WO 22-0056, Operating Corporations Summary of Actions Implemented for EA-18-165, Confirmatory Order, NRC Inspection Report 05000482/2019010 and NRC Investigation Report 4-2018-008

Operating Corporations Summary of Actions Implemented for EA-18-165, Confirmatory Order, NRC Inspection Report 05000482/2019010 and NRC Investigation Report 4-2018-008

ML22353A605
Person / Time
Site:	Wolf Creek
Issue date:	12/19/2022
From:	Mccoy J Wolf Creek
To:	Scott(Ois) Morris Office of Nuclear Reactor Regulation, NRC Region 4, Document Control Desk
References
WO 22-0056, EA-18-165, 4-2018-008 IR 2019010
Download: ML22353A605 (1)

Text

Jaime H. McCoy Site Vice President December 19, 2022 WO 22-0056 Scott A. Morris Regional Administrator U. S. Nuclear Regulatory Commission Region IV 1600 East Lamar Boulevard Arlington, TX 76011-4511

References:

1) Letter dated July 18, 2019, from S. A. Morris, USNRC, to A. C.

Heflin, WCNOC, Confirmatory Order, NRC Inspection Report 05000482/2019010 and NRC Investigation Report 4-2018-008

2) Letter dated December 23, 2020, from Jaime H. McCoy, WCNOC, to S. A. Morris, NRC, Wolf Creek Nuclear Operating Corporations Summary of Actions Implemented for EA-18-165, Confirmatory Order, NRC Inspection Report 05000482/2019010 and NRC Investigation Report 4-2018-008

3) Letter dated December 29, 2021, from Jaime H. McCoy, WCNOC, to S. A. Morris, NRC, Wolf Creek Nuclear Operating Corporations Summary of Actions Implemented for EA-18-165, Confirmatory Order, NRC Inspection Report 05000482/2019010 and NRC Investigation Report 4-2018-008

Subject:

Docket No. 50-482: Wolf Creek Nuclear Operating Corporations Summary of Actions Implemented for EA-18-165, Confirmatory Order, NRC Inspection Report 05000482/2019010 and NRC Investigation Report 4-2018-008

Dear Mr. Morris,

On July 18, 2019, the Nuclear Regulatory Commission (NRC) issued Order EA-18-165 to Wolf Creek Nuclear Operating Corporation (WCNOC). Reference 2 summarizes corrective actions already taken by Wolf Creek that were discussed in the Alternative Dispute Resolution and additional commitments made in the preliminary settlement agreement. Reference 3 summarizes the actions implemented for EA-18-165 for year end 2021.

P.O. Box 411 l Burlington, KS 66839 l 620-364-8831

WO 22-0056 Page 2 of 3 Item Q in Reference 1 requires the submission in writing of the actions implemented under this Confirmatory Order, the results achieved, and any additional corrective actions initiated as a result of this Confirmatory Order. Sixteen items, CO Communications Commitments A - P, including already completed corrective actions A - D, have been completed and a summary of the action closures are provided in the attachment to this letter. Following the transmittal of this December, 2022 letter, only administrative commitment Q, to provide in writing a summary of the actions implemented under this CO in 2023 remains open. Further work continues to develop closure packages for the actions to aid in the inspection process.

The letter contains no commitments. If you have any questions concerning this matter, please contact me at (620) 364-4156, or Dustin Hamman at (620) 364-4204.

Sincerely, Jaime H. McCoy JHM/jkt

Attachment:

Wolf Creek Nuclear Operating Corporations Summary of Actions Implemented for EA-18-165, Confirmatory Order, NRC Inspection Report 05000482/2019010 and NRC Investigation Report 4-2018-008 cc: Document Control Desk (NRC), w/a G. E. Werner (NRC), w/a Senior Resident Inspector (NRC), w/a

WO 22-0056 Page 3 of 3 STATE OF KANSAS )

) 55 COUNTY OF COFFEY )

Jaime H. McCoy, of lawful age, being first duly sworn upon oath says that he is Site Vice President of Wolf Creek Nuclear Operating Corporation ; that he has read the foregoing document and knows the contents thereof; that he has executed the same for and on behalf of said Corporation with full power and authority to do so; and that the facts therein stated are true and correct to the best of his knowledge, information and belief.

1~ j-/ meet By_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Jaime H. McCoy Site Vice President Expiration Date 3/io/2Ci2 Attachment to WO 22-0056 Page 1 of 14

Attachment:

Wolf Creek Nuclear Operating Corporations (WCNOC) Summary of Actions Implemented for EA-18-165, Confirmatory Order, NRC Inspection Report 05000482/2019010 and NRC Investigation Report 4-2018-008 The following is a summary of actions implemented under Confirmatory Order EA-18-165 (Item Q).

The Confirmatory Order commitments are being tracked in the Corrective Action Program under Condition Report (CR)134185.

During the ADR session held on May 30, 2019, Wolf Creek and the NRC reached a preliminary settlement agreement. Corrective actions already taken by Wolf Creek that were discussed included:

A. The Chief Nuclear Officer issued a communication to the entire plant regarding expectations for accurately performing and documenting work activities, focusing on "Your Signature Is Your Word" and "Look for, Understand, and Mitigate Risk" related to making assumptions.

B. Wolf Creek performed remediation with the individuals involved to reinforce and institutionalize Wolf Creek standards and expectations with a focus on complete and accurate documentation, which included face-to-face discussion with the plant manager and the site vice president.

C. Wolf Creek developed a procedure AP 18-001, "Emerging Concerns," to improve the quality of investigations, including investigations involving deliberate misconduct.

D. Wolf Creek conducted an internal investigation into employee deliberate misconduct with external counsel.

Additional commitments made in the preliminary settlement agreement, as signed by both parties, consist of the following:

Communications:

A. Within 1 month of the issuance date of the Confirmatory Order, Wolf Creek will issue a stand-alone communication from the Chief Nuclear Officer to all employees and contractor personnel that willful violations will not be tolerated. The communication will stress the importance of procedural adherence, ensuring that documents are complete and accurate, and of potential consequences for engaging in willful violations. This message will be balanced with the recognition that people do make mistakes and when that happens, it is Wolf Creek's expectation that its employees and contractors will identify and document issues in accordance with licensee procedures.

Item A (CR 134185-01-01) completed 08/20/2019, documented in Letter WO 19-0059. On 8/14/2019, the Chief Nuclear Officer (CNO) released a Corporate Communications stand-alone

Attachment to WO 22-0056 Page 2 of 14 electronic mail message to WCNOC employees that reiterated that willful violations will not be tolerated, stressed the importance of procedural adherence and consequences for willful violations, recognized that people make mistakes, and that employees/contractors should identify and document issues in accordance with procedures.

After this initial communication was electronically mailed, it was recognized that not all supplemental personnel, particularly those without site e-mail access, received the CNOs message. CR 135634 was initiated on 9/17/2019. To address CR 135634, the initial CNO communication was sent through the U.S. Postal Service. Active WCNOC employees addresses were obtained through the Human Resources program People Soft, and supplemental personnels mailing addresses were obtained from Access Screening. A total of 1,776 letters were mailed (863 active WCNOC employees and 913 supplemental personnel). The letters were taken to the Burlington, KS Post Office on 10/15/2019. CR 135634 was closed on 10/29/2019.

B. Within 4 months of the issuance date of the Confirmatory Order, Wolf Creek will hold meetings with all employees and long-term contractor personnel to address integrity and trustworthiness. The meetings will: (1) stress the importance of procedural adherence, ensuring that documents are complete and accurate, and of potential consequences for engaging in willful violations; (2) describe the circumstances of this case, the results of the root cause evaluation, and Wolf Creek's corrective actions; (3) include the expectation to immediately raise safety concerns when observed; (4) address how to proceed when work order documentation is incomplete.

Item B (CR 134185-01-02) completed 11/14/2019, documented in Letter WO 19-0059.

Leadership held meetings with all Wolf Creek employees and long-term contractor personnel to address integrity and trustworthiness, based on the material provided through an 8/27/2019 Leaders Digest communication. This material included Talking Points and a Treat Your Signature as Your Word presentation, which included a video from the CNO.

Through the use of the Talking Points, the meetings and presentation 1) stressed the importance of procedural adherence, ensuring documents are complete/accurate, and of potential consequences for engaging in willful violations; 2) described the circumstances of the case, results of the root cause and Wolf Creeks corrective actions; 3) included the expectation to immediately raise safety concerns when observed; 4) addressed how to proceed when Work Order documentation is incomplete. Evidence of meetings resides in the attendance sheets that were used to track completion.

C. Within 4 months of the issuance date of the Confirmatory Order, Wolf Creek will reinforce expectations with regards to 10 CFR 50.9, completeness and accuracy of information, and 10 CFR 50.5, deliberate misconduct, by providing an overview of the last 5 years of pertinent NRC enforcement actions with Operations, Fire Watch, Maintenance, and Radiation Protection staff.

Item C (CR 134185-01-03) completed 11/14/2019, documented in Letter WO 19-0059.

CERTREC provided a list of 10 CFR 50.9 and 10 CFR 50.5 violations and enforcement actions for the last 5 years, as of 10/22/2019. An additional column was added to identify the pertinent departments that need to review each example.

On 10/31/2019, a common database export of active WCNOC employees was pulled to identify personnel within the Operations, Maintenance and Radiation Protection (RP) departments. The Qual Tool was then used to identify personnel with a Fire Watch qualification, so that they could

Attachment to WO 22-0056 Page 3 of 14 be pulled into the spreadsheet for proper coverage in this action. There were 508 employees identified.

An email communication, with the CERTREC results attached, was sent to the leadership of those identified as Operations, Fire Watch, Maintenance and RP. Talking points were also provided, and included details of the proposed violation, summaries of the CERTREC results by pertinent departments and final takeaways. This communication was to be discussed in morning meetings or regularly scheduled staff meetings to reinforce expectations and the significance of accurate and complete documentation with their applicable personnel.

An additional email communication was then sent to the 508 Operations, Fire Watch, Maintenance and RP personnel (including the talking points and CERTREC results) to reinforce the significance of accurate and complete documentation.

D. Within 6 months of the issuance date of the Confirmatory Order, Wolf Creek will complete its efforts to reinforce site expectations through posters and the morning brief communications, which will specifically address 10 CFR 50.9 and 10 CFR 50.5, and its applicable "Professional to the Core" behaviors meant to ensure high quality work and high-quality work products.

Item D (CR 134185-01-04) completed 01/13/2020, documented in Letter WO 20-0058.

Communications developed a number of graphic elements and Communications messages for Professional to the Core and the behaviors Treat Your Signature as Your Word, Look for, Understand, and Mitigate Risk, and Adhere to Procedures and Follow the Rules. These behaviors were connected to communications regarding documentation and 10 CFR 50.9.

Communications on Treat Your Signature as Your Word and other Professional to the Core behaviors and were published in the online biweekly employee newsletter and the outage daily newsletter during RF23 in 2019. A series of visuals on these topics were developed in September 2019 and were included in the rotation of images on Wolf Creeks internal digital signage system, which are shown on approximately 25 TV displays across the station. Similar-style posters were developed in 2019 and were installed in January 2020. Slides on these topics were also developed for use on the back page of the daily Shift Manager Operational Focus Items for use in morning meetings.

E. Within 6 months of the issuance date of this Confirmatory Order, Wolf Creek will develop a presentation to be delivered to an appropriate industry forum (e.g., Regional Utility Group or Strategic Teaming and Resource Sharing) subject to acceptance of the conference organizing committees.

1. This presentation will include the significance of the incident that formed the basis for this violation, the consequences of the actions, the responsibilities of personnel involved, and the completed and planned corrective actions.

2. Wolf Creek will provide its proposed presentation to the NRC for its review. The NRC will communicate to the licensee any concerns regarding the presentation within 30 days of submittal.

Item E (CR 134185-01-05) completed 01/14/2020, documented in Letter WO 20-0058. A presentation titled, Treat Your Signature as Your Word, was developed and provided to the NRC for their review/approval. The presentation includes: a discussion of the initiating event, consequences, the responsibility of 10 CFR 50.9, Professional to the Core Behaviors, corrective actions, communication actions, and training actions.

Attachment to WO 22-0056 Page 4 of 14 F. Within 18 months of the issuance date of this Confirmatory Order, Wolf Creek will deliver the presentation developed in Element E to an industry forum.

Item F (CR 134185-01-06) completed 12/22/2020, documented in Letter WO 21-0064. Wolf Creek will deliver the presentation developed in Communications E, E1 and E2 (CR action 134185 05) to an appropriate industry forum (i.e., Regional Utility Group or Strategic Teaming & Resource Sharing). The Industry presentation has been prepared by Corporate Communications. The presentation has been uploaded for NRC review/approval to Certrec IMS Wolf Creek Frequently Used Documents request #19. This presentation was given on 9/15/2020 to the STARS Site Vice Presidents during their Site VP meeting. The presentation was delivered by WCs Site Vice President. A copy of the agenda for the meeting as well as a copy of the material presented is attached in Curator.

Evaluation:

G. Within 3 months of the issuance date of the Confirmatory Order, Wolf Creek will complete a root cause analysis of the circumstances that led to the incomplete and inaccurate information violation and develop corrective actions.

Item G (CR 134185-01-07) completed 10/15/2019, documented in Letter WO 19-0059. Condition Report 131147 was written on 3/27/2019 to document a potentially escalated greater than Severity Level IV Traditional Enforcement violation concerning the failure to meet 10CFR50.9, Completeness and accuracy of information. This CR was screened as a Root Cause. The root cause analysis was completed and approved by the Corrective Action Review Board (CARB) on 5/28/2019. The evaluation was closed on 6/12/19. On 8/20/2019, CR 134871 was initiated due to a review of the root cause analysis determining that changes to the document, including an additional contributing cause, would provide a more complete analysis. Revision 1 of the root cause analysis was completed and approved by CARB on 10/14/2019.

The root cause was determined to be the Control Rod Drive Mechanism (CRDM) installation and removal status was not formally tracked by either work order. The corrective action to prevent recurrence (CAPR) was to revise procedure MCM BB-007, Installation and Removal Canopy Seal Clamp Assemblies (CSCA), to incorporate a step in the prerequisites to state that if CRDMs/Digital Rod Position Indicators (DRPIs) are to be removed during the evolution, then the implementing work order shall provide a formal method for tracking and verification of which CRDMs/DRPIs are removed and re-installed on the reactor vessel head: Revision 7 of MCM BB-007 was released on 6/25/2019 to address the CAPR.

H. Within 6 months of the issuance date of the Confirmatory Order, Wolf Creek will benchmark 2 other licensee sites to determine how other licensees detect and address incomplete and inaccurate information, including falsified records, and then develop actions from the benchmarks as appropriate.

Item H (CR 134185-01-08) completed 01/13/2020, documented in Letter WO 20-0058.

Benchmarking was conducted at Diablo Canyon from 12/2/2019 to 12/3/2019 and at South Texas from 1/6/2020 to 1/7/2020. The benchmark at both sites was specifically focused on determining how the licensee detects and addresses incomplete and inaccurate information, including falsified records. Additional benchmarking was conducted on the topics of Employee Concerns, Corrective Action Program and Regulatory Affairs. The full benchmark report is captured within self- assessment report SA 2019-0149.

Attachment to WO 22-0056 Page 5 of 14 Findings from each station are as follows: Diablo Canyon benchmarking results: Recent Operating Experience (OE) and corrective actions related to record related violations within the company (Diablo Canyon) as well as in the nuclear industry (WC) highlighted the need for increased focus and attention on record accuracy and integrity, record verification and communication. To improve performance, Diablo Canyon created a Records Integrity Verification initiative which was kicked off in 2Q19. This initiative is currently underway in several departments including Security, Operations, Radiation Protection, Chemistry, Engineering, Maintenance and Cyber Security. The initiative focuses on industry OE and implements industry best practices in the areas of independent assessment of record accuracy, regular communication, and training.

These enhancements helped improve station awareness on the importance of records accuracy and impacts of willful violations and nuclear safety culture. This initiative was rolled out from the top down as an expectation for station leaders to integrate this into their everyday business. The new program owner for Integrity Verification met face to face with each department manager to determined how to implement this process specific to their department. Example - Fire watch may pull 20 records a quarter and verify them for completeness and accuracy where Chemistry may pull 9. Numbers are based on total number of quality records produced in a quarter and areas of concern. If there were to be a finding as a result of the preliminary sample, the scope would be increased to look at additional records from that time period. Their Nuclear Safety Culture Panel looks at the results each quarter. Integrity Verification has been added to their New Employee On-Boarding, site specific Nantel training and communications are sent out prior to and during outage focused on willful misconduct (what it is and the consequences). South Texas Benchmarking Results:

Recently South Texas has had concerns in the area of Fire Protection documentation as documentation has been falsified. South Texas does not have a formal process to recognize inconsistencies or falsification/errors. They rely on Quality audits to periodically review documentation and look for errors. Other than Quality, they only investigate potential for errors if there is a question or a condition report is written alleging an error may have taken place. It was recommended in a 2019 Regional Utility Group - Region IV (RUGIV) meeting for each station to go back to their site and look into what their station was doing regarding an integrity verification plan. Since that meeting, the Manager of Regulatory Affairs has retired, and a new Manager has been hired. The recently hired manager was not aware of the RUGIV discussion regarding an Integrity Verification plan. South Texas is using Operating Experience to identify and communicate 10CFR50.7 and 50.9 issues. A condition report was written in 2019 that identified 50.9 issues at Wolf Creek and Watts Bar. The operating experience was shared with all licensed operators and operations instructors.

Condition Reports written as a result of the benchmarks are CR 139819 - Records Integrity Verification, CR 139820 - Corrective Action Program Improvement, CR139822 - Regulatory Affairs Practices, and CR 139821 - Employee Concerns Program Recommendation.

Training:

I. Within 4 months of the issuance date of this Confirmatory Order, Wolf Creek will provide in-person training to station staff (employees and long-term contractors) that emphasizes expectations for completeness and accuracy in documentation, the expectation to stop when unsure, the expectation to write a condition report if encountering unexpected conditions, and what it means when an individual signs or initials a document. Wolf Creek will add training on these subjects to initial or "onboarding" training. The scope of the initial training may differ between Wolf Creek employees and contractors.

Item I (CR 134185-01-09) completed 11/13/2019, documented in Letter WO 19-0059. Accuracy and Completeness of Documentation training was held for all badged personnel (including supplementals) in July and August 2019, with a schedule of 31 regular class offerings. There

Attachment to WO 22-0056 Page 6 of 14 were also specific sessions for Operations, and sessions were built into existing cycle training for Maintenance, RP and Security. Evidence of training completion was tracked. This training provided a) expectations for completeness and accuracy in documentation; b) the expectation to stop when unsure; c) the expectation to write a CR if encountering unexpected conditions; and d) what it means when an individual signs or initials a document. Accuracy and Completeness of Documentation has been added to the onboarding training that occurs for new personnel, which includes long-term contractors ( > 180 days).

J. Within 12 months of the issuance date of this Confirmatory Order, Wolf Creek will provide training to all maintenance personnel (craft, supervisors, and managers) that describes work order process timeliness, signature or initial requirements, and the process to follow if documents are incomplete (e.g., missing signatures}. Subsequently, a training request will be initiated to analyze training frequency on this topic and Wolf Creek will follow its training process to completion.

Item J (CR 134185-01-10) completed 07/14/2020, documented in Letter WO 20-0058. The Maintenance Director performed training (MG8310801) during the 2Q20 Maintenance Team Matters (MTM) re-enforcing the documentation expectations and the procedural requirements for work order implementation, expectations for work order timeliness, signature and initial requirements, and the initiation of a condition report if incomplete documentation is found and cannot be corrected by the individuals that performed the work. Attendance was taken for the training.

New corrective action (CR 10021053):

While performing SA-2022-0179, annual effectiveness review related to Confirmatory Order EA 18-165 Item P, a recommendation was developed following review of the actions tied to CR 134185-01-10 (Item J). The conclusion reached from CR 134185-01-10 was that a reoccurring training frequency was not necessary per Confirmatory Order Commitment J. The training was found to not need a frequency based on the basic nature of topics being covered (TR #2019-0177-9). As a result of the effectiveness review performed in 2022, it is recommended that this conclusion be re-evaluated as the analysis does not seem sufficient to support not having a training frequency developed for recuring training. CR 10021053 is the condition report tracking this open action to determine if additional periodic recuring training should be provided per Confirmatory Order Commitment J on a reoccurring frequency.

K. Within 12 months of the issuance date of this Confirmatory Order, Wolf Creek will implement annual compliance and ethics training to all employees to address 10 CFR 50.9 and 10 CFR 50.5, compliance therewith, and consequences for non-compliance. In addition, the training will describe what it means when an individual signs or initials a document.

Item K (CR 134185-01-11) completed 07/15/2020, documented in Letter WO 20-0058. As a part of the consolidation efforts of the merger of Westar Energy and Great Plains Energy to form Evergy Inc., a new computer-based Code of Ethics (COE) training module (GT0335501) was delivered to all Evergy employees, including WCNOC employees. WCNOC staff completed the computer-based training on COE between January and April of 2020. Training attendance was taken. The training was developed by Evergy, and contained WCNOC specific material, but did not address the additional required elements related to 10 CFR 50.9 and 10 CFR 50.5 as stated in Commitment K of the Confirmatory Order. The remaining elements have been covered in other forums such as:

• Chief Nuclear Officer (CNO) communication to all WCNOC employees and supplemental personnel regarding lack of tolerance for willful violations, the importance of procedure

Attachment to WO 22-0056 Page 7 of 14 adherence and potential consequences for engaging in willful violations (Confirmatory Order Commitment A completed on October 29, 2019).

• Station leadership held meetings with all WCNOC employees and long-term contractor personnel to address integrity and trustworthiness, based on talking points and a Treat Your Signature as Your Word presentation, which included a video from the CNO (Confirmatory Order Commitment B completed on November 14, 2019).

• Accuracy and Completeness of Documentation training was held for all badged personnel, including supplementals. This training provided a) expectations for completeness and accuracy in documentation; b) the expectation to stop when unsure; c) the expectation to write a condition report if encountering unexpected conditions; and d) what it means when an individual signs or initials a document (Confirmatory Order Commitment I completed on November 13, 2019).

A new action 134185-01-24 was created to track the addition of all required elements from the Confirmatory Order in the COE training with a due date of 2/19/2021. During implementation of this action, it was found that the contents of Commitment K could NOT be incorporated into the 2021 Evergy COE training because the corporate training platform in use, ABSORB, was not able to produce QA records for verification of attendance. Based on this, a separate training course (TIN RA0134801 - WC Compliance Training Cert.) was developed to contain all prescribed items from Commitment K and placed on the NANTEL platform. The action was completed on 2/17/21 and documented in Letter WO 21-0064 with additional actions created as shown below:

• Action 134185-20029285 was generated to track to completion of frequency and personnel assignments for Wolf Creek Compliance Training (TIN RA0134801). It also stated To meet the requirements of Commitment K, the training will need to be required annual and be assigned to all employees. This action was completed on 5/27/21

• Action 134185-20029369 was generated to track the initial completion of TIN RA0134801 and was completed on 8/18/21.

• Action 134185-20031561 was generated to update the Ready to Work R2W process to require TIN RA0134801 prior to issuance of a badge. This additional step was needed to ensure the training occurred prior to badging a new employee. The action was completed on 9/29/21.

Corrective Actions:

L. Within 6 months of the completion of refueling outage 23, Wolf Creek will perform a self-assessment on work order documentation quality by sampling 40 quality-related sub-work order packages performed during the refueling outage. The work order packages selected shall include substantial in-field work. The sample scope will be approved by the regulatory affairs manager and provided to the Wolf Creek NRC resident staff. The assessment team composition shall include an external peer in addition to station personnel. The results of the self-assessment will be reviewed by the Corrective Action Review Board and documented in the corrective action program system.

Item L (CR 134185-01-12) completed 04/29/2020, documented in Letter WO 20-0058. On 4/30/2020 self-assessment SA-2020-0156 was completed which reviewed work order documentation quality by sampling more than 40 quality-related sub- work order packages performed during the Refuel 23. The SA was presented to CARB on 4/28/2020. The work order packages selected included substantial in-field work. The sample scope was approved by the Regulatory Affairs Director and provided to the Wolf Creek NRC resident staff.

Attachment to WO 22-0056 Page 8 of 14 The self-assessment team was led by the Maintenance supervisor of the Central Processing Center with team members that consisted of a Control Room Supervisor, a Maintenance Specialist in Corrective Action Program, a Quality Control Supervisor, a Maintenance Office Assistant that works in the Central Processing Center and an external peer from Callaway who was the Senior Manager Maintenance and has previously been their Outage Manager and a Shift Manager/Senior Reactor Operator.

A review of the selected work orders was performed to ensure procedural compliance in each of the focus areas. The team determined criteria based on procedural reviews and identified those requirements that used the terms should or shall be performed by either the workers or the reviewers. The team lead also met with the Supervisor Document Services and a long-term Document Services Analyst to determine the criteria that would be used when evaluating the work orders for compliance with AP 15A-003, Records. During these reviews, the team found documentation issues in AP 15C-002, Procedure Use and Adherence and AI 16C-008, Work Order Implementation. The less than adequate behaviors include incomplete documentation or incomplete records and inconsistent use of place-keeping and documentation of N/A standards that were not followed. While there were deficiencies identified and CRs written in each of the focus areas, the areas of M&TE and Surveillance Testing were overall satisfactory. In the areas of Procedure Use and Adherence and Work Order Implementation, several instances of incomplete documentation or incomplete records were identified during the review. These deficiencies were not isolated to any one work group and apply to most organizations across the site. Although individuals were contacted, and the complete story was communicated or could be re-created, the sites documentation does not tell the complete story on its own. Workers are not stopping when work cant be performed as written. Even though the team did not identify any nuclear safety concerns or conditions that would impact operability, the records reviewed do not meet station standards or the requirements of 10CFR50, Appendix B, Quality Assurance Records.

(CR 141957 has been generated to capture this condition). Twenty-one additional condition reports were initiated to capture identified deficiencies. The team did not identify any signs of misconduct or intentional falsification of records.

M. Within 6 months of the completion of refueling outage 24, Wolf Creek will perform a self-assessment on work order documentation quality by sampling 40 quality-related sub-work order packages performed during the refueling outage. The work order packages selected shall include substantial in-field work. The sample scope will be approved by the regulatory affairs manager and provided to the Wolf Creek NRC resident staff. The assessment team composition shall include an external peer in addition to station personnel. The results of the self-assessment will be reviewed by the Corrective Action Review Board and documented in the corrective action program system.

Item M (CR 134185-01-13) completed 11/10/2021, documented in Letter WO 21-0064. SA-2021-0170 reviewed work order documentation quality by sampling more than 40 quality-related sub-work order packages performed during the Refuel 24. The team did not identify any conditions that were adverse to quality or see any signs of misconduct or intentional falsification of records.

Additionally, the records reviewed meet station standards and the requirements of 10CFR50, Appendix B, Quality Assurance Records. Of the 50 work orders that were audited, there were 39 of them that met the procedural requirements identified in the scope.

The site continues to have solid performance in the areas of Measuring and Test Equipment (M&TE) and Surveillances. Performance in the area of Records is now meeting current station standards. This can be attributed to corrective actions implemented from the self-assessment (SA-2020-0156) performed for RF23 work orders. The team identified continued beneficial practice as defined in AP 28D- 002, Self-Assessment Process in the area of M&TE. The Maintenance clerical staff performs a review during work order close out to ensure that all M&TE is documented correctly in the work order and that it is entered electronically. Any corrections are

Attachment to WO 22-0056 Page 9 of 14 identified and processed prior to vaulting of the records. This practice should be continued. There is notable improvement in the areas of Procedure Use and Adherence (AP 15C-002) and Work Order Implementation (AI 16C-008) from the previous self-assessment. All of the issues that were identified in these areas can be characterized as very low-level or low-level errors as defined in the Standard/Methodology section and are administrative in nature. A review of the work order documentation trending data from January 2021 to October 2021 reflects improvement in completeness and accuracy. This can be attributed to the additional focus on work order documentation during all of the Maintenance Team Matters (MTM) presentations during cycle training in 2020-2021, coaching roll-up discussions, and additional emphasis on shop ownership at all levels. During the self- assessment week, Maintenance began facilitating the Work Order Documentation Dynamic Learning Activities (DLA - MG8342701). To date Mechanical Maintenance, Electrical Maintenance, Instrumentation and Controls and Maintenance Support have completed the DLAs with very positive results. As stated earlier, the team did not identify any conditions that were adverse to quality or see any signs of misconduct or intentional falsification of records. Additionally, the records reviewed meet station standards and the requirements of 10CFR50, Appendix B, Quality Assurance Records.

N. Within 4 months of the issuance date of the Confirmatory Order, Wolf Creek will conduct a nuclear safety culture survey developed by a third-party.

Item N (CR 134185-01-14) completed 11/04/2019, documented in Letter WO 19-0059. A Nuclear Safety Culture Survey was conducted June/July 2019 using the Utilities Service Alliance (USA) survey method. The survey was followed by a Nuclear Safety Culture Assessment (NSCA) conducted August 12-15, 2019. The NSCA was led by a member of USA with the team consisting of both external peers and WCNOC employees. The final NSCA report was received on 9/12/

2019. Overall, the assessment team noted that WCNOC has a safety culture that supports all INPO Traits of a Healthy Nuclear Safety Culture, has a respect for nuclear safety, and assures that nuclear safety is not compromised by production priorities. There were no Strengths or Weaknesses identified. Condition reports were generated for the Negative, Positive and General Observations.

O. Within 30 months of the completion of the survey in Element N, Wolf Creek will conduct a second nuclear safety culture survey.

Item O (CR 134185-01-15) completed 12/13/2021, documented in Letter WO 21-0064. A nuclear safety culture assessment was conducted by Utilities Service Alliance in the third quarter of 2019 to satisfy action 20025359, 00134185-01 Conduct Nuclear Safety Culture Survey. As a follow up to that action, a second nuclear safety culture assessment was once again completed by Utilities Service Alliance in the fourth quarter of 2021. SA-2021-0166 was conducted during the week of October 11-14, 2021. A pre-assessment survey was opened from September 13, 2021 through October 1, 2021.

The team identified no Strengths or Weaknesses, provided three Negative Observations, two Positive Observations, and five General Observations as described below, and the Corrective Action Program will document the resolution of the issues identified. Overall, the team noted that WCNOC has a safety culture that supports all the INPO Traits of a Healthy Nuclear Safety Culture, has a respect for nuclear safety, and assures that nuclear safety is not compromised by production priorities. Additionally, CR 10021055 was initiated from the annual effectiveness review completed in 2022, that it is recommended that one additional NSC survey be performed in 2023 to determine if there are any changes from the 2019/2021 surveys. This NSC survey is scheduled in May 2023.

Attachment to WO 22-0056 Page 10 of 14 P. By December 31 of 2020, 2021, and 2022, Wolf Creek will perform an annual effectiveness review of its corrective actions associated with the Confirmatory Order. The annual effectiveness review will include the insights from benchmarks, site performance, self-assessments, and safety culture surveys. Wolf Creek will modify its corrective actions, as needed and consistent with this Confirmatory Order, based on the results of the annual effectiveness review.

Item P (CR 134185-01-16) completed 12/15/2020, documented in Letter WO 20-0058.

The year ending 2020 effectiveness follow-up (EFU) is documented in self-assessment SA-2020-0154 and was approved by the Director Regulatory Affairs on 12/14/2020. The self-assessment was reviewed and accepted with comments by CARB on 12/22/2020 and comments were incorporated and verified on 12/23/2020. The annual effectiveness review included insights from benchmarks, site performance, self-assessments, and safety culture surveys. The review concluded that with a few exceptions, CR corrective actions were closed with quality in a timely manner. Conditions reports have been generated to correct the identified closure deficiencies.

The actions taken have been effective and additional CRs have been noted in this assessment where improvement areas were identified. Additionally, it is concluded that no modifications are needed to the corrective actions contained in the confirmatory order at this time.

Item P (CR 134185-01-17) completed 12/27/2021 documented in Letter WO 21-0064.

The year ending 2021 effectiveness review is documented in self-assessment SA-2021- 0168 and was approved by the Director Regulatory Affairs on 12/15/2021. The self-assessment was reviewed and accepted with comments by CARB on 12/21/2021 and comments were incorporated and verified on 12/22/2021. The annual effectiveness review included insights from benchmarks, site performance, self-assessments, and safety culture surveys. CR 10007336 was written for the following NRC observation at the 2Q2021 Integrated Inspection made by the Region IV Branch Chief: Wolf Creeks corrective actions from CR 134185, NRC Confirmatory Order, were determined to be ineffective, specifically around site training. The NRCs recommendation is that Wolf Creek review and strengthen the Corrective Actions from CR 134185, specifically around the corrective actions completed around site training. Action 20031744 to complete additional discussions with employees to ensure clarity on the "Signature is Your Word" is due to be complete by 3/22/2022. This action is meant to ensure that employees understand that the regulatory requirements apply to everyone.

CR 10007338 was written to document the violation associated with the event that occurred in 2019 when Operators signed for actions they were not certain they had performed when completing SYS EJ-110A, A RHR Train Fill and Vent Activities and ultimately leaving a valve in the incorrect position. CR 138420 addressed the specific issue and all corrective actions have been completed). The EFU is due to be completed by 3/22/2022. This is the only remaining action open for this issue.

The corrective actions to date have been effective as evident from the completed Self-Assessments 2020-0156 and 2021-0170 - Refuel 23 (SA-2020-0156) and Refuel 24 (SA-2021-0170) to satisfy Confirmatory Order (CO) Item L and M. The assessments focused on the completeness and accuracy of information in quality-related sub-work order packages. The self-assessments were found to be effective. The assessment areas gave specific values on how many issues occurred and what type, and clearly shows a steady decline in issues with documentation issues in work orders. CR 10007338 captures an event identified in 2019, prior to the completion of assignments from CRs 131147 and 134185 therefore although this condition report identifies an issue that could determine ineffectiveness of corrective actions, was not considered ineffective due to the age of the issue. CR 10007336 was written for the following NRC observation at the 2nd Quarter 2021 Integrated Inspection made by the Region IV Branch Chief: Wolf Creeks corrective actions from CR 134185, NRC Confirmatory Order, were

Attachment to WO 22-0056 Page 11 of 14 determined to be ineffective, specifically around site training. The NRCs recommendation is that Wolf Creek review and strengthen the Corrective Actions from CR 134185, specifically around the corrective actions completed around site training. Action 20031744 to complete additional discussions with employees to ensure clarity on the "Signature is Your Word" is due to be complete by 3/31/2022, therefore will be captured in the self-assessment due in December 2022.

One condition report was generated from this self-assessment. Corporate Communications was provided to the site on 8/14/2019 reinforcing that willful violations will not be tolerated. The communications discussed the expectation that documentation be complete and accurate and the associated consequences for engaging in willful violations. The communications were effective in relaying the importance that documentation must be complete and accurate, which is important based on the origin of the Confirmatory Order, however it was noted in the self-assessment (2021-0168) that the stand-alone communication did not discuss the topic of Procedure Use and Adherence as much as it could have. This was noted as a potential observation recommendation that additional communication could have been included on Procedure Use & Adherence and the impact this has on station performance. It is recommended that additional site communication be provided in 2022 which focuses on Procedure Use &

Adherence. For documentation to be complete and accurate, the worker must properly use Procedure Use & Adhere and know when to identify a shortcoming in said procedure (know when to stop). This was captured in a new condition report CR 10011216 in December 2021 as an observation and recommendation to provide additional site communication on Procedure Use &

Adherence as related to the Confirmatory Order in 2022.

This annual effectiveness review has been completed using information from completed corrective actions, self-assessments, site safety culture surveys, CAP searches, OE, and site trends identified in CRs. The review concluded, with a few exceptions identified during the review of CAP searches of possible adverse trends in documentation, that the actions completed to date represent Wolf Creek's actions are effective. The few minor exceptions identified, which illustrate possible adverse trends in documentation, will continue to be reviewed in future annual effectiveness reviews as these CRs still have open assignments against them and determined at this time to have no impact on completed actions to date or a need to modify completed actions to date. The review concluded corrective actions were closed with quality in a timely manner.

The actions taken have been effective and additional CRs have been noted in this assessment where improvement areas were identified. Additionally, it is concluded that no modifications are needed to the corrective actions contained in the confirmatory order at this time.

Item P (CR 134185-01-18) completed 12/16/2022, as documented in this Letter WO 22-0056.

The year ending 2022 effectiveness review is documented in self-assessment SA-2022-0179 and was approved by the Corrective Action Review Board (CARB) on 12/15/2022. The self-assessment was reviewed and accepted with comments by CARB on 12/15/2022 and comments were incorporated and verified on 12/16/2022. The annual effectiveness review included insights from benchmarks, site performance, self-assessments, and safety culture surveys as required by commitment P of the CO. The 2022 Confirmatory Order, Item P, Annual Effectiveness Review (SA-2022-0179) concluded that corrective actions were closed with quality and closed in a timely manner. All corrective actions were determined to provide resolution to the identified issue/action and determined to be effective.

The corrective actions to date have been effective as evident from the completed Self-Assessments 2020-0156 and 2021-0170 - Refuel 23 (SA-2020-0156) and Refuel 24 (SA-2021-0170) to satisfy Confirmatory Order (CO) Item L and M. The assessments focused on the completeness and accuracy of information in quality-related sub-work order packages. The self-assessments were found to be effective. The assessment areas gave specific values on how many issues occurred and what type, and clearly shows a steady decline in issues with documentation issues in work orders. The CR examples provided above provide issues with documentation that were self-identified by the station through the station's normal review processes. Although these provide negative examples of documentation and signature is your

Attachment to WO 22-0056 Page 12 of 14 word, the station's behaviors to self-identify and correct provide good examples of changes in station behaviors and ability to sustain document quality moving forward.

As part of this process, AI 36-003, Integrity Verifications, was created to complete additional integrity verifications. These verifications shall be completed at least semiannually for all applicable work groups. Verification results shall be documented on the applicable form and recorded in the appropriate condition report generated by Organizational Performance. If a discrepancy is found, promptly notify the Department Director/Manager and Director of Organizational Performance and Improvement and generate a separate condition report.

Completed Integrity Verifications shall be documented in the appropriate condition report generated by Organizational Performance.

Based on the completion of AI 36-003 integrity verifications, a review of the completed integrity verification forms from July 2021 to current was performed as part of this assessment. No discrepancies were noted.

Two new condition reports and one new CR assignment were generated from this self-assessment completed in 2022 (SA-2022-0179). These CRs are as follows:

CR 10021053:

While performing the annual effectiveness review related to Confirmatory Order EA 18-165, a recommendation was developed following review of the actions tied to CR 134185. The recommendation is related to action 10 of CR 134185 and the conclusions reached for determining if a training frequency was necessary for the training provided per Confirmatory Order Commitment J. The training was found to not need a frequency based on the basic nature of topics being covered. (TR #2019-0177-9) As a result of the effectiveness review performed, it is recommended that this conclusion be re-evaluated as the analysis does not seem sufficient to support not having a reoccurring training frequency.

CR 10021055:

While performing the annual effectiveness review related to Confirmatory Order EA-18-165, a recommendation was developed following review of Safety Culture Surveys completed since 2019. It is recommended that one additional Nuclear Safety Culture survey be performed in 2023 to determine if there are any changes from the 2019/2021 surveys. Reference CR actions 134185-01-14 and 134185-01-15 (Maximo assignments 20025359 and 20025463) for previous 2019 and 2021 NSC survey information.

Assignment 20037040 (CR 134185):

Based on the review of actions tied to CR 134185 from the 2022 Effectiveness Review, this action is being created to review the CR 134185 actions to ensure the documentation that completed the associated tasks is packaged and attached to this CR for ease of traceability.

This annual effectiveness review has been completed using information from completed corrective actions, self-assessments, site safety culture surveys, CAP searches, OE, and site trends identified in CRs. The review concluded, with a few minor exceptions identified during the review of CAP searches of possible adverse trends in documentation, that the actions completed to date represent Wolf Creek's actions are effective.

Attachment to WO 22-0056 Page 13 of 14 Administrative Items:

Q. By December 31 of each year until 2023, Wolf Creek will provide in writing to the Regional Administrator, Region IV, a summary of the actions implemented under this Confirmatory Order, the results achieved, and any additional corrective actions initiated as a result of this Confirmatory Order.

Item Q (CR 134185-01-19) completed 12/30/2019. A summary of actions completed in 2019 were submitted to the NRC Regional Administrator on 12/23/2019 via letter WO-19-0059.

Item Q (CR 134185-01-20) completed 12/23/2020. A summary of actions completed in 2020 were submitted to the NRC Regional Administrator on 12/23/2019 via letter WO-20-0058.

Item Q (CR 134185-01-21) completed 12/29/2021. A summary of actions completed in 2021 were submitted to the NRC Regional Administrator on 12/29/2021 via letter WO-21-0064.

Item Q (CR 134185-01-22) completed 12/19/2022. A summary of actions completed in 2022 are included in this NRC Regional Administrator letter dated 12/19/2022 via letter WO-22-0056.

Results Achieved:

1) Increased site awareness through written and electronic communication that willful violations will not be tolerated, the importance of procedural adherence, ensuring that documents are complete and accurate, the potential consequences for engaging in willful violations, and the expectation to identify and document issues.

2) Increased site awareness of 10 CFR 50.5, Deliberate misconduct and 10 CFR 50.9, Completeness and accuracy of information, with Operations, Fire Watch, Maintenance and RP staff through electronic communication and leadership meetings with their reports.

3) Completed the corrective action to prevent recurrence to address the root cause of the escalated violation.

4) Provided in-person training to WCNOC personnel and long-term contractors that emphasized the expectation for completeness and accuracy in documentation, the expectation to stop when unsure, the expectation to write a condition report if encountering unexpected conditions, and what it means when an individual signs or initials a document.

5) Added Accuracy and Completeness of Documentation to onboarding training for new personnel.

6) Determined that WCNOC has a safety culture that supports all INPO Traits of a Healthy Nuclear Safety Culture, has a respect for nuclear safety, and assures that nuclear safety is not compromised by production priorities.

7) Completed a self-assessment which included the review of more than 40 quality-related sub-work order packages performed during the Refuel 23. The team did not identify any signs of misconduct or intentional falsification of records. Condition reports were initiated to correct any documentation issues identified.

8) Completed a self-assessment which included the review of more than 40 quality-related sub-work order packages performed during the Refuel 24. The team did not identify any signs of misconduct or intentional falsification of records. Condition reports were initiated to correct any documentation issues identified.

Attachment to WO 22-0056 Page 14 of 14 Condition Report

References:

1) Condition Report 134185, Confirmatory Order Letter Receipt and Action Tracking

2) Condition Report 131147, Proposed Greater Than SLIV Traditional Enforcement Violation

3) Condition Report 134871, Issue with Documentation Practices

4) Condition Report 135634, Confirmatory Order Action A Concern

5) Condition Report 139819, Records Integrity Verification

6) Condition Report 139820, CAP Evaluator Qualification Recommendation from SA 2019-0149

7) Condition Report 139821, ECP resource Recommendation from SA 2019-0149

8) Condition Report 139822, Reg Affairs Submittal Recommendation from SA 2019-0149

9) Condition Report 141957, SA-2020-0156, Area for Improvement

10) Condition Report 10011216, Confirmatory Order Effectiveness Review Recommendation SA 2021-0168

11) Condition Report 10021053, Confirmatory Order Effectiveness Review Recommendation SA-2022-0179

12) Condition Report 10021055, SA-2022-0179 Recommendation