ML21266A112
| ML21266A112 | |
| Person / Time | |
|---|---|
| Site: | River Bend  |
| Issue date: | 08/16/2021 |
| From: | Entergy Corp |
| To: | NRC Region 4 |
| References | |
| Download: ML21266A112 (41) | |
Text
River Bend Pre-Decisional Enforcement Conference August 16, 2021
Agenda 1
Management Overview Kent Scott Confirmatory Order Perspective Jeff Reynolds Identification of Issues Tim Schenk Issue Overview & Enforcement Perspective
- NDE Proctor Tiffany Baban
- Operator Rounds Danny James
- CDA Key Mark Feltner Civil Penalty Assessment Tim Schenk Closing Comments Kent Scott
Management Overview Kent Scott Site Vice President River Bend Station 2
Nuclear Excellence Model 3
Confirmatory Order Perspective Jeff Reynolds Director, Regulatory Assurance &
Performance Improvement River Bend Station 4
Identification of Issues Tim Schenk Manager, Regulatory Assurance River Bend Station 6
Entergy identified three issues where individuals violated internal policies and procedures:
In September 2018, an NDE exam proctor chose to deliberately circumvent the exam process by recreating a completed NDE exam In September 2019, two non-licensed operators did not conduct all required inspections during Control Building rounds In March 2020, an operator issued a CDA key and provided it to a supervisor not part of the critical group Identification of Issue 7
Issue Overview Enforcement Perspective 8
NDE Exam Proctor Falsification Tiffany Baban Senior Manager, Fleet Inspection Services Nuclear Headquarters 9
- In September 2018, Entergy identified that an NDE exam proctor falsified a Magnetic Particle General Exam
- NDE Principal Level III identified and promptly reported receiving two exams for one test-taker
- Entergy investigation determined the proctor circumvented the exam process NDE Proctor: Identification 10
Prompt Corrective Actions:
Entergy placed the proctor on leave and removed access Entergy withheld all certifications for the NDE test-taker Entergy initiated a comprehensive investigation Cause Evaluation Results:
NDE exam proctor chose to deliberately circumvent the exam process NDE exam proctor maintained low standards of integrity related to the NDE qualification process NDE Proctor: Identification 11
Entergy completed a fleet extent of condition:
Review of examinations by the proctor Verified no other integrity lapses by the proctor Review of examinations by other NDE proctors Verified no indications of a more widespread NDE proctor issue Review of overall fleet proctoring issues Investigation Results:
Entergy identified there were no other exam falsification, willful misconduct or systemic integrity issues Issue was isolated to the NDE exam proctor decision to circumvent the exam process NDE Proctor: Identification 12
Entergy terminated the NDE proctors employment and denied unescorted access
Entergy completed a root cause evaluation
Entergy issued fleet-wide communication
Entergy successfully retested and later qualified the test-taker
Entergy completed a gap analysis of the NDE qualification program
Entergy revised the implementing guidance for administration and control of NDE NDE Proctor: Corrective Actions 13
Were there actual or potential safety consequences?
Was the NRCs ability to perform its regulatory function affected?
Were the issues isolated and not recurring?
Were the responsible individuals at a low level in the organization and acting without management involvement?
Were the issues the result of individual action and not caused by a lack of management oversight?
Did Entergy identify and promptly report the issues?
Did Entergy take prompt corrective actions to restore compliance?
Did Entergy take effective corrective actions to prevent recurrence?
NRC Enforcement Policy Sections 2.2.1, 2.3.2; NRC Enforcement Manual Section 2.2.2 Assessing Significance 14
Apparent Violation Failure to accomplish activities affecting quality in accordance with procedure CEP-NDE-0100, Administration and Control of NDE, when an exam proctor deliberately made an unauthorized copy of a Magnetic Particle General Exam with the same control number and falsified the answers.
Entergy Assessment Entergy concurs that the exam proctor violated written procedures.
We discovered this during the exam verification process and promptly took several corrective actions to restore compliance and prevent recurrence. Entergy contends that this issue has a very low safety significance.
NDE Proctor: Enforcement Perspective 15
NDE Proctor: Timeline 2018 2019 2020 2021 Confirmatory Order NDE Proctor Issue identified Effectiveness Review - Trend in Proctor Issues identified Fleet Proctor RCE Initial CAs Implemented Additional CAs Implemented today NDE RCE Completed CO Communications CO Communications NDE Proctor Investigation complete Effectiveness Review Effectiveness Review CO Training CO Communications CO Follow-Up Inspection CO Follow-Up Inspection 16 CO Follow-Up Inspection (RBS)
Effectiveness Review Fleet Proctor ACA
Very Low Safety Significance There were no actual or potential safety consequences No work was performed by an unqualified individual There was no impact to the NRCs ability to perform its regulatory function The proctors misconduct was not recurring The proctor acted without management involvement The proctors misconduct was not caused by a lack of management oversight The proctors misconduct did not afford him any specific advantage NDE Proctor: Enforcement Perspective 17
Operator Rounds Danny James Senior Manager, Operations River Bend Station 18
- In September 2019, an Entergy audit determined two non-licensed operators failed to inspect certain panels during their rounds
- Entergy investigation concluded each operator mistakenly thought the other inspected the panels Operator Rounds: Identification 19
Operator Rounds: Identification 20
Operator Rounds: Identification 21
Investigation Results:
The O/I operator did not maintain continuous control of the U/I operator Breakdown in communication Operators believed faulty assumptions that the other performed the inspection without validation Operators exhibited poor attention to detail Neither operator deliberately violated requirements nor acted with careless disregard Operator Rounds: Identification 23
Entergy removed the NLO qualifications pending investigation
Entergy formally disciplined each operator via a written warning for violation Entergy procedures
Entergy updated non-licensed qualification cards with specific guidance for rounds responsibilities
River Bend held a stand down with each Operations crew to brief O/I and U/I responsibilities and integrity standards
Additional corrective actions developed this month based on continuing to evaluate the issue in response to this apparent violation Operator Rounds: Corrective Actions 24
Apparent Violation Failure to complete operator rounds when a non-licensed operator assigned to the Control Building as over-instruction failed to properly observe the under-instruction complete all panel checks and failed to ensure a complete tour of all required areas of their watch station.
Entergy Assessment Entergy recognizes that the operators made a mistake that resulted in an unrecognized non-compliance of procedures. Neither operator intentionally failed to complete the round. Entergy discovered the non-compliance as a result of a self-auditing process implemented by River Bend Operations Management and promptly took several corrective actions to restore compliance and prevent recurrence.
Entergy contends that this issue was not willful and had very low safety significance.
Operator Rounds: Enforcement Perspective 25
Operator Rounds: Timeline 2016 2019 2020 2021 Confirmatory Order Operator Rounds Issues (violations issued in 2019 and 2020)
RCE Completed CAs Implemented OI/UI Rounds Issue CO Communications CO Follow-Up Inspection Operator Rounds Entered in CAP Effectiveness Review Effectiveness Review CO Training CO Communications CO Follow-Up Inspection 2017 2018 OI/UI Rounds Issue Investigated Effectiveness Review CAs Completed 26 today CO Follow-Up Inspection (RBS)
CO Communications
Very Low Safety Significance and Not Willful
- There is no evidence the operators acted willfully
- There were no actual or potential safety consequences; the equipment remained fully operational and actively monitored
- There was no impact to the NRCs ability to perform its regulatory function
- The missed panel check was an isolated issue
- The missed inspection was not caused by a lack of management oversight Operator Rounds: Enforcement Perspective 27
Critical Digital Asset Key Mark Feltner Assistant Manager, Operations River Bend Station 28
In April 2020, an Entergy Cyber Security audit determined a work week SRO provided a critical digital asset (CDA) key for the Met Tower Control Building to a supervisor who was not in the critical group The auditor promptly reported this discovery to the Cyber Security Manager, who initiated a causal evaluation to understand the CDA breach CDA Key: Identification 29
CDA Key: Identification 30
Cause Evaluation Results:
The SRO knowingly violated CDA key control requirements due to self-imposed schedule pressure The SRO worked under assumptions and failed to maintain a questioning attitude CDA Key: Identification 31
Entergy conducted a fleet extent of condition focusing on similar instances of CDA keys or media being issued to non-critical group members Entergy identified that there were no other instances identified, since October 2019, where cyber security keys were possessed inappropriately None of the issues resulted in cyber security issues or tampering CDA Key: Identification 32
River Bend disciplined both individuals issuing time off without pay and a written warning for violation of Entergy procedures
River Bend Operations Management reinforced with SROs the importance of verifying critical group status prior to issuing CDA keys
Robust changes were made to the software requiring verification of critical group status before issuing CDA keys
River Bend updated signage on doors which require a CDA key to alert individuals of the procedural requirements before opening
River Bend installed a new Key Control System with fingerprint identification protocol CDA Key: Corrective Actions 33
Apparent Violation Failure to comply with the River Bend Cyber Security Plan when a work week senior reactor operator failed to follow key control procedures, resulting in an unauthorized individual opening a door to an area containing critical digital assets.
Entergy Assessment Entergy concurs that the work week SROs actions violated written procedures. We identified this during a Cyber Security Audit and found no evidence that resulted in equipment or cyber security controls being manipulated or altered. Entergy promptly took several corrective actions to restore compliance and prevent recurrence.
Entergy contends that this violation has very low safety significance.
CDA Key: Enforcement Perspective 34
CDA Key: Timeline 2018 2019 2020 2021 Confirmatory Order ACA Completed CDA Key Investigation Additional CAs Implemented Initial CAs Completed CO Communications CO Communications CDA key Issue Effectiveness Review Effectiveness Review CO Training CO Communications CO Follow-Up Inspection CO Follow-Up Inspection 35 CO Follow-Up Inspection (RBS) today Effectiveness Review Only willful key issue that has occurred
Very Low Safety Significance There were no actual safety consequences The incident did not impact the NRCs ability to perform its regulatory function The issue was isolated and not recurring The work week SRO acted unilaterally and without management involvement The issue was not caused by a lack of management oversight CDA Key: Enforcement Perspective 36
Civil Penalty Assessment Tim Schenk Manager, Regulatory Assurance River Bend Station 37
No Civil Penalty No similar issues identified Entergy identified the issues Entergy took prompt and effective corrective actions in response to the issues Issues are of very low safety significance No previous escalated enforcement at River Bend attributed to events occurring within the last 2 years Civil Penalty Assessment 38
Enforcement Perspective Summary: Entergys Enforcement Perspective NDE Proctor:
- SL IV Non-Cited Violation
- No Civil Penalty Operator Rounds:
- Previously Issued SL IV Non-Cited Violation
- No Traditional Enforcement
- No Civil Penalty CDA Key:
- SL III Violation
- Prompt and Comprehensive Corrective Actions
- No Civil Penalty 39
Closing Comments Kent Scott Site Vice President River Bend Station 40