ML20204A841

TVA Corrective Action Statement (EA-19-092)

ML20204A841
Person / Time
Site:	Watts Bar
Issue date:	07/30/2021
From:	NRC/OE
To:	Tennessee Valley Authority
Gulla G
Shared Package
ML20204A831	List: ML20204A841
References
2-2016-042, EA 19-092
Download: ML20204A841 (10)

Text

Confidential l Withhold from public disclosure under 10 C.F.R. § 2.390(a)(6) & (a)(7)

NRC DOCKET NO. EA 19-092 TVA CORRECTIVE ACTION STATEMENT I. INTRODUCTION In addition to the specific corrective actions discussed in TVAs responses to each Apparent Violation, TVA has taken significant corrective actions over the past nearly five years that generally address three broad areas of conduct related to the allegations in the Apparent Violations:

• Procedural non-compliance associated with the pressurizer water level event of November 11, 2015 (RHR Event);

• Adherence to TVAs safety policy, as reflected in Watts Bar Nuclear Plant (WBN)

OPDP-1, Conduct of Operations; and

• The completeness and accuracy of information submitted to the NRC by TVA employees.

In this statement, TVA discusses a variety of actions implemented to correct performance issues associated generally with those three areas of focus that TVA identifies in the NRCs Apparent Violations.

II. ACTIONS TO CORRECT PERFORMANCE ISSUES ASSOCIATED WITH PROCEDURAL NON-COMPLIANCES ASSOCIATED WITH THE RHR EVENT A. In EA 19-092 Apparent Violations 3-6, the NRC alleges that apparent procedural non-compliances occurred in connection with the RHR Event.

B. Since November 2015, TVA has conducted necessary analyses to identify the causes of operational events at WBNincluding the RHR Eventand general deficiencies in Operator Fundamentals.

1. On November 25, 2015, Watts Bar Quality Assurance (QA) initiated Condition Report 1108509, which identified that Operations licensed personnel had not demonstrated adequate implementation of the Operator Fundamentals of Monitoring Plant Indications and Controlling Plant Evolutions Precisely. On December 21, 2015, QA initiated CR 1118150 to escalate the issues in CR 1108509 to the Operations Director.

a. CR 1118150 included an apparent cause evaluation to evaluate why WBN Operations licensed personnel had not demonstrated adequate Operator Fundamentals in monitoring, and precise control of plant evolutions.

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b. In the CR 1118150 apparent cause evaluation, the following apparent cause was identified: The apparent cause is a failure by WBN senior management to recognize deficiencies in Operator Fundamentals and reinforce high standards and expectations for performance.

c. In the CR 1118150 apparent cause evaluation, Contributing Cause 3 identified: Documentation of issues and day to day events in logs and the corrective action program has not been timely and in some cases has not occurred.

d. Actions to address the CR 1118150 causes included:

i. Oversight in the Main Control Room by Operations Superintendents 24/7 for one month; ii. A stand-down on the Unit 2 project; iii. Dedicated Operations personnel assigned to support the Unit 2 project; and iv. Daily (weekday) independent log reviews conducted to validate log entries for one month.

e. Additional actions to address the QA escalation are listed in CR 1118150.

2. On June 28, 2016, QA initiated Condition Report 1186630 to escalate the issues in CR 1118150 to the Plant Manager.

a. CR 1186630 included an apparent cause evaluation to evaluate the Operations department management lack of formality in the application of standards and human performance tools resulting in recurring preventable human performance events.

b. In the CR 1186630 apparent cause evaluation, the following apparent cause was identified: The apparent cause is a failure by operations managements to hold themselves and the workforce accountable to high standards of performance, resulting in preventable human performance errors.

c. In the CR 1186630 apparent cause evaluation, the following contributing cause was identified: Operations management has not provided adequate direction and mentorship to foster strong fundamental decision making competencies for Shift Managers and Unit Supervisors to support effective leadership for their crews and the station.

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d. Actions to address the CR 1186630 causes included:

i. Implement external mentorship expertise to provide direct feedback on-site to WBN Shift Managers; ii. Operations Director provide Operations Shift Manager and above team standards and expectations for leadership; and iii. Develop and Administer 1 to 2 brief (<15 minute) simulator scenarios to each crew during training week (emphasis on assignment of trigger values/conservative decision making).

e. Additional actions to address the QA escalation are listed in CR 1186630.

3. To evaluate the circumstances surrounding the November 11, 2015, Unit 1 heat-up with normal letdown isolated, TVA initiated apparent cause evaluation CR 1121520 on January 5, 2016 and root cause evaluation CR 1127691 on January 21, 2016.

a. The apparent cause evaluation and root cause evaluation led to the following corrective actions:

i. A case study covering issues associated with the November 11, 2015, heat-up was presented to licensed operators, Outage Control Center staff, and senior station leadership.

The case study included a discussion of the performance gaps associated with decision-making, risk management, stop when unsure, use of the corrective action program to document and resolve issues, and procedure use and adherence. Additionally, the roles of and dynamics between the OCC and MCR were discussed.

ii. Oral boards in January 2016 with all shift managers, conducted by WBN senior leaders (Site Vice President, Plant Manager and Unit 2 Project Vice President), to evaluate and reinforce: conservative decision-making, responsibility, authority for stopping when unsure, and procedure use and adherence, including the use of N/A.

Following the completion of all oral boards, the same senior leaders met with all Shift Managers to discuss common oral board learnings and expectations going forward. The Shift Managers formally signed for their understanding of those expectations.

iii. Revisions to plant procedures to ensure an established procedural mechanism to feed operational limitations 3

Confidential l Withhold from public disclosure under 10 C.F.R. § 2.390(a)(6) & (a)(7) identified in clearance development, such as Mode restraints, back to the work-implementing document.

iv. Revisions to plant procedures to add notes in appropriate procedures to ensure that RHR is not secured with only excess letdown in service during RCS heat-up.

b. Additional actions taken to correct the issues associated with the November 11, 2015, reactor heat-up are listed in the apparent cause evaluation report (CR 1121520) and the root cause evaluation report (CR 1127691).

III. ACTIONS TO CORRECT PERFORMANCE ISSUES ASSOCIATED WITH TVAS SAFETY POLICY AND WBN OPDP-1, CONDUCT OF OPERATIONS A. In EA 19-092 Apparent Violation 4, the NRC alleges that, when faced with an emerging issue, the licensee did not ensure that shift operations were conducted in a safe and conservative manner; did not stop when unsure and proceed in a deliberate and controlled manner; did not validate available information; allowed production to override safety; and proceeded in the face of uncertainty.

B. TVA has acknowledged that a chilled work environment developed in the WBN Operations Department in 2015 that ultimately led to the NRCs Chilling Effect Letter issued on March 23, 2016. The WBN work environment at that time did not meet TVAs expectations, and TVA has worked tirelessly since then to reestablish and sustain a healthy Nuclear Safety Culture and Safety Conscious Work Environment at WBN.

C. In its Chilling Effect Letter, the NRC:

1. Called into question whether TVA management was open to safety concerns raised by operators and whether there was a proper safety-first focus during plant operations; and

2. Had indications that there was undue influence and direction of licensed operators from sources external to the control room that affected operational performance.

D. The NRCs allegations in Apparent Violation 4 appear closely related to the issues the NRC raised in the Chilling Effect Letter; therefore, the corrective actions TVA took in reaction to the Chilling Effect Letter are relevant to the allegations in Apparent Violation 4.

E. Even before the NRCs Chilling Effect Letter, TVA was investigating concerns with the work environment at WBN.

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1. In early 2016, the TVA Employee Concerns Program (ECP) conducted an investigation to review an employee concern about the Operations Department work environment at WBN. The results of this investigation, memorialized in an ECP report, confirmed indications that a degraded work environment existed in the WBN Operations Department.

2. Once TVA senior management was aware of Operations Department chilling-effect concerns, a Watts Bar Nuclear Plant Work Environment Improvement Plan was developed to achieve improvement in the Operations Department work environment.

3. In addition, in February 2016, TVA Senior management assembled a Special Review Team (SRT). The SRTs report recommended actions that were added to the Work Environment Improvement Plan.

4. The ECP report and the SRT report were provided to the NRC in a letter dated March 24, 2016.

F. On April 22, 2016, TVA responded to the NRCs Chilling Effect Letter and provided a copy of the Chilled Work Environment Action Plan, which included:

actions taken prior to issuance of the Letter, immediate actions taken upon receipt of the Letter, and actions to assess the WBN climate. See ADAMS, Accession Number ML16113A228. The actions TVA took to assess the WBN climate included:

1. Key organizational alignment and support changes;

2. Independent observations of the Main Control Room and Outage Control Center to assess the safety climate for Operations; and

3. Evaluation of the effectiveness of both the Corrective Action Program and Employee Concerns Program.

G. Upon receipt of the NRCs Chilling Effect Letter, TVA initiated root cause evaluation CR 1155393. TVA completed the CR 1155393 Chilled Work Environment Root Cause Analysis (CWE RCA) Report on May 5, 2016, which identified the root causes of the chilled work environment as:

1. Root Cause 1: Senior leaders failed to recognize the potential impacts on the work environment associated with initiative to drive improvements in overall station performance.

2. Root Cause 2: A failure by management to communicate the rationale and bases for some personnel actions taken led to an atmosphere of fear by some workers.

H. In order to address these root causes, as well as the contributing causes it also identified, the CWE RCA Report provided an extensive list of corrective actions 5

Confidential l Withhold from public disclosure under 10 C.F.R. § 2.390(a)(6) & (a)(7) to be implemented, including the following Corrective Action to Preclude Repetition (CAPR): A WBN Business Planning Initiative was implemented that was specifically focused on improving senior leadership behaviors and creating accountability for senior leadership.

1. The CAPR was effective at improving management behaviors, so that today the WBN work environment supports employeesincluding operatorsin raising safety concerns without the fear of retaliation and encourages concerns being raised.

2. Additional actions to address the causes of the Operations Department Chilled Work Environment are listed in CR 1155393.

I. On April 12, 2017, TVA provided an update to its Chilling Effect Letter response.

The updated response incorporated independent contractor recommendations, NRC observations from Problem Identification and Resolution Inspections, and TVA management observations into Chilled Work Environment Action Plan, Revision 1.

1. In this update, TVA refined its focus to actions in four specific areas to address the feedback received from our employees and promote a respectful work environment where employees are willing to raise concerns. Those focus areas were:

a. Safety has priority over production.

b. CAP is effective.

c. Management and employees practice mutual respect.

d. Nuclear Safety Culture is understood and reinforced.

2. Actions in these focus areas included:

a. Outage nuclear safety culture actions such as monitoring safety culture behaviors, communicating performance results to the workforce, and obtaining workforce feedback and insights on strengths and weaknesses for lessons learned and additional actions needed.

b. Corrective action closure quality reviews.

c. Expanding Nuclear Safety Culture Monitoring Panel Participation.

d. Semi-annual seminars for the Senior Leadership Team through 2017 focused on managing and communicating in a changing work environment and managing performance expectations without creating a fear of retaliation.

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e. Established a Fleet Safety Culture Peer Team to monitor and discuss the health of the sites safety culture and safety conscious work environment.

J. On July 27, 2017, NRC issued Confirmatory Order (CO) EA-17-022 regarding an apparent violation of previously issued CO EA-09-009,203, dated December 22, 2009. Specifically, in part, TVA failed to implement a process to review proposed adverse employment actions at WBN before actions were taken to determine whether the proposed actions could negatively impact the SCWE. TVA agreed to implement actions required in CO EA-17-022, including the following:

1. TVA maintains a nuclear safety culture monitoring panel; ensures that annual safety conscious work environment training is provided to required staff, and conducts Executive Review Boards to review Adverse Employee Actions specified in CO 17-022; and

2. TVA evaluates Adverse Employee Actions for their impact on SCWE and develops and implements SCWE mitigation plans, as necessary.

3. All of the actions required by CO 17-022 are tracked in CR 1322419.

K. Over the course of several inspections, the NRC has recognized the effectiveness of the CWE RCA report and its corrective actions at improving the WBN work environment.

1. On February 2, 2018, the NRC completed a follow-up inspection of CO EA-17-022 and the Chilling Effect Letter at WBN and issued Inspection Report 05000390/2017009, 05000391/2017009, on March 14, 2018. In this inspection report, the NRC found that:

a. All of the actions in the TVA Chilled Work Environment Action Plan, Revision 1 were reviewed and no findings were identified.

The NRC listed a status for the actions as no further inspection at this time.

b. No findings related to implementation of CO EA-17-022 requirements.

2. On June 29, 2018, the NRC completed a follow-up inspection of CO EA-17-022 and Chilling Effect Letter at WBN and issued Inspection Report 05000390/2018012, 05000391/2018012 on August 17, 2018. In this inspection report, the NRC found that:

a. RCA CR 1155393 was adequate. The NRC also determined that, overall, the final effectiveness review demonstrated that the corrective actions and enhancements were being implemented and were ultimately having a positive effect on the work environment 7

Confidential l Withhold from public disclosure under 10 C.F.R. § 2.390(a)(6) & (a)(7) within the operations department in addition to providing site-wide monitoring of safety culture.

b. TVA had made progress in improving the nuclear safety culture at Watts Bar and that the work environment supported operators to raise nuclear safety concerns without fear of retaliation.

c. TVA faced challenges related to identification and evaluation of department-specific work environment trends.

d. There were indications of a chilled work environment within the Radiation Protection (RP) department which suggested continued challenges to Watts Bars ability to proactively detect and prevent chilled work environments.

L. On the August 31, 2018, the NRC issued a WBN Assessment Follow-up letter, which identified a Safety Conscious Work Environment cross-cutting issue, left the Chilling Effects Letter open, and established Chilling Effect Letter and Cross-cutting Issue closure criteria.

1. In response to the NRCs letter, TVA conducted an investigation and root cause analysis CR 1452420.

a. TVAs investigation identified employee misconduct and appropriate disciplinary actions were taken.

b. TVAs root cause analysis confirmed the NRCs assertions of weaknesses associated with safety culture monitoring at the Department level and included the following action to prevent recurrence:

i. Revise NPG-SPP-01.7.2 (Nuclear Safety Culture Monitoring) to include a tool/matrix that aggregates GWE/CWE data at both the station and department specific level, and process controls for the review of the tool/matrix to support proactively assessing and acting upon GWE/CWE issues.

ii. Additional actions to address the causes of the Radiation Protection Department Chilled Work Environment are listed in CR 1452420.

2. Once TVAs safety culture monitoring efforts and root cause effectiveness review determined that the Chilling Effect Letter and Cross-cutting Issue closure criteria were met, TVA notified the NRC on October 3, 2019 of its readiness for the NRC follow-up inspection. See ADAMS, Accession Number ML19276C380. TVAs letter included a summary of the actions taken to address the closure criteria, including sustained improvement in 8

Confidential l Withhold from public disclosure under 10 C.F.R. § 2.390(a)(6) & (a)(7) the Operations Department work environment, which are relevant to contributing causes for operator actions and decision-making during the November 11, 2015 heat-up.

3. On October 24, 2019, the NRC completed a follow-up inspection of CO EA-17-022 and the Chilling Effect Letter at WBN and issued Inspection Report 05000390/2019012, 05000391/2019012, on December 23, 2019. In this inspection report, the NRC found that:

a. Based on the results of interviews, safety culture surveys, and assessments, the team determined, there was evidence of improvement in the safety conscious work environment in the Radiation Protection Department and sustained improvement in the Operations department.

b. There were no findings identified during this inspection.

M. On March 3, 2020, the NRC issued an Annual Performance Assessment letter for Watts Bar and determined that TVA has made progress to address the Chilling Effect Letter and Cross-Cutting Issue closure criteria. No new criteria were specified and no new follow-up inspections have been planned.

N. TVA believes that the actions taken to address the 2015 operational events and operator performance issues, along with the actions taken to meet the Chilling Effect Letter and Cross-cutting Issue closure criteria, have successfully addressed the organizational and operator performance issues associated with the apparent violations in EA 19-092.

O. TVA remains committed to effective safety culture monitoring and to implementing improvements as necessary to sustain a healthy safety culture and safety conscious work environment across the fleet.

P. The TVA Fiscal Year 20-22 Nuclear Fleet Business Plan includes the Business Planning Initiative, Achieve a Culture of Excellence. Specific safety culture actions are contained in this initiative in the following areas:

1. Improve leadership engagement and communication with employees

2. Implement safety culture improvement plans

3. Implement measures to drive consistent and efficient implementation of the safety culture monitoring program

4. Establish a sustainable Fleet Nuclear Safety Culture assessment process 9

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IV. ACTIONS TO CORRECT PERFORMANCE ISSUES ASSOCIATED WITH MAINTAINING AND SUBMITTING COMPLETE AND ACCURATE INFORMATION TO THE NRC A. In EA 19-092 Apparent Violations 7-12, the NRC alleges that TVA maintained and/or submitted to the NRC incomplete and/or inaccurate information in violation of 10 CFR 50.9.

1. With the exception of one isolated instance, TVA denies that incomplete and/or inaccurate information was maintained and/or submitted to the NRC as alleged in EA 19-092.

2. Even though TVA has taken this position with respect to the apparent violations of 10 CFR 50.9, TVA has implemented actions to ensure complete and accurate information is maintained and/or submitted to the NRC.

a. Specifically, TVA recently revised Procedure NPG-SPP-03.10, Managing TVA's Interface with NRC, including multiple changes to the validation process for NRC submittals. This procedure also requires TVA personnel who interact with NRC to do so in a complete and accurate manner.

i. In EA,19-042, which concerns a 10 CFR 50.9 violation, NRC gave TVA credit for corrective actions taken to address a 10 CFR 50.9 violation.

ii. Similarly, TVA should receive credit for these corrective actions in connection with EA 19-092.

b. Additionally, subsequent to receiving the Notice of Apparent Violation in 19-092, the TVA Chief Nuclear Officer issued a communication reemphasizing to all TVA Nuclear personnel the requirement for all interactions with the NRC to be complete and accurate in every way.

B. TVA believes that these actions are sufficient to correct compliance issues with 10 CFR 50.9.

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