RBG-48128, Reply to a Notice of Violation; EA-21-017, 030 and 050
| ML21302A020 | |
| Person / Time | |
|---|---|
| Site: | River Bend  |
| Issue date: | 10/29/2021 |
| From: | Karenina Scott Entergy Operations |
| To: | Document Control Desk, Office of Nuclear Reactor Regulation, NRC/OE |
| References | |
| EA-21-017, EA-21-030, EA-21-050, RBG-48128 | |
| Download: ML21302A020 (10) | |
Text
-~ Entergy RBG-48128 October 29, 2021 Director, Office of Enforcement U.S. Nuclear Regulatory Commission Washington, DC 20555-0001
Subject:
Reply to a Notice of Violation; EA-21-017, 030 and 050 River Bend Station, Unit 1 NRC Docket No. 50-458 Renewed Facility Operating License No. NPF-47 Entergy Operations, Inc.
River Bend Station 5485 U.S. Highway 61 N St. Francisville, LA 70775 Tel 225-381-4374 Kent Scott Site Vice President 10 CFR 2.201
Reference:
NRC letter to Entergy, "River Bend Station - Notice of Violation and Proposed Imposition of $150,000 Civil Penalty, NRC Inspection Report 05000458/
2021091 and Investigation Reports 4-2020-008, 4-2020-009 and 4-2020-019,"
(ADAMS Accession No. ML21272A215) dated September 30, 2021.
Entergy Operations, Inc. (Entergy) hereby submits the Reply to a Notice of Violation; EA-21-017, 030 and 050 for River Bend Station in the Enclosure. As requested, the Enclosure contains the following for each violation: (1) the reason for the violation; (2) the corrective steps that have been taken and the results achieved; (3) the corrective steps that will be taken; and (4) the date when full compliance will be achieved.
As Entergy discussed in the Predecisional Enforcement Conference on August 16, 2021, Entergy takes very seriously any integrity violation and we recognize and own the shortfalls in performance that resulted in these violations. Entergy understands the importance of ensuring the highest level of integrity when performing work in the nuclear industry.
This letter contains no new regulatory commitments.
Should you have any questions, please contact Mr. Tim Schenk, Regulatory Assurance Manager, at 225-381-4177.
KS/ts/blj
Enclosure:
Reply to a Notice of Violation; EA-21-017, 030 and 050
RBG-48128 Page 2 of 2 cc:
NRC Regional Administrator - Region IV NRC Senior Resident Inspector - River Bend Station NRC Document Control Desk R4Enforcement@nrc.gov
Enclosure RBG-48128 Reply to a Notice of Violation; EA-21-017, 030 and 050
RBG-48128 Enclosure Page 1 of 7 Entergy Operations, Inc.
Reply to a Notice of Violation; EA-21-017, 030 and 050 By letter dated September 30, 2021 to Entergy Operations, Inc. (Entergy), the Nuclear Regulatory Commission (NRC) issued "River Bend Station - Notice of Violation and Proposed Imposition of $150,000 Civil Penalty, NRC Inspection Report 05000458/2021091 and Investigation Reports 4-2020-008, 4-2020-009 and 4-2020-019" (ADAMS Accession No. ML21272A215).
Entergy accepts the violations as cited in the referenced letter. Specifically, the NRC issued three violations of NRC requirements involving individuals' deliberate misconduct associated with failures to: A) control critical digital asset access keys (previously accepted as deliberate misconduct by Entergy to NRC); B) ensure a tour of all required non-lincensed operator watchstation areas are completed (previously accepted as misconduct by Entergy); and C) ensure that training examinations were appropriately proctored (previously accepted as deliberate misconduct by Entergy).
In accordance with 1 O CFR 2.201, this Enclosure provides Entergy's Reply to the Notice of Violation. For each of the violations, Entergy briefly provides a description of the violation and:
(1) the reason for the violation; 2) the corrective steps that have been taken and the results achieved; 3) the corrective steps that will be taken; and 4) the date when full compliance will be achieved.
A.
EA-21-030 - Violation Assessed a Civil Penalty Description of Violation On March 31, 2020, a member of the critical group provided a key that is used to control access to a room that contains critical digital assets to a person who was not a critical group member. Specifically, a licensed Senior Reactor Operator provided a critical digital asset key to a maintenance supervisor, whom the Senior Reactor Operator knew at the time was not a critical group member, and the maintenance supervisor accessed a room containing critical digital assets.
The Reason for the Violation As discussed at the August 16, 2021 Predecisional Enforcement Conference, on March 31, 2020, a Mechanical Maintenance supervisor discussed with an Operations Work Week SRO the performance of scheduled maintenance on the Met Tower propane generator, located in a utility shed. During their discussion, the supervisor requested a CDA key from the SRO. Both individuals were uncertain if a CDA key was required to perform the scheduled work. Using the key control database, the SRO verified that the supervisor was not in the critical group and explained that he could not issue him a CDA key. He also checked the qualifications of other members of Mechanical Maintenance and determined that no one in the department was in the critical group. Additionally, he verified there were no non-licensed operators available to escort the supervisor. The SRO then chose to issue the key to himself and gave the key to the supervisor. The SRO requested the supervisor check with the other Maintenance shops to see if they had a member of the critical group
RBG-48128 Enclosure Page 2 of 7 available to be an escort. The SRO explained that he would transfer the key responsibility to the critical group member, if one were located. The SRO also told the supervisor that if he were unable to locate an escort and, entry in the Met Tower Control Building was necessary, the supervisor must contact the Work Management Center and he, himself, would be the escort. Upon arrival at the Met Tower, the supervisor and his crew determined that a CDA key was not required to perform the scheduled maintenance; however, the Mechanical Maintenance supervisor did use the CDA key to open the door and briefly enter the Met Tower Control Building.
During the performance of a Cyber Security audit in April 2020 (eight days later), Entergy identified the unauthorized entry into the Met Tower Control Building. The auditor reported this discovery to the Cyber Security Manager, who promptly directed the initiation of a condition report, which led to a causal evaluation. This evaluation identified that the SRO knowingly violated the CDA key control requirements due to self-imposed schedule pressure. The SRO assumed that the supervisor would not access the Met Tower Control Building as they had discussed, without first ensuring that he had a qualified escort. The SRO, by providing the key to an unqualified supervisor, failed to question how he could ensure the security of the CDA without maintaining personal control of the key. It is noted that, following the audit, Entergy confirmed no cyber security controls were manipulated or altered.
As discussed in the referenced letter, the NRC determined that Identification credit was warranted for this issue because Entergy identified the condition and entered it into the corrective action program.
Corrective Steps Taken and Results Achieved Entergy took prompt actions after discovering this issue. Entergy conducted a fleet-wide extent of condition review focusing on similar instances of CDA keys or media being issued to non-critical group members dating back to October 2019. The review found no other instances where cyber security keys were possessed inappropriately.
As a part of the initial causal product, Entergy performed a culpability model review on the SRO, as required by procedure. This review determined the SRO's behavior was the result of an individual performance issue, not an organizational or programmatic problem. The SRO maintained low standards of integrity in that he deliberately circumvented the CDA Key Control process. The SRO understood the standard and made a choice to voluntarily and deliberately violate the standard. Based on that result, Entergy disciplined the SRO and did not perform an Organizational and Programmatic (O&P) evaluation for his actions.
Entergy did, however, conduct an O&P evaluation focusing on the Mechanical Maintenance supervisor's actions.
Entergy also assessed the work environment at River Bend Station to ensure a strong nuclear safety culture exists, as explained during the Predecisional Enforcement Conference. Entergy conducts these assessments routinely through meetings including the Nuclear Safety Culture Monitoring Panel with members from Employee Concerns, Human Resources, Regulatory Assurance, Performance Improvement, Security and Nuclear Independent Oversight. Safety culture is also assessed as part of our INPO Evaluation and annual Organizational Health Index surveys. These assessments have concluded that River Bend Station has a solid nuclear safety culture and does not promote
RBG-48128 Enclosure Page 3 of 7 production over safety. Recently, River Bend Station received positive feedback from the NRC after their follow-up inspection for the Confirmatory Order actions. The NRC interviews of station personnel confirmed that there is no indication of schedule pressure over safety.
Entergy disciplined both individuals involved in this issue which demonstrates the seriousness of the violation to other employees and deter others from deviating from requirements. Entergy Operations management reinforced with SROs at River Bend Station the importance of verifying critical group status prior to issuing CDA keys. Entergy made robust changes to the software requiring verification of critical group status prior to issuing CDA keys. Entergy Operations management at River Bend Station provided direct communication and coaching of behaviors related to issuance of keys, with a focus on CDA keys. The signage on doors that require a CDA key at River Bend Station was updated to alert individuals of the procedural requirements before opening. River Bend Station also installed a new Key Control System that uses a fingerprint identification protocol that verifies critical group status prior to the issuance of CDA keys to qualified individuals.
These measures have resulted in no further CDA key issues at River Bend Station.
Corrective Steps that Will Be Taken The NRC determined that the prompt corrective actions taken by Entergy were not sufficiently comprehensive, and therefore did not warrant Corrective Action credit for this issue. Specifically, the NRC concluded Entergy did not take sufficient action for O&P causal factors, apply the corrective actions that were implemented at other Entergy facilities, or otherwise take sufficient actions to prevent recurrence. Accordingly, Entergy is taking further actions to reinforce expectations and provide sufficient actions to prevent recurrence of the violation.
As a result of the NRC's feedback, Entergy is undertaking two supplemental causal evaluations related to this violation. First, Entergy is performing a root cause evaluation on the violation which will include a more robust O&P evaluation. The purpose of this evaluation is to determine what additional actions would be comprehensive and effectively prevent recurrence of the violation. The root cause evaluation will also specifically include an operating experience review and the resulting actions will incorporate relevant corrective actions from other plants in the Entergy fleet and the industry. In addition, Entergy is performing a causal evaluation to determine what actions are necessary for Entergy, as a fleet, to ensure O&P evaluations are conducted for willful misconduct incidents related to NRC requirements. These casual evaluations are currently underway with the expectation that the actions resulting from them will be completed prior to the end of 2021.
Date When Full Compliance Achieved Entergy was in full compliance on April 8, 2020 when the CDA key was recovered and properly controlled and validation was complete that no CDAs were compromised in the Met Tower Control Building.
RBG-48128 Enclosure Page 4 of 7 B.
EA-21-050 - Violation Assessed with no Civil Penalty Description of Violation On September 1, 2019, a watchstander failed to tour all required areas of their watchstation. Specifically, a non-licensed operator assigned to the control building as "over-instruction" failed to properly observe the "under-instruction" operator complete all panel checks and failed to ensure a complete tour of all required areas of their watchstation.
The Reason for the Violation As discussed at the August 16, 2021 Predecisional Enforcement Conference, two non-licensed operators (NLOs) failed to inspect certain panels during Control Building rounds.
As part of Entergy's self-auditing process, Operations management periodically places a yellow piece of paper, colloquially referred to as a Golden Ticket, on a specific piece of equipment that is required to be inspected as part of routine operator rounds. Upon discovery, the operator is supposed to retrieve the Golden Ticket and return it with the completed rounds. In this case, the Golden Ticket was on a non-safety related alarm panel. Entergy identified the potentially missed inspection when the two NLOs did not return the Golden Ticket to operations management as the instructions on the Golden Ticket require.
The subsequent independent investigation concluded that each operator incorrectly assumed the other completed this portion of the inspection. While the over-instruction watchstander has the overall responsibility for the rounds, both operators were culpable.
The gap in communication caused this miss since neither validated their assumption that the other completed the inspection.
As discussed in the referenced letter, the NRC determined that Identification credit was warranted for this issue because Entergy identified the condition and entered it into the corrective action program and implemented comprehensive corrective actions for long-term sustained compliance.
Corrective Steps Taken and Results Achieved Entergy took prompt actions after discovering this issue. Corrective actions were taken to remove the NLO qualifications pending investigation. Each operator was formally disciplined with a written warning for violation of Entergy procedures. In addition to the direct actions for the individuals, Entergy recognized an opportunity to enhance the behaviors of other personnel to ensure over-instruction/under-instruction conduct is in line with expectations of excellence and integrity. With that in mind, Entergy updated non-licensed operator qualification cards with a section to ensure appropriate understanding for over-instruction and under-instruction responsibilities. Each crew also held a standdown to brief the responsibilities and ensure understanding on what rounds integrity meant.
Following the issuance of the apparent violation, which included the NRC's determination of willfulness, Entergy conducted a new causal evaluation to determine if further corrective actions were necessary to prevent recurrence. Additional actions taken include:
RBG-48128 Enclosure Page 5 of 7 Establishing the expectation for a briefing that discusses River Bend Station operating experience related to rounds and trainer/trainee conduct to be conducted by a member of Operations management with each class of new operators prior to their first shift assignment Establishing a setting and frequency for a member of Operations management to cover the following with operators on shift:
o The significance of signing your name on a legal record such as Operator Logs o
The roles and responsibilities of the trainer (over-instruction) and trainee (under-instrcution) as it pertains to taking rounds o
River Bend Station operating experience related to rounds and trainer/trainee conduct o
The severity of committing "willful misconduct" or willful violations" and the potential repercussions Adding a management observation to the first trainee set of rounds in every non-license operator qualification card The NRC agreed Corrective Action credit was warranted for the operator rounds issue based on information Entergy presented during the August 16, 2021 Predecisional Enforcement Conference and in the supplemental information provided on August 20, 2021. Entergy plans no additional corrective actions. River Bend Station has not identified willful violations of NRC requirement involving operator rounds over the last two years.
Corrective Steps that Will Be Taken No further corrective actions are planned for this issue.
Date When Full Compliance Achieved Entergy was in full compliance on September 1, 2019 when the rounds in question were appropriately completed.
C.
EA-21-017 - Violation Assessed with no Civil Penalty Description of Violation On August 13, 2018, an exam proctor made an unauthorized copy of an exam with the same control number. Specifically, following administration of an exam to an applicant, the exam proctor thought he lost the original exam and printed a duplicate exam with the same control number, falsified the answers, and submitted the exam to prevent identification of an error on his part.
The Reason for the Violation As discussed at the August 16, 2021 Predecisional Enforcement Conference, Entergy identified that a NOE exam proctor falsified an exam. The NOE Principal Level Ill discovered that there were two exams, apparently taken by the same person, with the same examination number. The first test had a passing score, and the second test was a
RBG-48128 Enclosure Page 6 of 7 failure. It is important to note that the falsified exam was the second exam - the examinee's actual test was the first test - which had a passing score. The NOE Principal Level Ill immediately reported the issue.
During the fact finding and subsequent investigation, the proctor admitted that he thought he lost the original test. He then reprinted another test and falsified the exam by retaking the test with the answers he thought the test-taker submitted. The test-taker was unaware his exam was lost, and unaware that his proctor had tried to recreate it.
The reason for this issue was that the proctor maintained low standards of integrity in that he deliberately circumvented the NOE exam process. He understood the standard and made a choice to voluntarily and deliberately violate the standard.
As discussed in the referenced letter, the NRC determined that Identification credit was warranted for this issue because Entergy identified the condition and entered it into the corrective action program and implemented comprehensive corrective actions for long-term sustained compliance.
Corrective Steps Taken and Results Achieved Entergy took prompt actions after discovering this issue. Entergy placed the proctor on leave and removed his access authorization, pending the investigation. Entergy withheld certifications (for all types of NOE methods) for the NOE test-taker. Entergy initiated a comprehensive internal investigation. Entergy identified there were no other instances of exam falsification, willful misconduct or systemic integrity issues identified among NOE proctors. The issue was isolated to the NOE exam proctor's decision to circumvent the exam process in this one instance.
Following the investigation, Entergy terminated the employment of the proctor and denied his unescorted access. 1 Entergy completed a root cause evaluation to delve into the organizational and programmatic aspects of the issue. Entergy issued fleet-wide communications to discuss the operating experience. Entergy successfully retested and later qualified the test-taker. Entergy completed a gap analysis of the NOE qualification program to identify potential process improvements as the NOE qualification program is not an accredited training program. Finally, Entergy revised the implementing NOE procedures to institutionalize periodic management observations of the proctoring process and a periodic self-assessment of the NOE qualification program.
The NRC agreed Corrective Action credit is warranted for the exam proctor issue based on information Entergy presented during the August 16, 2021 Predecisional Enforcement Conference and in the supplemental information provided on August 20, 2021. Entergy In the Notice of Violation, the NRG stated that, "Entergy did not pursue an earlier opportunity to conduct a more comprehensive extent of condition review following deliberate exam proctor violations at the Grand Gulf Nuclear Station." The NRG continued, "[h]ad a more comprehensive review been performed, Entergy might have recognized that training program management oversight and controls for 'hard copy' exam processes, like the River Bend Station exam proctor case, were not adequate."
To be clear, when the NOE exam proctor created a false exam in August 2018, Entergy was in the early stages (approximately one-sixth) of implementing its three-year Confirmatory Order corrective actions.
RBG-48128 Enclosure Page 7 of 7 plans no additional corrective actions. River Bend Station has not identified willful violations of NRG requirement by proctors of examinations over the last two years.
Corrective Steps that Will Be Taken No further corrective actions are planned for this issue.
Date When Full Compliance Achieved Entergy was in full compliance on November 14, 2018 when the proctor's qualifications were removed, the examinee successfully retook the NOE exam and restored his qualifications.
Identification of Willful Misconduct In the Notice of Violation, the NRG wrote, "we have continued to observe gaps in some areas that require your attention," one of which was that "significant differences between what we [the NRG] determine to be deliberate misconduct and what Entergy determines to be deliberate misconduct continue to exist."2 The NRG has expressed frustration that Entergy did not agree with the NRC's finding of deliberate misconduct in this case and instead offered at the Predecisional Enforcement Conference (PEG) a different understanding of the basis for the operator's actions.3 Entergy offered this explanation not because it fails to understand willful misconduct, but because this explanation was the one supported by the evidence available to Entergy at the time of the PEG, and because Entergy understands the purpose of PECs is for licensees to provide their perspective on the apparent violations in question.
Entergy takes very seriously any integrity violation and understands the importance of ensuring the highest level of integrity when performing work in the nuclear industry. Entergy is committed to understanding the differences between what the NRG determines to be deliberate misconduct and what Entergy determines to be deliberate misconduct. Entergy will continue to work with the staff to understand and address this gap.
2 3
River Bend Station - Notice of Violation and Proposed Imposition of $150,000 Civil Penalty, NRC Inspection report 05000458/2021091 and Investigation Reports 4-2020-008, 4-2020-009, and 4-2020-019 at 3 (Sept. 30, 2021) ("Notice of Violation").
See, e.g., Notice of Violation at 3 ("you did not recognize deliberate misconduct in [the non-licensed operator case] (as discussed in our July 1, 2021, inspection report providing a detailed factual summary)"; see also the related telephonic exit meeting conducted between the NRC and Entergy on September 30, 2021.