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Category:Letter type:NL
MONTHYEARNL-24-0031, Inservice Inspection Program Owner'S Activity Report (OAR-1) for Outage 2R232024-01-29029 January 2024 Inservice Inspection Program Owner'S Activity Report (OAR-1) for Outage 2R23 NL-24-0020, Plan, Unit 1 Responses to NRC Request for Additional Information for Refueling Outage 1R24 Steam Generator Tube Inspection Report2024-01-22022 January 2024 Plan, Unit 1 Responses to NRC Request for Additional Information for Refueling Outage 1R24 Steam Generator Tube Inspection Report NL-23-0926, Correction of Technical Specification Typographical Error2024-01-12012 January 2024 Correction of Technical Specification Typographical Error NL-23-0878, Request for Exemption from Security Event Notification Implementation2023-11-29029 November 2023 Request for Exemption from Security Event Notification Implementation NL-23-0827, Response to Requests for Additional Information for a License Amendment Request and a Proposed Alternative Related to TS 3.4.142023-11-17017 November 2023 Response to Requests for Additional Information for a License Amendment Request and a Proposed Alternative Related to TS 3.4.14 NL-23-0750, Response to Second Request for Additional Information Regarding License Amendment Request: Technical Specification Revision to Adopt TSTF-339-A, Relocate Technical Specification Parameters to the Colr2023-10-0404 October 2023 Response to Second Request for Additional Information Regarding License Amendment Request: Technical Specification Revision to Adopt TSTF-339-A, Relocate Technical Specification Parameters to the Colr NL-23-0745, Refueling Outage 1R24 Steam Generator Tube Inspection Report2023-09-22022 September 2023 Refueling Outage 1R24 Steam Generator Tube Inspection Report NL-23-0695, Response to Round 2 Request for Additional Information Regarding License Amendment Request for Technical Specification 3.8.3, Inverters Operating, Completion Time Extension (LAR-22-002S2)2023-08-31031 August 2023 Response to Round 2 Request for Additional Information Regarding License Amendment Request for Technical Specification 3.8.3, Inverters Operating, Completion Time Extension (LAR-22-002S2) NL-23-0666, License Amendment Request: Remove Combined License Appendix C (LAR 23-008)2023-08-28028 August 2023 License Amendment Request: Remove Combined License Appendix C (LAR 23-008) NL-23-0670, Response to Request for Additional Information Regarding License Amendment Request: Technical Specification Revision to Adopt TSTF-339-A, Relocate Technical Specification Parameters to the COLR Consistent with WCAP-144832023-08-11011 August 2023 Response to Request for Additional Information Regarding License Amendment Request: Technical Specification Revision to Adopt TSTF-339-A, Relocate Technical Specification Parameters to the COLR Consistent with WCAP-14483 NL-23-0658, Southern Nuclear Operating Company - Response to Request for Additional Information Regarding Quality Assurance Topical Report Submittal2023-08-11011 August 2023 Southern Nuclear Operating Company - Response to Request for Additional Information Regarding Quality Assurance Topical Report Submittal NL-23-0672, Licensee Guarantees of Payment of Deferred Premiums2023-08-10010 August 2023 Licensee Guarantees of Payment of Deferred Premiums NL-23-0542, CFR 50.46 ECCS Evaluation Model Annual Report for 20222023-08-0909 August 2023 CFR 50.46 ECCS Evaluation Model Annual Report for 2022 NL-23-0624, Report of Changes to Emergency Plan and Summary of 50.54(q) Analysis2023-08-0404 August 2023 Report of Changes to Emergency Plan and Summary of 50.54(q) Analysis NL-23-0611, Core Operating Limits Report, Cycle 11 Version 12023-07-19019 July 2023 Core Operating Limits Report, Cycle 11 Version 1 NL-23-0584, Preservice Inspection Program Owner'S Activity Report2023-07-10010 July 2023 Preservice Inspection Program Owner'S Activity Report NL-23-0555, Request for Exemption from Physical Barrier Requirement2023-07-0707 July 2023 Request for Exemption from Physical Barrier Requirement NL-23-0506, to Non-Voluntary License Amendment Request: Technical Specification Revision to Adopt WCAP-17661-P-A, Improved RAOC and CAOC Fq Surveillance Technical Specifications2023-07-0505 July 2023 to Non-Voluntary License Amendment Request: Technical Specification Revision to Adopt WCAP-17661-P-A, Improved RAOC and CAOC Fq Surveillance Technical Specifications NL-23-0541, Inservice Inspection Program Owners Activity Report for Outage 1R242023-06-28028 June 2023 Inservice Inspection Program Owners Activity Report for Outage 1R24 NL-23-0444, Quality Assurance Topical Report Submittal2023-06-15015 June 2023 Quality Assurance Topical Report Submittal NL-23-0339, Response to Request for Additional Information Regarding License Amendment Request for Technical Specification 3.8.3, Inverters - Operating, Completion Time Extension (LAR-22-002S1)2023-06-13013 June 2023 Response to Request for Additional Information Regarding License Amendment Request for Technical Specification 3.8.3, Inverters - Operating, Completion Time Extension (LAR-22-002S1) NL-23-0455, Report of 10 CFR 50.59 Changes, Tests, and Experiments and 10 CFR 52 Appendix D Departure Report2023-06-12012 June 2023 Report of 10 CFR 50.59 Changes, Tests, and Experiments and 10 CFR 52 Appendix D Departure Report NL-23-0467, Response to Request for Additional Information Regarding License Amendment Request: Timing of Unit 4 Technical Specifications Effectiveness Prior to Initial Criticality (LAR-23-005S1)2023-06-0909 June 2023 Response to Request for Additional Information Regarding License Amendment Request: Timing of Unit 4 Technical Specifications Effectiveness Prior to Initial Criticality (LAR-23-005S1) NL-23-0346, License Amendment Request for Exception to Regulatory Guide 1.163 (LAR 23-007)2023-05-25025 May 2023 License Amendment Request for Exception to Regulatory Guide 1.163 (LAR 23-007) NL-23-0383, SNC Response to Regulatory Issue Summary 2023-01:Preparation And.2023-05-19019 May 2023 SNC Response to Regulatory Issue Summary 2023-01:Preparation And. NL-23-0385, License Amendment Request: More Restrictive Action for Technical Specification 3.1.9 (LAR-23-006R1)2023-05-17017 May 2023 License Amendment Request: More Restrictive Action for Technical Specification 3.1.9 (LAR-23-006R1) NL-23-0398, Withdrawal of Request of License Amendment Request Regarding More Restrictive Action for Technical Specification 3.1.9 (LAR-23-006)2023-05-16016 May 2023 Withdrawal of Request of License Amendment Request Regarding More Restrictive Action for Technical Specification 3.1.9 (LAR-23-006) NL-23-0372, Units 1 & 2, Joseph M. Farley Nuclear Plant - Units 1 & 2, Vogtle Electric Generating Plant - Units 1 & 2, Annual Radiological Environmental Operating Reports for 20222023-05-10010 May 2023 Units 1 & 2, Joseph M. Farley Nuclear Plant - Units 1 & 2, Vogtle Electric Generating Plant - Units 1 & 2, Annual Radiological Environmental Operating Reports for 2022 NL-23-0360, Supplement to License Amendment Request and Exemptions to Allow Use of Lead Test Assemblies for Accident-Tolerant Fuel2023-05-0505 May 2023 Supplement to License Amendment Request and Exemptions to Allow Use of Lead Test Assemblies for Accident-Tolerant Fuel NL-23-0326, Response to Apparent Violation in NRC Inspection Report 05000424, 425/2023090; EA-22-1082023-05-0101 May 2023 Response to Apparent Violation in NRC Inspection Report 05000424, 425/2023090; EA-22-108 NL-23-0217, License Amendment Request to Revise Technical Specification Surveillance Requirement 3.4.14.1 and Proposed Inservice Testing Alternative ALT-VR-022023-05-0101 May 2023 License Amendment Request to Revise Technical Specification Surveillance Requirement 3.4.14.1 and Proposed Inservice Testing Alternative ALT-VR-02 NL-23-0330, Core Operating Limits Report, Cycle 25, Version 12023-04-26026 April 2023 Core Operating Limits Report, Cycle 25, Version 1 NL-23-0310, Annual Non-Radiological Environmental Operating Reports and Annual Radioactive Effluent Release Reports for 20222023-04-25025 April 2023 Annual Non-Radiological Environmental Operating Reports and Annual Radioactive Effluent Release Reports for 2022 NL-23-0135, License Amendment Request: Timing of Technical Specifications Effectiveness Prior to Initial Criticality (LAR-23-005)2023-04-17017 April 2023 License Amendment Request: Timing of Technical Specifications Effectiveness Prior to Initial Criticality (LAR-23-005) NL-23-0019, GEN-ISI-ALT-2023-01, Request to Use Provision of a Later Edition of the ASME Boiler and Pressure Vessel Code, Section XI2023-04-12012 April 2023 GEN-ISI-ALT-2023-01, Request to Use Provision of a Later Edition of the ASME Boiler and Pressure Vessel Code, Section XI NL-23-0152, License Amendment Request: Technical Specification Revision to Adopt TSTF-339-A, Relocate Technical Specification Parameters to the COLR Consistent with WCAP-144832023-04-11011 April 2023 License Amendment Request: Technical Specification Revision to Adopt TSTF-339-A, Relocate Technical Specification Parameters to the COLR Consistent with WCAP-14483 NL-23-0263, Southern Nuclear Company Submittal of Drug and Alcohol Testing Errors Identified 10 CFR 26.719(c) 30-Day Report2023-04-0505 April 2023 Southern Nuclear Company Submittal of Drug and Alcohol Testing Errors Identified 10 CFR 26.719(c) 30-Day Report NL-23-0136, License Amendment Request: More Restrictive Action for Technical Specification 3.1.9 (LAR-23-006)2023-04-0505 April 2023 License Amendment Request: More Restrictive Action for Technical Specification 3.1.9 (LAR-23-006) NL-23-0132, License Amendment Request: Remove Combined License Appendix C (LAR 23-001)2023-04-0404 April 2023 License Amendment Request: Remove Combined License Appendix C (LAR 23-001) NL-23-0014, Southern Nuclear Operating Co Submittal of Report on Status of Decommissioning Funding2023-03-29029 March 2023 Southern Nuclear Operating Co Submittal of Report on Status of Decommissioning Funding NL-23-0208, Independent Spent Fuel Storage Installation ISFSI, Decommissioning Funding Plan Triennial Update2023-03-29029 March 2023 Independent Spent Fuel Storage Installation ISFSI, Decommissioning Funding Plan Triennial Update NL-23-0193, Request for License Amendment: Relocation of TS 3.7.9, Spent Fuel Pool Makeup Water Sources (LAR-23-003)2023-03-24024 March 2023 Request for License Amendment: Relocation of TS 3.7.9, Spent Fuel Pool Makeup Water Sources (LAR-23-003) NL-23-0196, Response to Request for Additional Information Regarding License Amendment Request for Alternative Source Term, TSTF-51, TSTF-471, and TSTF-4902023-03-24024 March 2023 Response to Request for Additional Information Regarding License Amendment Request for Alternative Source Term, TSTF-51, TSTF-471, and TSTF-490 NL-23-0228, Nuclear Property Insurance Coverage as of April 1, 2023 and Licensee Guarantees of Payment of Deferred Premiums (10 CFR 140.21)2023-03-20020 March 2023 Nuclear Property Insurance Coverage as of April 1, 2023 and Licensee Guarantees of Payment of Deferred Premiums (10 CFR 140.21) NL-22-0977, License Amendment Request to Modify Technical Specification 5.5.11.c Acceptance Criteria for Charcoal Filter Testing2023-02-0909 February 2023 License Amendment Request to Modify Technical Specification 5.5.11.c Acceptance Criteria for Charcoal Filter Testing NL-23-0010, Response to Request for Additional Information Regarding License Amendment Request for Alternative Source Term, TSTF-51, TSTF-471, and TSTF-4902023-02-0606 February 2023 Response to Request for Additional Information Regarding License Amendment Request for Alternative Source Term, TSTF-51, TSTF-471, and TSTF-490 NL-23-0076, Exigent License Amendment Request: Technical Specification Exceptions for In-containment Refueling Water Storage Tank Operability Prior to Initial Criticality (LAR-23-004)2023-01-31031 January 2023 Exigent License Amendment Request: Technical Specification Exceptions for In-containment Refueling Water Storage Tank Operability Prior to Initial Criticality (LAR-23-004) NL-23-0013, Response to Request for Additional Information Related to 10CFR 50.75 Decommissioning Funding Assurance Requirements2023-01-30030 January 2023 Response to Request for Additional Information Related to 10CFR 50.75 Decommissioning Funding Assurance Requirements NL-23-0068, Responses to NRC Request for Additional Information Related to the Refueling Outage 2R22 Steam Generator Tube Inspection Report2023-01-27027 January 2023 Responses to NRC Request for Additional Information Related to the Refueling Outage 2R22 Steam Generator Tube Inspection Report NL-23-0012, Post-Audit Supplement to License Amendment Request and Exemptions to Allow Use of Lead Test Assemblies for Accident-Tolerant Fuel2023-01-20020 January 2023 Post-Audit Supplement to License Amendment Request and Exemptions to Allow Use of Lead Test Assemblies for Accident-Tolerant Fuel 2024-01-29
[Table view] Category:Licensee Response to Enforcement Action
[Table view] Category:Licensee Response to Notice of Violation
MONTHYEARNL-23-0326, Response to Apparent Violation in NRC Inspection Report 05000424, 425/2023090; EA-22-1082023-05-0101 May 2023 Response to Apparent Violation in NRC Inspection Report 05000424, 425/2023090; EA-22-108 ML23116A2482023-04-26026 April 2023 (Vegp), Unit 3 - Response to Apparent Violation in NRC Inspection Report 05200025/2022011: EA-22-081 NL-21-0887, Response to Apparent Violation Noted in Inspection Report 05000424/2021401 and 05000425/2021401, EA-21-0262021-10-19019 October 2021 Response to Apparent Violation Noted in Inspection Report 05000424/2021401 and 05000425/2021401, EA-21-026 ML21278A3542021-10-0505 October 2021 Enclosure 1: Smc Position and Additional Information for the Final Significance Determination for Apparent Violations in NRC Letter EA-21-109 NL-20-0484, Reply to a Notice of Violation; EA-19-112, Inspection Report 05000424/2019-003 and 05000425/2019-0032020-04-30030 April 2020 Reply to a Notice of Violation; EA-19-112, Inspection Report 05000424/2019-003 and 05000425/2019-003 NL-20-0037, Pre-decisional Reply to EA-19-112, NRC Inspection Report 05000424/2019090 and 05000425/2019090 and Preliminary White Finding and Apparent Violation2020-01-31031 January 2020 Pre-decisional Reply to EA-19-112, NRC Inspection Report 05000424/2019090 and 05000425/2019090 and Preliminary White Finding and Apparent Violation NL-18-0297, Units 1 and 2 - Notice of Violation and Proposed Imposition of Civil Penalty Method of Payment2018-03-15015 March 2018 Units 1 and 2 - Notice of Violation and Proposed Imposition of Civil Penalty Method of Payment NL-17-0844, Reply to a Notice of Violation; EA-17-0142017-05-23023 May 2017 Reply to a Notice of Violation; EA-17-014 NL-17-0384, Response to EA-17-014, Preliminary White Finding and Related Apparent Violation from Inspection Report 05000424/2017503 and 05000425/20175032017-03-16016 March 2017 Response to EA-17-014, Preliminary White Finding and Related Apparent Violation from Inspection Report 05000424/2017503 and 05000425/2017503 NL-15-0723, Reply to a Notice of Violation; EA-14-158, Inspection Report Nos. 05000424/2014009 and 05000425/20140092015-04-21021 April 2015 Reply to a Notice of Violation; EA-14-158, Inspection Report Nos. 05000424/2014009 and 05000425/2014009 NL-09-0124, Units 1 & 2, Additional Information Regarding NRC Supplemental Inspection Report 05000424-08-009 and 05000425-08-0092009-02-0202 February 2009 Units 1 & 2, Additional Information Regarding NRC Supplemental Inspection Report 05000424-08-009 and 05000425-08-009 ML0300307032002-12-20020 December 2002 Supplemental Response to Notice of Violation Dated May 29, 1996 (EA 95-171) 2023-05-01
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3535 Colonnade Parkway Birmingham, AL 35243
205 992 5000 May 1, 2023 Docket Nos.: 50-424 NL-23-0326 50-425 U.S. Nuclear Regulatory Commission ATTN: Document Control Desk Washington, DC 20555-0001 Vogtle Electric Generating Plant - Units 1 and 2 Response to Apparent Violation in NRC Inspection Report 05000424, 425/2023090; EA-22-108 Ladies and Gentlemen:
By letter dated March 30, 2023, the Nuclear Regulatory Commission (NRC) provided to Southern Nuclear Operating Company (SNC) the results of a recently completed inspection. The NRC letter, dated March 30, 2023, is titled, Vogtle Electric Generating Plant, Units 1 and 2 - NRC Inspection Report 05000424/2023090 and 05000425/2023090, and Investigation Report 2-2022-006; and Apparent Violation. That letter states, Before the NRC makes its enforcement decision, we are providing you an opportunity to (1) respond in writing to the apparent violation addressed in this inspection report within 30 days of the date of this letter, (2) request a Pre-decisional Enforcement Conference (PEC), or (3) request Alternative Dispute Resolution (ADR). SNC has chosen the first option of providing a written position on the apparent violation.
The enclosure to this letter provides the requested information.
The information included in the enclosure is intended to assist the NRC in the determination of final significance for the apparent violation identified in the NRC letter dated March 30, 2023.
This letter contains no regulatory commitments.
Should you have questions regarding the enclosed information, please contact Amy Chamberlain at 205-992-6361.
Respectfully submitted, R. Keith Brown Regulatory Affairs Director
U.S. Nuclear Regulatory Commission NL-23-0326 Page 2 of 2 RKB/kmo/cag cc: Regional Administrator, Region II NRR Project Manager - Vogtle 1 & 2 Senior Resident Inspector - Vogtle 1 & 2 Director, Division of Reactor Safety, Region II RType: CVC7000
Enclosure:
Response to Apparent Violation in NRC Inspection Report 05000424, 425/2023090; EA-22-108
Vogtle Electric Generating Plant - Units 1 and 2 Response to Apparent Violation in NRC Inspection Report 05000424, 425/2023090; EA-22-108 Enclosure Response to Apparent Violation in NRC Inspection Report 05000424, 425/2023039; EA-22-108
U.S. Nuclear Regulatory Commission NL-23-0326 Enclosure Page 1 of 3 SNC has reviewed the information provided in NRC letter dated March 30, 2023. The apparent violation (AV) is summarized below:
AV 05000424/2023090 and 05000425/2023092 Failure to Comply with Radiation Work Permit (RWP)
An apparent violation of Technical Specification (TS) 5.4.1 was identified when two contract employees, along with and under the direct supervision of a contract supervisor, entered Unit 1 containment on a radiation work permit (RWP) that did not allow containment access.
The following provides SNCs response to the AV, as requested in the NRC letter dated March 30, 2023.
(1) The reason for the AVs or, if contested, the basis for disputing the AVs:
Contract workers entered Unit 1 containment without logging onto the proper radiation work permit (RWP) as required. As a result, VEGP may have been in violation of Technical Specification 5.4.1. All three individuals had been given the required briefing for entering containment earlier in the day and were aware of SNCs administrative controls established to prevent this type of event. SNC had also emphasized RWP adherence in its outage handbook, provided to all outage workers, including contract workers. The handbook stated:
Do not go into the radiologically controlled area (RCA) unless you must be in there to perform specific work, have successfully completed radiation worker training, are correctly dressed in the appropriate protective clothing, and have signed onto a radiation work permit (RWP). Read, understand and follow the requirements spelled out in your RWP.
Minimize the time you spend in the RCA, and use good radworker practices to minimize dose.
However, the actions of the individuals violated these administrative controls and SNCs direction. Although the two contractors correctly questioned the contractor supervisors decision, a lack of questioning attitude and willingness to stop when the questions were raised on the part of the contract supervisor contributed to the failure to log into the correct RWP.
(2) The corrective steps that have been taken and the results achieved:
Immediately following the event, the individuals were excluded from Radiation Control Area (RCA) entry pending investigation and supplemental surveys were performed in the area where the dose alarm was received. Condition Report (CR) 10828726 was initiated to document the event. To prevent recurrence, a time out was taken with the crews to reinforce expectations in using Human Performance Tools and Core 4, described below. Additionally, prior to all outages since this event, a pre-outage brief has been or will be held with supplemental supervision to reinforce the importance of procedure adherence, as well as site standards and expectations.
VEGP also included specific focus on RWPs in the subsequent outage handbook provided to contract workers. Rather than included a general description, SNC added a color-coded list of each available RWP and its coverage to the handbook.
U.S. Nuclear Regulatory Commission NL-23-0326 Enclosure Page 2 of 3 In July 2021, just prior to this event, SNC began launching a sustained focus on its Core 4 human performance tools, including Time out. Stop when unsure. Gain more information before proceeding when uncertainty arises. This focus began with a video to all employees featuring the chief nuclear officer and VEGP plant manager. Shortly after this event, on September 27, 2021, another fleet-wide video was sent to all SNC employees about the meaning and importance of the time out tool and not proceeding in the face of uncertainty.
The Core 4, including the Time out performance tool, have been featured consistently since this time in a broad array of communications, briefings, and has been incorporated into the description of SNCs central strategic areas. At VEGP specifically, every employee was issued a Core 4 lanyard cards as are all outage workers. Core 4 posters and fliers are ubiquitous around the site, and VEGP leadership features Core 4 as a recurring message in search lanes and the personnel entrance to the protected area, ensuring that both employees and contract workers are consistently reminded of the importance of taking a time out rather than proceeding in the face of uncertainty.
SNC has also taken additional actions to address both physical entry into the RCA and improving compliance focus, risk recognition and fostering a questioning attitude. VEGP has already implemented new smart turnstile technology that digitally assesses a worker to the approved RWP for entry into containment. These new smart turnstiles provide a physical barrier to prevent entry into containment on an incorrect RWP. This technology was used during the Spring 2023 VEGP Unit 1 outage and will be used in subsequent outages for containment entry.
In mid 2021, SNC launched a fleet-wide initiative, emphasizing the importance of regulatory compliance and procedure adherence and education for leaders and supervisors about better understanding and identifying risk. The SNC vice president of regulatory affairs and additional regulatory personnel conducted in-person training at VEGP in January 2022. In February 2022, the vice president of regulatory affairs issued a video along with the chief nuclear officer to all SNC employees reminding them that compliance with regulations, procedures and technical specifications is always necessary, as well as the importance of having a culture where any worker can raise a compliance question.
In January 2023, SNC proactively completed a check-in self-assessment of the radiation protection fundamental behaviors at VEGP. This assessment was independent of VEGP, including two industry peers and the radiation protection manager at another SNC site. This assessment did not identify ongoing issues associated with entry into containment under incorrect RWPs. The assessment specifically gauged the current understanding of individual responsibilities to ensure a strong healthy radiological safety conscious work environment (SCWE), including interviews around radiological conscience which garnered favorable responses. No gaps were identified in this cultural area.
The primary results achieved, based on the actions summarized above, include prevention of a similar event due to physical barriers added to equipment, an enhanced focus on regulatory and technical specification compliance, and strong recognition across both employees and contract workers of the importance of stopping when a question is raised, rather than proceeding in the face of uncertainty.
(3) The corrective steps that will be taken:
In addition to the corrective actions taken immediately following the event and the additional actions taken by SNC since that time, a causal analysis is being performed on this apparent
U.S. Nuclear Regulatory Commission NL-23-0326 Enclosure Page 3 of 3 violation and is scheduled to be completed by June 6, 2023. If additional actions are recommended by this analysis, those will be completed pursuant to SNCs corrective action program processes.
(4) The date when full compliance will be achieved.
Full compliance was achieved on September 21, 2021 when the survey was completed and the individuals were removed from the RCA.
Additional Information:
In addition to the information contained above, SNC respectfully requests the NRC consider the following factors. First, SNC identified the issue because SNCs radiation protection processes provide for conservatively set RWP task dose rate alarms for the self-reading dosimeters based on conditions expected to be encountered to ensure all radiological work is performed in a safe manner rather than the RWP administrative limits. Thus, these dosimeters alarm when an individual is exposed to dose or dose rates in excess of their RWP task limits. SNCs immediate review of the event determined that the issue was related to the contractor supervisors decision-making. Second, as explained above, the corrective actions associated with this event were prompt and comprehensive. The immediate corrective actions were focused on restoring compliance as well as preventing recurrence. Since the time of the event, SNC has continued to take actions to emphasize regulatory compliance and using the time out human performance tool to stop if there is any question about whether an activity is compliant. SNC has also taken additional measures to enhance physical equipment that would prevent recurrence of this type of event.