IR 05000293/2018011

Confirmatory Action Letter (EA-17-086) Follow-Up Inspection Report 05000293/2018011

ML18282A039
Person / Time
Site:	Pilgrim
Issue date:	10/09/2018
From:	Anthony Dimitriadis NRC/RGN-I/DRP/PB5
To:	Brian Sullivan Entergy Nuclear Operations
Dimitriadis A
References
EA-15-081, EA-17-086 IR 2018011
Download: ML18282A039 (18)

Text

October 9, 2018

SUBJECT:

PILGRIM NUCLEAR POWER STATION - CONFIRMATORY ACTION LETTER (EA-17-086) FOLLOW-UP INSPECTION REPORT 05000293/2018011

Dear Mr. Sullivan:

On June 8, 2018, the U.S. Nuclear Regulatory Commission (NRC) completed an on-site team inspection at Pilgrim Nuclear Power Station (PNPS). The NRC inspectors discussed the results of this inspection with you and other members of your staff during an onsite debrief on June 8, 2018, and via teleconference exits on August 24, 2018, and October 3, 2018. The results of this inspection are documented in the enclosed report.

The NRC inspection team reviewed PNPS's prog ress in implementing the actions from the PNPS Recovery Plan that were committed to in the Confirmatory Action Letter (CAL) dated August 2, 2017 (NRC's Agencywide Documents Access and Management System (ADAMS) Accession No. ML17214A088) (EA-17-086). Specifically, for this inspection the team reviewed the adequacy of the corrective actions PNPS completed to address 33 individual CAL items in

the Corrective Action Program (CAP) and the Procedure Use and Adherence (PUA) Area Action Plans. The team also reviewed site performance to determine whether all the actions completed for these plans, in aggregate, achieved the safety performance improvement objectives stated in the PNPS Recovery Plan for the two area action plans.

The team determined that 30 of the 33 individual CAL items reviewed were adequately completed and effective in achieving the associated PNPS Recovery Plan performance improvement objectives. Three CAL Items-CAP 1.3, CAP 1.8, and PUA 4.2-could not be closed. CAP 1.3 and CAP 1.8 require additional NRC review of site safety culture by qualified NRC safety culture assessors. For PUA 4.2, the NRC determined Entergy's actions for this item were not effective. Therefore, the Corrective Action Program Area Action Plan and the Procedure Use and Adherence Area Action Plan could not be closed at this time. During the course of the inspection for CAP 1.3 and CAP 1.8, the NRC determined that the PNPS Recovery Plan specified a sustained positive change in safety culture as a measure of effectiveness for these two items. Therefore, to verify the effectiveness of the actions taken by Entergy for these CAL items, NRC-qualified sa fety culture assessors will need to conduct assessments during a future inspection activity. CAP 1.3 and CAP 1.8, and the Corrective Action Program Area Action Plan will remain open until these assessments are satisfactorily

completed.

For PUA 4.2, the inspection team observed several maintenance evolutions that were conducted using continuous use or reference use procedures. During some of the evolutions observed by the team, performance was contrary to Entergy's procedure use and adherence standards. No findings or violations of NRC requirements were identified, but the team concluded that additional action was needed to ensure the performance improvement objectives described in the PNPS Recovery Plan were met. Therefore, the inspection team concluded that the observed progress was not sufficient for the NRC to close CAL Item PUA 4.2 or the Procedure Use and Adherence Area Action Plan. PNPS staff entered the issue into the PNPS corrective action process to perform further review. After you notify us that your reviews are completed, we will follow up on the results of your actions to address our concerns in the Procedure Use and Adherence Area Action Plan during a future inspection activity. This item will remain open until the satisfactory completion of this follow-up inspection.

In accordance with the guidance in Inspection Manual Chapter 0305, "Operating Reactor Assessment Program," PNPS will remain within the Multiple/Repetitive Degraded Cornerstone column of the NRC's Reactor Oversight Process Action Matrix pending completion of all actions needed to close the CAL. To review the remaining CAL actions and area action plans, the NRC currently plans to complete two additional quarterly CAL follow-up inspections in addition to the three already completed. The NRC staff will assess the effectiveness of Entergy's implementation of these corrective actions and evaluate whether the safety performance of PNPS has demonstrated sustained improvement warranting transition of PNPS out of Column 4 in accordance with Inspection Manual Chapter 0305, Section 10.02d, paragraph 7. The NRC plans to communicate the results of this determination at a public meeting following the successful completion of these CAL closure activities. The final on-site CAL follow-up inspection is currently scheduled to be completed in December 2018, and the report documenting the results of that inspection to be issued shortly thereafter. 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 10 CFR 2.390, "Public Inspections, Exemptions, Requests for Withholding."

Sincerely,

/RA/ Anthony Dimitriadis, Chief Reactor Projects Branch 5

Division of Reactor Projects

Docket No. 50-293 License No. DPR-35

Enclosure:

Inspection Report 05000293/2018011 w/Attachment: Confirmatory Action Letter Item Status

Inspection Report

Docket Number: 50-293

License Number: DPR-35

Report Number: 05000293/2018011

Licensee: Entergy Nuclear Operations, Inc. (Entergy)

Facility: Pilgrim Nuclear Power Station (PNPS)

Location: Plymouth, MA

Inspection Dates: 06/04/2018 - 06/08/2018

Team Lead: J. Kulp, Senior Reactor Inspector

Inspectors: J. Ambrosini, Senior Emergency Preparedness Inspector P. Finney, Senior Resident Inspector P. Meier, Resident Inspector E. Andrews, Resident Inspector M. Hardgrove, Project Engineer

Approved By: Anthony Dimitriadis, Chief Reactor Projects Branch 5 Division of Reactor Projects

2

SUMMARY

The U.S. Nuclear Regulatory Commission (NRC) continued monitoring Entergy's performance at PNPS by conducting the confirmatory action letter (CAL) follow-up inspection in accordance with the Reactor Oversight Process. The Reac tor Oversight Process is the NRC's program for overseeing the safe operation of commercial nuclear power reactors. Refer to https://www.nrc.gov/reactors/operating/oversight.html for more information.

The team reviewed 33 of the 156 items that Entergy committed to complete in the PNPS CAL (EA-17-086). The items reviewed were associated with the Corrective Action Program (CAP) Area Action Plan and the Procedure Use and Adherence (PUA) Area Action Plan. The team determined that 30 of the 33 individual CAL items reviewed were adequately completed and effective in achieving the associated PNPS Recovery Plan performance improvement objectives. Three CAL Items-CAP 1.3, CAP 1.8, and PUA 4.2-could not be closed at this time. CAP 1.3 and CAP 1.8 require additional NRC review of site safety culture to verify that the effectiveness measures established by the PNPS Recovery Plan are met. For PUA 4.2, the NRC determined Entergy's actions for this item were not effective based on the results of inspector field observations of maintenance activities. Entergy initiated additional corrective actions to address this concern. Therefore, the CAP Area Action Plan and the PUA Area Action Plan will remain open until satisfactory comple tion of an NRC safety culture assessment and future follow-up inspection of Entergy's additional actions to address performance deficiencies identified during the NRC's review of PUA 4.2.

No findings or more-than-minor violations were identified.

Additional Tracking Items Type Issue number Title Report Section Status CAL EA-17-086 PNPS Confirmatory Action Letter Inspection Results 92702 Discussed

3

INSPECTION SCOPE

This inspection was conducted using the appropriate portions of the applicable inspection procedure in effect at the beginning of the inspection unless otherwise noted. Currently approved inspection procedures with their attached revision histories are located on the public

website at http://www.nrc.gov/reading-rm/doc-co llections/insp-manual/inspection-procedure/index.html. The inspectors reviewed selected procedures and records, observed activities, and interviewed personnel to assess Entergy's performance and compliance with Commission rules and regulations, license conditions, site procedures, and standards.

OTHER ACTIVITIES

- TEMPORARY INSTRUCTIONS, INFREQUENT, AND ABNORMAL 92702 - Follow-up on Traditional Enforcement Actions Including Violations, Deviations, Confirmatory Action Letters, Confirmatory Orders, and Alternative Dispute Resolution Confirmatory Orders The inspectors reviewed the status of the corrective actions that Entergy had reported completed for 33 of the 156 items listed on Enclosure 2 of the PNPS CAL (EA-17-086)

(ADAMS Accession No. ML17214A088). All 33 items reviewed for this inspection are identified in the Confirmatory Action Letter Item Status summary table included as an Attachment to this report. The inspectors also reviewed the status of the area action plans associated with these 33 items, which in accordance with Enclosure 2 of the PNPS CAL included the CAP and the PUA Area Action Plans. Entergy had reported these two area action plans were complete and effective.

The inspectors evaluated each item to determine if:

(1) CAL item corrective actions were completed in a timely manner consistent with their safety significance;

(2) Area action plans were effective at addressing the performance issues identified in the CAL;

(3) CAL performance metrics were appropriate and accurate; and,

(4) Closure of each CAL item and area action plan was completed in accordance with established PNPS procedural guidance.

During this review, the inspectors completed the following specific activities:

(1) Reviewed Entergy's closure packages for each CAL action included in the scope of this inspection.

(2) Reviewed Entergy's closure reports for the CAP and PUA Area Action Plans.

(3) Reviewed Entergy's effectiveness reviews and self-assessments completed for the CAP and PUA Area Action Plans.

(4) Performed numerous walk-downs and four independent field observations of the conduct of operations and performance of maintenance evolutions.

(5) Attended Departmental Performance Indicator Coordinator (DPIC) meetings.

(6) Attended Performance Review Group (PRG) meetings.

(7) Attended Leadership & Assessment meetings.

(8) Interviewed select DPIC members.

(9) Interviewed select PRG members.

(10) Interviewed a sample of operations, maintenance, and engineering station employees pertaining to the importance of self-identification of adverse conditions.

(11) Interviewed maintenance technicians, maintenance supervisors, a maintenance superintendent, control room operators, CAL item owners, and Performance Improvement department staff concerning PUA topics.

(12) Validated how the CAP performance metrics are compiled.

(13) Analyzed data and metrics associated with PUA observations during the period of June 2016 to May 2018.

INSPECTION RESULTS

Observation 92702 CAL Items Closed The team closed the following 30 CAL items (a narrative description of each item is listed in Enclosure 1 to the PNPS CAL (ADAMS Accession No. ML17214A088):

Corrective Action Program (CAP) - 1.2, 1.4, 1.5, 1.7, 1.9, 1.10, 1.11, 2.1, 2.2, 2.3, 3.1, 3.2, 4.2, 4.3 Procedure Use and Adherence (PUA) - 1.6, 2.2, 2.3, 2.4, 2.5, 3.1, 3.2, 3.3, 3.4, 4.1, 4.3, 5.1, 5.2, 5.7, 5.8, 5.9 CAL Items Not Closed The team did not close the following three CAL items:

CAP 1.3 and CAP 1.8 o These two CAL items required the use of subject matter experts and mentors in the following areas: CAP, operating experience, trending, self assessments, bench marking, safety culture monitoring, and operations department and control room mentoring. Entergy's effectiveness reviews for CAP 1.3 and 1.8 stated that CAP subject matter experts and mentors would be retained onsite until satisfactory closure of the CAP Area Action Plan. The effectiveness review also stated that the

use of the subject matter experts and mentors would continue until a positive change in safety culture was sustained and verified by NRC inspection.

o The inspectors determined that CAP 1.3 and CAP 1.8 will remain open until NRC safety culture assessors confirm a sustained positive change in safety culture during a future inspection activity.

PUA 4.2 o The CAL requirement was to develop and im plement actions to improve the PUA standards for Reference Use and Continuous Use procedures in Maintenance.

o PNPS provided oversight of selected activities and observed/coached technicians on PUA with a focus on component identification and verification for a period of 10 days. Additionally, PNPS reviewed PUA case studies to train the technicians in the importance of PUA.

o The inspectors determined that PUA 4.2 was not fully effective and should remain open based primarily on the results of independent field observations performed by the inspectors. The inspectors observed the conduct of four surveillances that utilized either continuous use or reference use procedures. During three of the four observations, Entergy staff deviated from the expectations listed in Entergy procedure, EN-HU-106, "Procedure and Work Instruction Use and Adherence,"

Revision 6. The inspectors observed technicians perform a maintenance activity from the control room. During implementation of a continuous use procedure, contrary to guidance provided in EN-HU-106, step 5.4.4, technicians did not fully read procedural steps as required in a reader-doer environment and three-part communication was not consistently implemented. Specifically, technicians directing completion of this activity from the control room did not read an entire procedure step to the technicians performing a task at a remote location, which would increase the likelihood that the wrong action would be completed by the doer. The inspectors also had to prompt the Control Room Supervisor observing the activity to coach the technicians regarding the observed departure from human performance expectations. The inspectors observed technicians perform a maintenance activity in the plant control complex. During implementation of a continuous use procedure in a reader-doer environment, technicians did not utilize three-way communications consistently. This is contrary to guidance provided in EN-HU-106, step 5.4.4. The inspectors observed technicians perform a maintenance activity in the control room. During implementation of a reference use procedure, a procedural step was circle/slashed and initialed as complete prior to actual completion, which is contrary to the guidance provided in EN-HU-106, step 5.6.12. Contrary to EN-HU-16, step 5.4.4.1, during multiple concurrent verification steps, the performer signed as the verifier and the verifier signed as the doer. Finally, technicians in the control room signed for steps completed by a reactor operator in the same area when EN-HU-106, step 5.5.2 directs that, "whenever practical, the person performing the step should COMPLETE the procedure signoff and data entry."

o The inspectors determined that these performance deficiencies were not considered more-than-minor because the objec tives for each activity were met and each evolution was safely completed in accordance with the associated procedures. Each identified performance deficiency, by itself, did not adversely affect a cornerstone objective, could not be considered a precursor to a signicant event, did not affect a performance indicator result, and if left uncorrected would not have the potential to lead to a more significant safety concern.

In response to these observations:

o PNPS entered the performance deficiencies into their CAP as CR-PNP-2018-4849, CR-PNP-2018-4916, and CR-PNP-2018-4918, and conducted an hour long site stand-down to discuss Entegy procedure EN-HU-106 use and adherence requirements and the proper use of human performance tools including 3-way communications and place-keeping.

o PNPS completed an Adverse Cause Analysis (CR-PNP-2018-5580) to collectively evaluate human performance tool usage in operations and maintenance. PNPS identified weaknesses in placekeeping, adherence use, self-check and peer check, and pre-job brief and job site reviews.

o PNPS implemented a comprehensive station human performance gap closure plan to address these weakness. The plan included 8 weeks of actions to re-educate staff on human performance tool use standards, demonstrate human performance tool use, and reinforce human performance tool use standards using leadership focused observations in the field. The plan was initiated on August 20, 2018.

CAP Area Action Plan Summary Review The inspectors concluded that, because individual items CAP 1.3 and CAP 1.8 could not be closed, the overall CAP Area Action Plan was not completed and the associated performance improvement objectives described in the PNPS Recovery Plan could not be validated. The CAP Area Action Plan will remain open.

NRC-qualified safety culture assessors will c onduct assessments to confirm a sustained positive change in safety culture during a future inspection activity.

PUA Area Action Plan Summary Review The inspectors concluded, based upon the PUA performance deficiencies described above, that PUA 4.2 was not adequately completed and the associated performance improvement objectives described in the PNPS Recovery Plan for the PUA Area Action Plan were not fully met. The PUA Area Action Plan will remain open pending further review.

PNPS staff entered the performance deficiencies identified during the review of the actions taken related to PUA 4.2 into the PNPS corrective action process and initiated a plan to address the concerns. After PNPS notifies the NRC that follow-up actions are completed, the NRC will review the results of the additional actions completed to address the performance deficiencies in the area of PUA during future inspection activities.

EXIT MEETINGS AND DEBRIEFS

The inspectors verified no proprietary information was retained or documented in this report.

On June 8, 2018, the inspectors conducted an onsite debrief on the status of CAL follow-up inspection activities to Mr. Brian Sullivan, Site Vice President, and other members of PNPS staff. On August 24, 2018, the inspectors conducted a telephonic exit meeting for the CAL follow-up inspection activities to Mr. Brian Sullivan, Site Vice President, and other members of PNPS staff. On October 3, 2018, the inspectors conducted a telephonic exit meeting and presented the final results for the CAL follow-up inspection items documented in this report to Mr. Drayton Pitts, General Manager Plant Operations, and other members of PNPS staff.

DOCUMENTS REVIEWED

CAL Item Closure Packages

CAP-1.2

CAP-1.3

CAP-1.4

CAP-1.5

CAP-1.7

CAP-1.8 CAP-1.9 CAP-1.10

CAP-1.11

CAP-2.1

CAP-2.2 CAP-2.3 CAP-3.1

CAP-3.2

CAP-4.2

CAP-4.3

PUA-1.6 PUA-2.2 PUA-2.3

PUA 2.4

PUA-2.5

PUA-3.1 PUA-3.2 PUA-3.3

PUA-3.4

PUA-4.1

PUA-4.2

PUA-4.3 PUA-5.1 PUA-5.2

PUA-5.8

PUA-5.9

PUA-5.7 Procedures 1.13.2, Vendor and Technical Information Reviews, Revision 1

1.3.142, PNPS Risk Review and Disposition, Revision 6

1.3.142, Critical Decision Process, Revision 7 3.M.3-47, Load Shed Relay Operational/Functional Test - Critical Maintenance, Revision 93 8.M.2-2.10.8.3, Diesel Generator 'A' Initiation by Core Spray Logic, Revision 37

8.M.2-1.3.2, Refueling Floor Vent Exhaust Monitors Functional Test, Revision 26

8.M.1-32.5.1, Analog Trip System - Trip Unit Calibration with Gross Fail Check Cabinet C2233A Section A - Critical Maintenance, Revision 7 8.E.29.1, Salt Service Water (SSW) Instrumentation Calibration and Functional Test,

Revision 21 EN-WM-105, Planning, Revision 20

EN-HU-106, Procedure and Work Instruction Use and Adherence, Revision 6

EN-HU-105, Human Performance - Managed Defenses, Revision 17

EN-LI-121, Trend and Performance Review Process, Revision 22 through 24 EN-LI-104, Self-Assessment and Benchmark Process, Revision 11 EN-HU-105, Human Performance - Managed Defenses, Revision 15

EN-HU-106, Procedure and Work Instruction Use and Adherence, Revision 3

EN-OP-117, Operations Assessment Resources, Revision 13

EN-LI-118, Cause Evaluation Process, Revision 26

EN-LI-102, Corrective Action Program, Revision 33

EN-FAP-LI-001, Performance Improvement Review Group (PRG) Process, Revision 12 LO-PNPLO-2018-0025, CAP Effectiveness Review, Revision 1

1.3.34, Operations Administrative Policies and Processes, Revision 151

Audits/Self Assessments/Surveillances QS-2018-PNP-05 R1 CAP PUA Surveillance Report, NIOS Assessment of the Recovery Corrective Action Program (CAP) Fundamental Problem and Procedure Use and

Adherence (PUA) Problem Area for Readiness for NRC Inspection, 4/23/18

Condition ReportsCR-PNP-2016-2059 CR-PNP-2017-6753 CR-PNP-2018-4838* CR-PNP-2018-4841* CR-PNP-2018-4593 CR-PNP-2018-4842* CR-PNP-2018-4849* CR-PNP-2018-4916* CR-PNP-2018-3023*

CR-PNP-2018-4962* CR-PNP-2018-4931* CR-PNP-2018-4404

CR-PNP-2018-4465 CR-PNP-2018-4863* CR-PNP-2018-4879*

CR-PNP-2018-4887* CR-PNP-2018-2276 CR-PNP-2018-4941* CR-PNP-2018-4943* CR-PNP-2016-7407 CR-PNP-2016-7993

CR-PNP-2017-0294 CR-PNP-2017-0296 CR-PNP-2016-10326 CR-PNP-2016-09739 CR-PNP-2016-0259 CR-PNP-2017-6753 CR-PNP-2018-3262 CR-PNP-2017-2622 CR-PNP-2018-1949

CR-PNP-2017-7373 CR-PNP-2018-0501 CR-PNP-2018-0704

CR-PNP-2018-0816 CR-PNP-2018-0899 CR-PNP-2018-1401

CR-PNP-2018-2425 CR-PNP-2018-2537 CR-PNP-2018-2920

CR-PNP-2018-3271 CR-PNP-2018-4697 CR-PNP-2018-4965* CR-PNP-2018-4960* CR-PNP-2016-0936 CR-PNP-2016-6635 CR-PNP-2018-3026 CR-PNP-2018-3553 CR-PNP-2016-09739

CR-PNP-2016-10148 CR-PNP-2016-00716 CR-PNP-2017-00410

CR-PNP-2017-05857 CR-PNP-2017-00339 CR-PNP-2018-03017

CR-PNP-2018-01264 CR-PNP-2018-01633 CR-PNP-2018-01804 CR-PNP-2018-03694 CR-PNP-2018-03698 CR-PNP-2018-03941 CR-PNP-2018-04362

Miscellaneous Comprehensive Recovery Plan Corrective Action Program Area Action Plan Closure Report 1Q2018 CAP Subject Matter Expert Assessment Report 4Q2017 CAP Subject Matter Expert Assessment Report

3Q2017 CAP Subject Matter Expert Assessment Report

PRG packages for 6/4, 6/5, and 6/7/2018

Attachment Confirmatory Action Letter Item Status

Line Item Area Action Plan CAL Item Inspection Report Number Closed 1 Nuclear Safety Culture NSC-1.1

Nuclear Safety Culture NSC-1.2

Nuclear Safety Culture NSC-1.3

Nuclear Safety Culture NSC-1.4

Nuclear Safety Culture NSC-1.5

Nuclear Safety Culture NSC-1.6

Nuclear Safety Culture NSC-1.7

Nuclear Safety Culture NSC-1.8

Nuclear Safety Culture NSC-1.10

Nuclear Safety Culture NSC-2.2

Nuclear Safety Culture NSC-2.3

Nuclear Safety Culture NSC-3.1

Nuclear Safety Culture NSC-3.2

Nuclear Safety Culture NSC-3.3

Nuclear Safety Culture NSC-3.4

Nuclear Safety Culture NSC-3.5

Nuclear Safety Culture NSC-3.6

Nuclear Safety Culture NSC-3.7

Nuclear Safety Culture NSC-3.8

Nuclear Safety Culture NSC-4.1

Nuclear Safety Culture NSC-4.2

Nuclear Safety Culture NSC-5.1

Nuclear Safety Culture NSC-5.2

Nuclear Safety Culture NSC-5.3

Nuclear Safety Culture NSC-5.4

Nuclear Safety Culture NSC-6.1

Nuclear Safety Culture NSC-7.1

Nuclear Safety Culture NSC-8.1

Nuclear Safety Culture NSC-8.6

Nuclear Safety Culture NSC-8.8

Nuclear Safety Culture NSC-8.9

Nuclear Safety Culture NSC-8.10

Nuclear Safety Culture NSC-8.21

Nuclear Safety Culture NSC-8.22

Nuclear Safety Culture NSC-8.25

Nuclear Safety Culture NSC-8.26

Nuclear Safety Culture NSC-8.27

Nuclear Safety Culture NSC-8.28

Nuclear Safety Culture NSC-8.29

Corrective Action Program CAP-1.1 05000293/2017010

Y

Line Item Area Action Plan CAL Item Inspection Report Number Closed 41 Corrective Action Program CAP-1.2 05000293/2018010

Y 42 Corrective Action Program CAP-1.3 Reviewed 05000293/2018010

N 43 Corrective Action Program CAP-1.4 05000293/2018010

Y 44 Corrective Action Program CAP-1.5 05000293/2018010

Y 45 Corrective Action Program CAP-1.7 05000293/2018010

Y 46 Corrective Action Program CAP-1.8 Reviewed 05000293/2018010

N 47 Corrective Action Program CAP-1.9 05000293/2018010

Y 48 Corrective Action Program CAP-1.10 05000293/2018010

Y 49 Corrective Action Program CAP-1.11 05000293/2018010

Y 50 Corrective Action Program CAP-2.1 05000293/2018010

Y 51 Corrective Action Program CAP-2.2 05000293/2018010

Y 52 Corrective Action Program CAP-2.3 05000293/2018010

Y 53 Corrective Action Program CAP-3.1 05000293/2018010

Y 54 Corrective Action Program CAP-3.2 05000293/2018010

Y 55 Corrective Action Program CAP-4.2 05000293/2018010

Y 56 Corrective Action Program CAP-4.3 05000293/2018010

Y 57 Procedure Use and

Adherence PUA-1.1 05000293/2017010 Y 58 Procedure Use and

Adherence PUA-1.2 05000293/2017010 Y 59 Procedure Use and

Adherence PUA-1.3 05000293/2017010 Y 60 Procedure Use and

Adherence PUA-1.4 05000293/2017010 Y 61 Procedure Use and

Adherence PUA-1.6 05000293/2018010 Y 62 Procedure Use and

Adherence PUA-2.2 05000293/2018010 Y 63 Procedure Use and

Adherence PUA-2.3 05000293/2018010 Y 64 Procedure Use and

Adherence PUA-2.4 05000293/2018010 Y 65 Procedure Use and

Adherence PUA-2.5 05000293/2018010 Y 66 Procedure Use and

Adherence PUA-3.1 05000293/2018010 Y 67 Procedure Use and

Adherence PUA-3.2 05000293/2018010 Y 68 Procedure Use and

Adherence PUA-3.3 05000293/2018010 Y 69 Procedure Use and

Adherence PUA-3.4 05000293/2018010 Y

Line Item Area Action Plan CAL Item Inspection Report Number Closed 70 Procedure Use and

Adherence PUA-4.1 05000293/2018010 Y 71 Procedure Use and

Adherence PUA-4.2 Reviewed 05000293/2018010 N 72 Procedure Use and

Adherence PUA-4.3 05000293/2018010 Y 73 Procedure Use and

Adherence PUA-5.1 05000293/2018010 Y 74 Procedure Use and

Adherence PUA-5.2 05000293/2018010 Y 75 Procedure Use and

Adherence PUA-5.7 05000293/2018010 Y 76 Procedure Use and

Adherence PUA-5.8 05000293/2018010 Y 77 Procedure Use and

Adherence PUA-5.9 05000293/2018010 Y 78 Operability Determinations and Functionality Assessments

ODFA-1.1 05000293/2017010 Y 79 Operability Determinations and Functionality Assessments

ODFA-1.2 05000293/2018010 Y 80 Operability Determinations and Functionality Assessments

ODFA-1.3 05000293/2018010 Y 81 Operability Determinations and Functionality Assessments

ODFA-1.4 05000293/2018010 Y 82 Operability Determinations and Functionality Assessments

ODFA-1.5 05000293/2018010 Y 83 Operability Determinations and Functionality Assessments

ODFA-1.6 05000293/2018010 Y 84 Operability Determinations and Functionality Assessments

ODFA-2.2 05000293/2018010 Y 85 Operability Determinations and Functionality Assessments

ODFA-3.1 05000293/2018010 Y 86 Operability Determinations and Functionality Assessments

ODFA-5.1 05000293/2018010 Y

Line Item Area Action Plan CAL Item Inspection Report Number Closed 87 Operability Determinations and Functionality Assessments

ODFA-5.2 05000293/2018010 Y 88 Operability Determinations and Functionality Assessments

ODFA-5.3 05000293/2018010 Y 89 Operability Determinations and Functionality Assessments

ODFA-5.4 05000293/2018010 Y 90 Operability Determinations and Functionality Assessments

ODFA-5.5 05000293/2018010 Y 91 Operability Determinations and Functionality Assessments

ODFA-5.6 05000293/2018010 Y 92 Operability Determinations and Functionality Assessments

ODFA-5.7 05000293/2018010 Y

Operability Determinations and Functionality Assessments

ODFA-5.8 05000293/2018010

Y 94 Operations Department Standards and Leadership OPS-1.1 95 Operations Department Standards and Leadership OPS-1.2 96 Operations Department Standards and Leadership OPS-1.4 97 Operations Department Standards and Leadership OPS-1.6 98 Operations Department Standards and Leadership OPS-1.7 99 Operations Department Standards and Leadership OPS-2.2 100 Operations Department Standards and Leadership OPS-3.1 101 Operations Department Standards and Leadership OPS-3.2 102 Operations Department Standards and Leadership OPS-4.1 103 Operations Department Standards and Leadership OPS-4.2 104 Risk Recognition and Decision Making RRDM-1.1

Line Item Area Action Plan CAL Item Inspection Report Number Closed 105 Risk Recognition and Decision Making RRDM-1.2 106 Risk Recognition and Decision Making RRDM-1.3 107 Risk Recognition and Decision Making RRDM-2.1 108 Risk Recognition and Decision Making RRDM-3.1 109 Risk Recognition and Decision Making RRDM-3.2 110 Risk Recognition and Decision Making RRDM-3.3 111 Risk Recognition and Decision Making RRDM-4.3 112 Risk Recognition and Decision Making RRDM-4.8 113 Risk Recognition and Decision Making RRDM-4.9 114 Procedure Quality PQ-1.1 Reviewed - 05000293/2017010 N 115 Procedure Quality PQ-2.1 05000293/2017010 Y 116 Procedure Quality PQ-2.2 05000293/2017010 Y 117 Procedure Quality PQ-3.1 05000293/2017010 Y 118 Procedure Quality PQ-3.2 05000293/2017010 Y 119 Procedure Quality PQ-3.3 05000293/2017010 Y 120 Procedure Quality PQ-5.1 05000293/2017010 Y 121 Procedure Quality PQ-5.2 Reviewed - 05000293/2017010 N 122 SRV White Finding SRV-1.1 05000293/2018010 Y 123 SRV White Finding SRV-1.2 05000293/2018010 Y 124 SRV White Finding SRV-1.3 05000293/2017010 Y 125 SRV White Finding SRV-2.1 05000293/2017010 Y 126 SRV White Finding SRV-3.1 05000293/2018010 Y 127 SRV White Finding SRV-3.2 05000293/2018010 Y 128 SRV White Finding SRV-3.3 05000293/2018010 Y 129 SRV White Finding SRV-3.4 05000293/2018010 Y 130 SRV White Finding SRV-4.1 05000293/2018010 Y 131 SRV White Finding SRV-5.1 05000293/2018010 Y 132 SRV White Finding SRV-5.2 05000293/2018010 Y 133 Engineering Programs EP-1.1 05000293/2017010 Y 134 Engineering Programs EP-1.2 135 Engineering Programs EP-2.1 136 Engineering Programs EP-2.2 137 Engineering Programs EP-2.3 138 Engineering Programs EP-2.4

Line Item Area Action Plan CAL Item Inspection Report Number Closed 139 Engineering Programs EP-3.1 140 Engineering Programs EP-4.1 141 Equipment Reliability ER-1.1 05000293/2017010 Y 142 Equipment Reliability ER-1.2 05000293/2017010 Y 143 Equipment Reliability ER-1.3 144 Equipment Reliability ER-2.1 145 Equipment Reliability ER-2.2 146 Equipment Reliability ER-3.1 147 Equipment Reliability ER-3.2 148 Equipment Reliability ER-3.3 149 Work Management WM-1.1 150 Work Management WM-1.2 151 Work Management WM-1.3 152 Work Management WM-2.1 153 Work Management WM-2.2 154 Work Management WM-3.1 155 Work Management WM-3.3 156 Work Management WM-4.2