ML25118A217
| ML25118A217 | |
| Person / Time | |
|---|---|
| Site: | Salem  |
| Issue date: | 04/28/2025 |
| From: | Nicole Warnek Division of Operating Reactors |
| To: | Mcfeaters C Public Service Enterprise Group |
| References | |
| IR 2025001 | |
| Download: ML25118A217 (1) | |
Text
April 28, 2025 Charles McFeaters President and Chief Nuclear Officer PSEG Nuclear, LLC P.O. Box 236 Hancocks Bridge, NJ 08038
SUBJECT:
SALEM NUCLEAR GENERATING STATION, UNITS 1 AND 2 - INTEGRATED INSPECTION REPORT 05000272/2025001 AND 05000311/2025001
Dear Charles McFeaters:
On March 31, 2025, the U.S. Nuclear Regulatory Commission (NRC) completed an inspection at Salem Nuclear Generating Station, Units 1 and 2. On April 9, 2025, the NRC inspectors discussed the results of this inspection with David Sharbaugh, Site Vice President, and other members of your staff. The results of this inspection are documented in the enclosed report.
No findings or violations of more than minor significance were identified during this inspection.
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 Title 10 of the Code of Federal Regulations 2.390, Public Inspections, Exemptions, Requests for Withholding.
Sincerely, Nicole S. Warnek, Chief Projects Branch 3 Division of Operating Reactor Safety Docket Nos. 05000272 and 05000311 License Nos. DPR-70 and DPR-75
Enclosure:
As stated cc w/ encl: Distribution via ListServ NICOLE WARNEK Digitally signed by NICOLE WARNEK Date: 2025.04.28 14:04:57 -04'00'
ü SUNSI Review Non-Sensitive Sensitive Publicly Available Non-Publicly Available OFFICE RI/DORS RI/DORS RI/DORS NAME JPatel RClagg NWarnek DATE 4/28/2025 4/28/2025 4/28/2025
Enclosure U.S. NUCLEAR REGULATORY COMMISSION Inspection Report Docket Numbers:
05000272 and 05000311 License Numbers:
DPR-70 and DPR-75 Report Numbers:
05000272/2025001 and 05000311/2025001 Enterprise Identifier: I-2025-001-0046 Licensee:
Salem Nuclear Generating Station, Units 1 and 2 Location:
Hancocks Bridge, NJ Inspection Dates:
January 01, 2025 to March 31, 2025 Inspectors:
J. Patel, Senior Resident Inspector S. Quiroga, Resident Inspector R. Clagg, Senior Project Engineer L. Dumont, Senior Reactor Inspector M. Henrion, Senior Project Engineer J. Kepley, Operations Engineer R. Rolph, Senior Health Physicist Approved By:
Nicole S. Warnek, Chief Projects Branch 3 Division of Operating Reactor Safety
2
SUMMARY
The U.S. Nuclear Regulatory Commission (NRC) continued monitoring the licensees performance by conducting an integrated inspection at Salem Nuclear Generating Station, Units 1 and 2, in accordance with the Reactor Oversight Process. The Reactor Oversight Process is the NRCs program for overseeing the safe operation of commercial nuclear power reactors.
Refer to https://www.nrc.gov/reactors/operating/oversight.html for more information.
List of Findings and Violations No findings or violations of more than minor significance were identified.
Additional Tracking Items None.
3 PLANT STATUS Unit 1 began the inspection period at rated thermal power. On January 16, 2025, the unit was down powered to 80 percent power in response to a chemistry trend indicating potential main condenser tube leak. To avoid exceeding steam generator chemistry Electric Power Research Institute limits, the unit was further reduced to 20 percent power. On January 17, 2025, after chemistry sample results exceeded Electric Power Research Institute Action Level 3, the unit was shut down. The unit returned to rated thermal power on January 20, 2025. On March 2, 2025, the unit was down powered to 80 percent power for the removal of 11A and 12A circulating water pumps to address a main condenser tube leak and returned to rated thermal power on March 3, 2025. However, the same day, the unit was again down powered to 80 percent power due to another main condenser tube leak. The unit was restored to rated thermal power on March 6, 2025. On March 17, 2025, the unit commenced coastdown in preparation for the planned refueling outage 30 (S1R30). The unit was at approximately 91 percent rated thermal power at the end of the inspection period.
Unit 2 began the inspection period at rated thermal power. On March 16, 2025, the unit was reduced to 78 percent power at the direction of the electric grid system operator to support grid stability. It was returned to rated thermal power on March 17, 2025. The unit operated at or near rated thermal power for the remainder of the inspection period.
INSPECTION SCOPES Inspections were conducted using the appropriate portions of the inspection procedures (IPs) in effect at the beginning of the inspection unless otherwise noted. Currently approved IPs with their attached revision histories are located on the public website at http://www.nrc.gov/reading-rm/doc-collections/insp-manual/inspection-procedure/index.html. Samples were declared complete when the IP requirements most appropriate to the inspection activity were met consistent with Inspection Manual Chapter (IMC) 2515, Light-Water Reactor Inspection Program - Operations Phase. The inspectors performed activities described in IMC 2515, Appendix D, Plant Status, observed risk significant activities, and completed on-site portions of IPs. The inspectors reviewed selected procedures and records, observed activities, and interviewed personnel to assess licensee performance and compliance with Commission rules and regulations, license conditions, site procedures, and standards.
REACTOR SAFETY 71111.01 - Adverse Weather Protection Impending Severe Weather Sample (IP Section 03.02) (1 Sample)
(1)
The inspectors evaluated readiness for impending extreme cold air temperature less than 25 degrees Fahrenheit during the week of January 26, 2025.
71111.04 - Equipment Alignment Partial Walkdown Sample (IP Section 03.01) (3 Samples)
The inspectors evaluated system configurations during partial walkdowns of the following systems/trains:
4 (1)
Unit 2, 21 auxiliary feedwater (AFW) equipment alignment during the 22 AFW surveillance, January 24, 2025 (2)
Unit 1, 11 chilled water train during maintenance window of the 12 chilled water train, January 29, 2025 (3)
Unit 1, 13 AFW equipment alignment following inservice testing (IST), March 14, 2025 71111.05 - Fire Protection Fire Area Walkdown and Inspection Sample (IP Section 03.01) (5 Samples)
The inspectors evaluated the implementation of the fire protection program by conducting a walkdown and performing a review to verify program compliance, equipment functionality, material condition, and operational readiness of the following fire areas:
(1)
Unit 2, diesel generator area, pre-fire plan FP-SA-2555, January 22, 2025 (2)
Unit 2, 4160V switchgear and battery rooms, pre-fire plan FP-SA-2531, January 27, 2025 (3)
Unit 1, charging pump, spray additive tank, pre-fire plan FP-SA-1544, January 28, 2025 (4)
Unit 1, relay and battery room corridor, pre-fire plan FP-SA-1551, March 6, 2025 (5)
Unit 1, service water (SW) intake structure area, pre-fire plan FP-SA-1651, March 25, 2025 Fire Brigade Drill Performance Sample (IP Section 03.02) (1 Sample)
(1)
The inspectors evaluated the onsite fire brigade training and performance during an unannounced fire drill on February 6, 2025.
71111.06 - Flood Protection Measures Flooding Sample (IP Section 03.01) (1 Sample)
(1)
The inspectors evaluated internal flooding mitigation protections in the Unit 2 component cooling pump and heat exchanger room during the week of March 24, 2025.
71111.11Q - Licensed Operator Requalification Program and Licensed Operator Performance Licensed Operator Performance in the Actual Plant/Main Control Room (IP Section 03.01)
(1 Sample)
(1)
The inspectors observed Unit 1 operation's personnel performance in the main control room during power descension to address out of specification chemistry of the steam generators and reactor startup activities including reactivity manipulations on January 18, 2025.
Licensed Operator Requalification Training/Examinations (IP Section 03.02) (1 Sample)
(1)
The inspectors observed and evaluated licensed operators in the plants simulator during a licensed operator requalification examination on January 28, 2025.
5 71111.12 - Maintenance Effectiveness Maintenance Effectiveness (IP Section 03.01) (1 Sample)
The inspectors evaluated the effectiveness of maintenance to ensure the following structures, systems, and components (SSCs) remain capable of performing their intended function:
(1)
Unit 2, 2C emergency diesel generator (EDG) SW inlet air operated valve, 23SW39, failed to fully open during the EDG start, January 19, 2025 (Notification (NOTF) 20985939) 71111.13 - Maintenance Risk Assessments and Emergent Work Control Risk Assessment and Management Sample (IP Section 03.01) (4 Samples)
The inspectors evaluated the accuracy and completeness of risk assessments for the following planned and emergent work activities to ensure configuration changes and appropriate work controls were addressed:
(1)
Unit 2, elevated risk during scheduled maintenance overhaul on 2C EDG, week of January 14, 2025 (2)
Unit 1, elevated risk during scheduled activity on 12 chiller pump, week of January 30, 2025 (3)
Unit 1, elevated risk during planned maintenance on 1A EDG, February 24, 2025 (4)
Unit 1, elevated risk during scheduled activity on 230VAC vital control center for 12 safety injection pump suction valve and cold leg valve, March 24, 2025 71111.15 - Operability Determinations and Functionality Assessments Operability Determination or Functionality Assessment (IP Section 03.01) (6 Samples)
The inspectors evaluated the licensee's justifications and actions associated with the following operability determinations and functionality assessments:
(1)
Unit 2, core exit thermocouple panel alarm and CE31 failing, January 3, 2025 (NOTF 20984904)
(2)
Unit 2, 2B EDG due to wire pulled from conduit, January 8, 2025 (NOTF 20884840)
(3)
Unit 1, 13 AFW steam generator inlet check valve, 13AF920, thread engagement not uniform, January 9, 2025 (NOTF 20985367)
(4)
Unit 1, 1B EDG due to the jacket water aftercooler heater breaker unable to close, March 6, 2025 (NOTF 20987720)
(5)
Unit 1, power distribution monitoring system due to removal of core exit thermocouple 23 from BEACON, March 11, 2025 (NOTF 20988130)
(6)
Unit 1, 12 containment fan cooler unit failed to start in high speed, March 13, 2025 (NOTF 20988222) 71111.24 - Testing and Maintenance of Equipment Important to Risk The inspectors evaluated the following testing and maintenance activities to verify system operability and/or functionality:
6 Post-Maintenance Testing (PMT) (IP Section 03.01) (5 Samples)
(1)
Unit 2, 2C EDG following engine overhaul, January 21, 2025 (Work Order (WO) 30381175)
(2)
Unit 1, 1A EDG following fuel rack solenoid valve replacement, air start motor preventive maintenance, and pressure switches preventive maintenance, February 24 and 25, 2025 (WO 30310742 and 30358613)
(3)
Unit 1, 13 chiller system following time delay relay replacement, March 11, 2025 (WO 30392672)
(4)
Unit 1, 230VAC vital control center for 12 safety injection pump suction valve and cold leg valve following test and replacement of overload relays and contactor coils, March 24, 2025 (WO 30315264 and 30387223)
(5)
Unit 1, 12 AFW pump following calibration of the discharge flow transmitter, 1FA1038, and switch, 1FD6130, March 6, 2025 (WO 30338493)
Surveillance Testing (IP Section 03.01) (3 Samples)
(1)
Unit 2, S2.OP-ST.DG-0002, "2B Diesel Generator Surveillance Test,"
January 7, 2025 (WO 50255351)
(2)
Unit 1, S1.OP-ST.AF-0002, "Inservice Testing - 12 Auxiliary Feedwater Pump,"
January 8, 2025 (WO 50253762)
(3)
Unit 2, S2.OP-ST.AF-0002(Q), "Inservice Testing - 22 Auxiliary Feedwater Pump,"
January 31, 2025 (WO 50255117)
Inservice Testing (IST) (IP Section 03.01) (1 Sample)
(1)
Unit 1, S1.OP-ST.SJ-0001, "Inservice Testing 11 Safety Injection Pump,"
February 25, 2025 (WO 50253982) 71114.02 - Alert and Notification System Testing Inspection Review (IP Section 02.01-02.04) (1 Sample)
(1)
The inspectors evaluated the licensee's maintenance and testing of the station alert and notification system on March 17 through March 20, 2025, for the period of June 2023 through February 2025.
71114.03 - Emergency Response Organization Staffing and Augmentation System Inspection Review (IP Section 02.01-02.02) (1 Sample)
(1)
The inspectors evaluated the readiness of the licensee's Emergency Preparedness Organization on March 17 through March 20, 2025.
71114.04 - Emergency Action Level and Emergency Plan Changes Inspection Review (IP Section 02.01-02.03) (1 Sample)
(1)
The inspectors evaluated the following submitted Emergency Action Level and Emergency Plan changes:
7 2024-09, E-plan Section 1, Introduction, Revision 18 2024-15, E-plan Section 15, Exercises and Drills, Revision 18 2024-18, E-plan Section 6, Notification Methods - Response Organizations, Revision 22 2024-19, E-plan Section 2, Assignment of Responsibility, Revision 26 2024-36, E-plan Section 7, Emergency Communications, Revision 19 2024-37, E-plan Section 11, Protective Response, Revision 17 2024-38, EP-SA-325-237, Attachment 6 - Salem Emergency Action Level (EAL) Radiation Setpoint Calculation Document, Revision 2 2024-40, EP-SA-325-103, Revision 2/EP-SA-325-140, Revision 2/EP-SA-325-203, Revision 2, Salem Radiation EAL Changes This evaluation does not constitute NRC approval.
71114.05 - Maintenance of Emergency Preparedness Inspection Review (IP Section 02.01 - 02.11) (1 Sample)
(1)
The inspectors evaluated the licensee's maintenance and testing of the emergency preparedness program on March 17 through March 20, 2025, for the period of June 2023 through February 2025.
71114.06 - Drill Evaluation Required Emergency Preparedness Drill (1 Sample)
(1)
The inspectors evaluated the conduct of a routine PSEG emergency preparedness drill, S25-01, on March 4, 2025.
RADIATION SAFETY 71124.08 - Radioactive Solid Waste Processing & Radioactive Material Handling, Storage, &
Transportation Radioactive Material Storage (IP Section 03.01) (2 Samples)
The inspectors evaluated the licensees performance in controlling, labeling and securing the following radioactive materials:
(1)
Unit 2, yard area sea-land vans, boxes and containers (2)
Units 1 and 2, hot shop. Kelley enclosures, drums of equipment, and trash bags ready for disposal Radioactive Waste System Walkdown (IP Section 03.02) (2 Samples)
The inspectors walked down the following accessible portions of the solid radioactive waste systems and evaluated system configuration and functionality:
(1)
Unit 1, liquid waste treatment system and preparing to process resin to the spent resin tank
8 (2)
Unit 1, gaseous waste process system. Four tanks are used to hold up gaseous waste to allow short-lived isotopes to decay Waste Characterization and Classification (IP Section 03.03) (2 Samples)
The inspectors evaluated the following characterization and classification of radioactive waste:
(1)
For shipment #23-033, reactor coolant pump motor upper bearing oil was characterized as Dep Iron Oxides and Liquid and the classification was Limited Quantity (2)
For shipment #24-019, s vial of reactor coolant system (RCS) sampled for boron verification was characterized as liquid, Dep Iron Oxide and classified as a Limited Quantity Shipping Records (IP Section 03.05) (4 Samples)
The inspectors evaluated the following non-excepted radioactive material shipments through a record review:
(1)
Shipment #23-002, 2 Sea-land containers on a flatbed truck, Class A, LSA II Dry Active Waste (2)
Shipment #23-026, dewatered resin, Class A, Solid, Dep Met Oxide (3)
Shipment #24-013, dewatered resin, Class A, Solid, Dep Met Oxide (4)
Shipment #24-043, dewatered resin, Class A, LSA II, Solid, Dep Met Oxide OTHER ACTIVITIES - BASELINE 71151 - Performance Indicator Verification The inspectors verified licensee performance indicators submittals listed below:
MS05: Safety System Functional Failures (SSFFs) Sample (IP Section 02.04) (2 Samples)
(1)
Unit 1, January 1, 2024 to December 31, 2024 (2)
Unit 2, January 1, 2024 to December 31, 2024 BI01: RCS Specific Activity Sample (IP Section 02.10) (2 Samples)
(1)
Unit 1, January 1, 2024 to December 31, 2024 (2)
Unit 2, January 1, 2024 to December 31, 2024 BI02: RCS Leak Rate Sample (IP Section 02.11) (2 Samples)
(1)
Unit 1, January 1, 2024 to December 31, 2024 (2)
Unit 2, January 1, 2024 to December 31, 2024 EP01: Drill/Exercise Performance (DEP) Sample (IP Section 02.12) (1 Sample)
(1)
April 1, 2024 to December 31, 2024
9 EP02: Emergency Response Organization (ERO) Drill Participation (IP Section 02.13)
(1 Sample)
(1)
April 1, 2024 to December 31, 2024 EP04: Emergency Response Facility and Equipment Readiness (ERFER) (IP Section 02.14)
This is a new NRC performance indicator, introduced in NEI 99-02, Revision 8 (ML24331A114). Licensees began collecting data for this performance indicator on January 1, 2025. Therefore, at the time of inspection, there was no quarterly data compiled and submitted to the NRC. Verifications will take place on later inspections.
71152A - Annual Follow-up Problem Identification and Resolution Annual Follow-up of Selected Issues (Section 03.03) (2 Samples)
The inspectors reviewed the licensees implementation of its corrective action program related to the following issues:
(1)
Review of corrective action program evaluation and corrective actions related to the stroke time failure of the EDG SW cooling valves, SW39, for Units 1 and 2 (2)
Review of corrective action program evaluation and corrective actions associated with the Unit 2 auxiliary building ventilation supply and exhaust fans bearing failures INSPECTION RESULTS Observation: Emergency Diesel Generator Service Water Cooling Valve, SW39, Failures 71152A The inspectors conducted a review of corrective action program evaluations and corrective actions related to the stroke time failure of SW cooling valve 22SW39 for the 2B EDG, and the failure of the 1C EDGs 13SW39 valve to fully open during a monthly EDG test. The inspectors also reviewed trends in SW39 valve performance across all six EDGs at Salem Units 1 and 2 to assess potential recurring issues. Additionally, the inspectors evaluated PSEGs determination of Maintenance Rule Functional Failures to ensure adequate performance monitoring and adequacy of corrective actions taken.
For the Unit 2, 2B EDG 22SW39 valve failure to stroke within the IST required time on June 4, 2024, NOTF 20967302, PSEG performed troubleshooting to investigate the air operator, solenoid valve, and restrictor valve that could have affected the stroke time of the valve. On September 24, 2024, PSEG determined that the restrictor valve, which controls the speed of the stroke, required adjustment to restore the stroke time within the acceptable range.
For the Unit 1, 1C EDG 13SW39 valve failure to fully open during the monthly EDG test on August 12, 2024, NOTF 20973425, PSEG performed a work group evaluation (WGE) and determined the likely cause of the failure was an internal binding of the actuator or valve, likely due to the spring binding from fully extending or the valve itself may have been bound by debris, restricting the actuator from fully opening the valve.
As a result of these failures, the inspectors reviewed trends in SW39 valve performance over the past five years. The inspectors noted that there had been a total of five failures during this
10 period. The causes of these failures varied and included solenoid valve malfunctions, improper limit switch adjustments, internal binding due to spring or actuator issues, SW system debris leading to internal binding, and speed adjustment problems.
The inspectors identified the following observations:
NOTF 20967302, related to the 22SW39 valve failing to stroke within IST required time on June 4, 2024, did not include documented recommendations from the Station Ownership Committee regarding the appropriate level of effort for evaluation type.
Specifically, the evaluation type was not determined using the risk and cause uncertainty matrix from Attachment 3, Guidelines for Determining Evaluation Type, of procedure LS-AA-120, Issue Identification and Screening Process, Revision 26.
The cause of the failure was not investigated until September 24, 2024, when troubleshooting was finally performed. As a result, the cause remained uncertain, and a documented response identifying the appropriate evaluation type should have been included to address this condition adverse to quality.
WGE 70236814, associated with the failure of the 13SW39 valve on August 12, 2024, did not include a corrective action to address the likely cause in accordance with Step 4.11.3 of procedure LS-AA-125-1001, Cause Analysis, Revision 29. While the procedure allows for a waiver of Step 4.11.3 when the cause is a "most likely cause,"
PSEG's use of this waiver was not documented.
Previous Equipment Reliability Evaluation (ERE) 70215829, from December 9, 2020, addressing a stroke time exceedance of the 22SW39 valve beyond the IST required action range, did not assign a corrective action to address the identified cause, which was determined to be SW debris wedged between the valve ball and the seat ring.
PSEG did not assess these failures collectively as a potential negative trend in SW39 valve performance, and did not consider whether a common cause evaluation was required, as defined by LS-AA-125, "Corrective Action Program," Revision 29.
The inspectors noted that PSEG screened each of these five failures for Maintenance Rule Functional Failures. While two failures were classified as condition monitoring events, the other three were determined to be neither functional failures nor condition monitoring events. The inspectors noted inconsistencies in monitoring these failures under the Maintenance Rule.
PSEG documented these issues in their corrective action program as NOTFs 20990523, 20990524, 20990525, 20991161, and 20991263. The inspectors did not identify any findings or violations of more than minor significance as a result of this inspection.
Observation: Auxiliary Building Ventilation Supply Fan Bearing Failures 71152A The inspectors evaluated PSEGs corrective actions associated with the Unit 2, 21 auxiliary building ventilation supply fan, 2VHE43, bearing failures. The issue and the completed corrective actions were documented in PSEGs corrective action program under NOTFs 20970400 and 20973939. Additionally, PSEG conducted an ERE 70237067 to assess the bearing failure and develop corrective actions to address both the failure and its underlying cause. The cause of the failure was attributed to the inability of the tapered locking mounting adapter to maintain contact with the rotating shaft, which was due to improper product selection used during the repair of the fan shaft in a previous bearing replacement.
The shaft repair performed during the initial bearing replacement window in July 2024 used Enecons CeramAlloy CP+, a product approved for non-load bearing shaft areas (underneath
11 the bearing labyrinth seals). However, due to the lack of a PSEG procedure or industry standard providing guidance on approved shaft repair methodologies, this product was inappropriately used on the bearing mounting surface of the 21 auxiliary building ventilation supply fan, leading to the bearing failure. In response, PSEG initiated an action to develop a procedure for in-situ shaft repairs based on industry benchmarking results. Inspectors noted that this action was tracked as an ACIT, outside of the corrective action program.
PSEG documented these issues into their corrective action program as NOTF 20990850. The inspectors reviewed PSEGs evaluation, work order documentation, and both planned and completed corrective actions, as applicable, and did not identify any performance deficiency of more than minor significance.
EXIT MEETINGS AND DEBRIEFS The inspectors verified no proprietary information was retained or documented in this report.
On April 9, 2025, the inspectors presented the integrated inspection results to David Sharbaugh, Site Vice President, and other members of the licensee staff.
On February 20, 2025, the inspectors presented the radiation protection radwaste 71124.08 inspection results to Richard DeSanctis, Plant Manager, and other members of the licensee staff.
On March 20, 2025, the inspectors presented the emergency preparedness program inspection results to Richard DeSanctis, Plant Manager, and other members of the licensee staff.
12 DOCUMENTS REVIEWED Inspection Procedure Type Designation Description or Title Revision or Date 71111.24 Corrective Action Documents Resulting from Inspection NOTF 20985367 NOTF 20985375 NOTF 20985433 71114.02 Miscellaneous Final 2005 REP-10 Design Review Report, PSEG Salem and Hope Creek Generating Stations Revision 1 71114.03 Miscellaneous Hope Creek Generating Station and Salem Generating Station On-Shift Staffing Analysis Report Revision 0 Procedures EP-AA-120-1007 Maintenance of Emergency Response Organization Revision 11 71114.04 Procedures EP-AA-120-1001 10 CFR 50.54(q) Change Evaluation Revision 5 71114.05 Miscellaneous PSEG Nuclear LLC Emergency Plan 71124.08 Corrective Action Documents Resulting from Inspection 20987010 Double Posting, RM Tags and Placard "Radioactive 7" 02/19/2025 20987011 Housekeeping in the Hot Shop 02/19/2025 20987012 Control Room Notification Prior to Entering Areas Where Operation Can Change Radiological Conditions 02/19/2025 71151 Corrective Action Documents Resulting from Inspection 20987606 Notification for Missed RCS Leak Rate 20987751 Review of PIs 71152A Corrective Action Documents Resulting from Inspection 20990523 13SW39 PI&R Sample - WGE 70236814 20990524 SW39 EDG Cooling Inlet Valve CCE 20990525 13SW39 MRule Screening 20990850 ERE 70237067 Lacks CRCA for Cause 20991161 Corrective Action Improvements for ERE 20991263 22SW39 Observations