios M. Zoulis Digitally signed by Antonios M. Zoulis Date: 2019.10.07 09:35:56 -04'00'

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1. NCP Tracking Number NCP-2019-005 Date 10/7/2019 Section B - To Be Completed By Non-Concurring Employee's Supervisor

2. Title of Subject Document MONTICELLO NUCLEAR GENERATING PLANT - FOLLOW-UP INSPECTION REGARDING THE ASSESSMENT AND MANAGEMENT OF SHUTDOWN RISK

3. ADAMS Accession Number N/A

4. Name of Non-Concurring Employee's Supervisor Russell Felts

5. Office (Choose from the drop down list or fill in)

NRR

6. Title of Non-Concurring Employee's Supervisor Deputy Director, Division of Risk Assessment

7. Supervisor's Telephone Number (Enter 10 numeric digits)

(301) 415-2884

8. Comments for the NCP Reviewer to Consider NRR/DRA division management agrees with this nonconcurrence.

9. Signature and Date of Non-Concurring Employee's Supervisor Russell N. Felts Digitally signed by Russell N. Felts Date: 2019.10.08 06:44:48 -04'00'

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1. NCP Tracking Number NCP-2019-005 Date 10/7/2019 Section C - To Be Completed By NCP Coordinator

2. Title of Subject Document MONTICELLO NUCLEAR GENERATING PLANT - FOLLOW-UP INSPECTION REGARDING THE ASSESSMENT AND MANAGEMENT OF SHUTDOWN RISK

3. ADAMS Accession Number N/A

4. Name of NCP Coordinator Billy C. Dickson, Jr.

5. Office (Choose from the drop down list or fill in)

RIII

6. Title of NCP Coordinator Chief, Branch 2, Division of Reactor Projects

7. Coordinator's Telephone Number (Enter 10 numeric digits)

(630) 829-9827

8. Agreed Upon Summary of Issues The non-concurring employee contends that the performance deficiency (PD) as written in draft Monticello inspection report 0500263/2019012, establishes a new regulatory precedent. The PD sets new and unrealistic NRC standards regarding the scope and level of assessment needed in pre-outage shutdown safety plans.

Summary of Issues The loss of safety function experienced at Monticello was caused by the procedure inadequacies identified in the inspection report and it is not reasonable to expect the licensee to identify those procedural issues as part of the safety shutdown plan development. As defined in NRC Inspection Manual Chapter 0612, a PD represents a licensee's failure to satisfy one or more regulatory requirements or self-imposed standards where such failure was reasonably foreseeable and preventable. The technical issue that resulted in all four Residual Heat Removal (RHR) sub-systems being inoperable per the licensee's technical specifications was not foreseeable and not preventable via the shutdown safety plan.

The licensee should have foreseen and prevented the procedure error during the actual procedure review.

The shutdown plan assumes procedures and processes are correct. The licensee is not required to identify and consider such an error in the development of the shutdown plan.

The licensee-developed and implemented Shutdown Safety Plan was not required by 10 CFR Part 50.65 (a)

(4) and the inspector's conclusion that the licensee violated 10 CFR Part 50.65 (a)(4) is contrary to established NRC enforcement guidance and past practices. The licensee met the requirements by completing the Critical Safety System Checklist in accordance with their program requirements. The level of detail as expressed in the performance deficiency and throughout the inspection report writeup would establish new and unrealistic expectations for meeting the regulatory requirement to assess and manage the risk before maintenance activities.

The new guidance and training on backfit and forward fit states: Any communication has the potential to convey unjustifiable backfitting or forward fitting and the training specifically calls out inspection reports. In this case, we believe this finding represents an unintended backfit without following the agency's processes and without performing a backfit analysis.

For a 10 CFR 50.65 (a)(4) violation to be more than minor, the licensee must have been required to take additional actions to manage the risk. Even if this finding is determined to be accurate in that the licensee failed to assess the risk, what other actions would the licensee have taken? The guidance in NUMAR 91-06, which is called out in the inspection report, is vague and dated given the changes to outage management and other advancements related to hardening and water inventory controls.

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1. NCP Tracking Number NCP-2019-005 Date 10/7/2019

9. Evaluation of Non-Concurrence and Rationale for Decision Based on the NCP coordinator's review of NRC SECY-99-133, "Final Revision to 10 CFR 50.65, To Require Licensees to Perform Assessments Before Performing Maintenance, Regulatory Guide 1.160, NUMARC documents 93-01 and 91-06, and the NRC enforcement manual, the coordinator concluded that the requirements of (a)(4) are met when licensees use an integrated approach involving both the pre-maintenance planning and assessment efforts, and the continuous monitoring and management of the availability of systems structures and components (SSCs) throughout maintenance activities.

Historical Staff Expectations Associated with the implementation of 10 CFR 50.65 (a)(4)

In SECY-99-133, the staff discussed its expectations related to assessing and managing risk in terms of meeting the requirements of Maintenance Rule (a)(4). It states "The staff expects that, while performing on-line or shutdown maintenance, the licensee will remain in conformance with its Technical Specifications. In addition, the licensee's pre-maintenance planning is expected to include, to the depth necessary for the complexity of the maintenance activities, (1) identification of the equipment to be protected during the maintenance activity and (2) contingency plans that identify equipment to be restored first, if necessary, should a random equipment failure occur, and compensatory actions to be taken should the proposed outage duration be exceeded.

In this SECY, the staff established that "Licensees will be expected to review the current plant configuration and the anticipated changes caused by the proposed maintenance activities, although licensees may limit the scope of their assessments through use of an appropriate risk-informed evaluation process. Licensees are expected to consider potential failures and emergent maintenance requirements. The sophistication of the assessments, ranging from deterministic judgments to in-depth analyses, is expected to be commensurate with the complexity of the involved configurations."

For more detailed assessments, the staff expects that the assessment involves probabilistic analyses where possible and include considerations of key plant safety functions to be maintained and defense-in-depth. Attachment 1 of SECY-99-133 discusses these considerations. Specifically, Item 4 in Section III of the Final Rule for Maintenance Rule (a)(4), states that an appropriate assessment and management process should include the following considerations:

1. The likelihood that the maintenance activity will increase the frequency of an initiating event;

2. The probability that the activity will affect the ability to mitigate the initiating event;

3. The probability that the activity will affect the ability to maintain containment integrity;

4. Whether multiple trains are affected;

5. How probabilistic insights are used;

6. How non-probabilistic insights are used;

7. Component and system dependencies;

8. Measures to prevent concurrent unavailabilities of equipment necessary for accident mitigation;

i.

Methods to determine the duration of the activity and account for the projected duration;

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1. NCP Tracking Number NCP-2019-005 Date 10/7/2019 ii.

The analytical basis for allowed configurations (quantitative or qualitative consideration);

iii.

Provisions for accommodating configurations not encompassed by pre-analyzed, acceptable configurations; and iv.

Scope and quality of analysis for quantified assessments.

Validity of 10 CFR 50.65 (a)(4) Violation and Stated Performance Deficiency According to NCP-2019-005, NRR/DRA does not agree with the attribution of the Performance Deficiency (PD) to 10CFR50.65 (a)(4). The submitter contends that the performance deficiency establishes a new precedent for maintenance rule implementation with regards to managing and accessing risk at licensee facilities. Additionally, the NCP-2019-005 contends, that the inspection report conflates the shutdown safety plan with the actual (a)(4) risk assessment implementation by the licensee. The submitter believes that the licensee's risk assessment is conducted using form 2270 "Critical Safety System Checklist" at least once per shift.

The coordinator did not find any information in the enforcement manual or in Regulatory Guide 1.160 (or the NUMARC documents) that would lead the coordinator to conclude that the risk assessment subject to the requirements of 10 CFR 50.65 (a)(4) was limited to a discrete document created by licensees. The regulatory decision regarding whether the licensee's assessment was adequate should be based on the outcome of the licensee's final assessment before the start of the maintenance activity. As stated in the background material referenced above, the rule emphasizes performance. A licensee's assessment process is expected to identify the impact on safety that is caused by the performance of maintenance. The assessment process is expected to be incorporated into the maintenance planning and scheduling process and into work package requirements. Moreover, control room operators, who are expected to understand, use, and know the limitations of the assessment tools, generally use and maintain a variety of documents, such as logs and checklists, that contain information relating to out-of-service SSCs.

In terms of whether there is a failure to perform an adequate risk assessment, NRC Enforcement Manual Part II - 2, Reactor Topics, discusses issues that are violations of 10 CFR 50.65. Specifically, Section 2.1.11.D.1.b. identifies issues that are violations of 10 CFR 50.65 (a)(4) for failure to perform an adequate assessment.

This section of the enforcement manual states that: to support a violation, there should be a technically justifiable reason as to why the assessment is determined to be inadequate. It amplifies this statement by stating that if the assessment is sufficient in complexity, technically justifiable, and reasonable, it would be difficult to conclude that the assessment was inadequate. The sophistication of the assessment should be commensurate with the complexity of the configuration and should meet the test of reasonableness.

The NRC must provide a justifiable argument that it was reasonable for the licensee, using the guidance in NUMARC 93-01 and Section 4.0 of NUMARC 91-06, to have identified that removing both RHR suction valves from service by opening and de-energizing the valves, would have resulted in the loss of a key safety function. The inspection report does not provide an explicit discussion regarding why the inspectors believe that the test of reasonableness was not met. A test of reasonableness could have been derived from the information contained in Attachment 1 of SECY-99-133 discussed above. Moreover, there is no discussion of previous operating experience that should have led the organization performing the assessment to know that deenergizing the valves would result in the failure of the RHR pumps to start. There is no discussion in the inspection report related to operator training that recognized this interlock. Section 4.1.2.1 of NUMARC 91-06, does provide guidelines regarding how decay heat removal (DHR) system logic/interlocks should be evaluated for applicability to shutdown conditions. It states that consideration should be given to disabling logic or interlocks that are evaluated as detrimental for a given condition (i.e., systems and component dependencies). This is not discussed in the inspection report.

In terms of the failure to manage the increase in risk that may result from the proposed maintenance activity, the enforcement manual states that the process for managing risk involves using the results of the licensee's

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1. NCP Tracking Number NCP-2019-005 Date 10/7/2019 assessment in plant decision-making to control the overall risk impact. NRC Enforcement Manual Part II - 2, Reactor Topics, Section 2.1.11.1, Examples of Violation Example 3, depicts a violation of (a)(4) for the licensee failure to properly manage the increase in risk that may result from the proposed maintenance activities.

The significance determination section of the report discusses several adverse conditions that resulted because the licensee did not do an effective job of using the results of the SSD Plan. For example, this section contains the following statement, "the spent fuel pool system was not aligned to provide fuel cooling to the reactor vessel and the decay heat load exceeded the capability of the reactor water cleanup system. The licensee's alternative heat strategies relied on the safety relief valves (SRVs) and main steam isolation valve (MSIV) drain valves. Planned maintenance on April 13, 2019, resulted in air being isolated to all eight SRVs and the closure of the MSIV drain valves. These actions prevented the licensee from implementing the alternate decay heat removal strategy." Another example where the significance determination contains information that indicated that the licensee did not use the results of the SSD assessment to manage the risk associated with the maintenance activity was during the discussion associated with the inventory control safety function. Specifically, the following statement was included in this section: Inventory control was also an important function of shutdown risk management. The shutdown safety plan credited the core spray and LPCI systems for providing water injection into the vessel but did not address the ability to isolate the RHR system should there be a loss of inventory. Specifically, de-energizing the RHR suction valves, meant that these valves were unavailable to isolate a leak, until the function was restored on April 26.

Although the isolation function was not required by TS, the NUMARC guidance specifically states that this key safety function be maintained. The description section of the report does not discuss or give context to either of these examples as it relates to the overall regulatory impact of these conclusions.

Inspection Manual Chapter 0612 In Inspection Manual Chapter 0612, a performance deficiency is defined as the licensee's failure to satisfy one or more regulatory requirement or self-imposed standards where such failure was reasonably foreseeable and preventable. A standard includes a self-imposed standard such as a voluntary initiative or a standard required by regulation. To determine this cause, inspectors need not complete a rigorous root-cause evaluation, but instead may complete an evaluation based on reasonable inspector assessment and judgment.

Based on the information contained in the significance determination section of the inspection report, the coordinator concluded that the licensee failed to meet the requirement contained in 10 CFR 50.65(a)(4) related to managing the risk resulting from the proposed maintenance activity. Therefore, attribution of the performance deficiency to a failure to meet 10 CFR 50.65(a)(4) is supportable. On the other hand, the reviewer concluded that, as written, the inspection report fails to show that it was reasonable based on the complexity of the proposed maintenance activity that the licensee should have identified the affect of deenergizing both MO 2029 and 2030 as part of the SSD Plan development. The NCP reviewer concluded that the summary of the Performance Deficiency and the Contrary to statement in the Enforcement Section of the inspection report related to the (a)(4) violation should be modified to not include the discussion related to the licensee failure to properly assess the risk associated with implementation of procedure 9111-05, Decay Heat Removal Hardening, Revision 0.

Back-fit Concerns In addition to the concerns discussed above, the NCP submitter expressed that for a 10 CFR 50.65 (a)(4) violation to be more than minor, the licensee must have been required to take additional actions to manage the risk. The NCP coordinator reviewed the Screening section of the inspection report and concluded that the inspectors appropriately determined that the performance deficiency was More-than-Minor using IMC 0612, Appendix B. The coordinator did note that the Enforcement Manual does contain information relative to managing the risk associated with maintenance activities. It states that the licensee is not bound to keeping risk below some threshold or for taking particular actions when risk exceeds some threshold. The licensee is responsible for making conscious decisions as to how the increase in risk will be handled, then by following their own action plan for handling the increased risk.

The inspection documents the corrective actions taken by the licensee upon discovery of this issue. The inspection report also documents other corrective actions developed by the licensee to address causal factors identified during

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1. NCP Tracking Number NCP-2019-005 Date 10/7/2019 their apparent cause evaluation.

Lastly, the NCP submitter expressed concerns that we (NRR/DRA) believe this finding represents an unintended backfit without following the agency's processes and without performing a backfit analysis. Relative to this finding, the coordinator concluded that NRC Enforcement Manual Part II - 2, Reactor Topics, Section 2.1.11.1, Examples of Violation Example 3, showed that a licensee failure to manage the risk associated with maintenance activities based on licensee's assessment results is not a new regulatory position. In fact, the reviewer identified previous NRC inspection reports that documented a violation like this. One of these inspection reports includes Grand Gulf Nuclear Station - NRC Special Inspection Report 05000416/2016008.

However, as stated earlier, including the failure to assess risk in the contrary to statement contained in the Enforcement Section of the inspection report and in the Performance Deficiency section, without a thorough discussion related to why the inspectors believe that it was reasonable for the licensee to have known that the change associated with procedure 9511-05, Decay Heat Removal Hardening, Revision 1, would result in the loss of the available RHR pumps, would create a new NRC expectation.

Updated Assessment by NCP Coordinator:

The NCP coordinator reviewed the updated draft inspection report input provided by Region III, DRP Branch 3, related to the Branch's conclusion that the Monticello site personnel failed to adequately assess and manage the risk associated with outage activities. The NCP coordinator concluded that all previous concerns discussed above have been adequately addressed. Though not explicitly stated by the inspector in the inspection report input, the information in the writeup does establish that known Component and system dependencies were not adequately assessed before the maintenance activities began. The NCP coordinator concluded that the writeup as documented establishes a basis for why it was reasonable for the licensee to have known and considered the effect of closing the RHR suction valves. Additionally, based on the information contained in the revised draft inspection report input, the NCP coordinator concluded that the Measures to prevent concurrent unavailabilities of equipment necessary for accident mitigation were not properly managed by the licensee.

10. Signature and Date of NCP Coordinator

11. Signature and Date of NCP Approver Billy C. Dickson Digitally signed by Billy C. Dickson Date: 2019.11.05 09:59:27 -06'00' Mohammed A. Shuaibi Digitally signed by Mohammed A. Shuaibi Date: 2019.11.21 09:30:38 -06'00'