IR 05000277/2007404

IR 05000277-07-404, 05000278-07-404, on 09/21/2007 - 09/27/2007, Peach Bottom Atomic Power Station (Pbaps), Units 2 and 3; Augmented Inspection

ML073090061
Person / Time
Site:	Peach Bottom
Issue date:	11/05/2007
From:	Collins S Region 1 Administrator
To:	Crane C Exelon Generation Co, Exelon Nuclear
References
IR-07-404
Download: ML073090061 (26)

Text

ber 5, 2007

SUBJECT:

PEACH BOTTOM ATOMIC POWER STATION - NRC AUGMENTED INSPECTION TEAM (AIT) REPORT 05000277/2007404 AND 05000278/2007404

Dear Mr. Crane:

On September 28, 2007, the U. S. Nuclear Regulatory Commission (NRC) completed an augmented inspection at your Peach Bottom Atomic Power Station (PBAPS), Units 2 and 3.

This inspection was initiated in accordance with NRC Management Directive 8.3, NRC Incident Investigation Program, and Inspection Manual Chapter 0309, Reactive Inspection Decision Basis for Reactors, and conducted in accordance with Inspection Procedure 93800, Augmented Inspection Team. The enclosed inspection report documents the observations and issues developed by the team and discussed on September 28, 2007, with Mr. Joseph Grimes. A public exit meeting was conducted with Mr. Ron DeGregorio and other members of your staff on October 9, 2007.

The events that led to this inspection began when a PBAPS security officer videotaped multiple instances of several security officers inattentive to duty at the stations former and current power block ready rooms. The NRC was made aware of the existence of these videos, by WCBS-TV (New York City), on September 10, 2007. While the validity and nature of inattentiveness was not yet known, the NRC began enhanced inspection oversight of security at PBAPS and verbally referred the information to Exelon management for investigation the same day. The NRC had the opportunity to first view these videos on September 19, 2007, which depicted multiple security officers inattentive to duty on four separate occasions in the stations ready room between March and August 2007. In response to the viewing of these videos and NRC knowledge of Exelons investigation details, it was determined on September 19, 2007, that an augmented inspection team was warranted. A charter was developed on September 20, 2007, and the NRC commenced an Augmented Inspection Team at PBAPS on September 21, 2007.

The Augmented Inspection Team concluded that your staffs prompt compensatory measures and immediate actions, in response to the videotaped inattentive security officers, were appropriate to ensure the stations continued ability to properly implement the Security Plan.

Additionally, the NRC issued confirmatory action letter 1-07-005, dated October 19, 2007, to ensure those compensatory measures remain in place until the NRC has completed its review of your causal evaluation and corrective action plan.

C. Notwithstanding the confirmatory action letter, the Augmented Inspection Team identified performance issues associated with security officer attentiveness, security management and supervisor effectiveness, implementation of the stations behavioral observation program, and the corrective action program. The augmented inspection was a fact-finding effort and, therefore, these performance issues will require additional NRC inspection follow-up and further review prior to determining what enforcement action, if any, is appropriate. The NRC AIT follow-up inspection will be conducted during the week of November 5, 2007.

In accordance with 10 CFR 2.390 of the NRC's "Rules of Practice," a copy of this letter, its enclosures, and your response (if any) will be available electronically for public inspection in the NRC Public Document Room or from the Publicly Available Records (PARS) component of the NRC's document system (ADAMS). ADAMS is accessible from the NRC Website at http://www.nrc.gov/reading-rm/adams.html (the Public Electronic Reading Room).

Sincerely,

/RA/

Samuel J. Collins Regional Administrator Docket Nos: 50-277, 50-278 License Nos: DPR-44, DPR-56 Enclosure: Inspection Report 05000277/2007404 and 05000278/2007404 w/Attachments Attachments:

(A) Supplemental Information (B) Augmented Inspection Team Charter (C) Event Chronology

SUMMARY OF FINDINGS

IR 05000277/2007-404, 05000278/2007-404; 09/21/2007 - 09/28/2007; Peach Bottom Atomic

Power Station (PBAPS), Units 2 and 3; Augmented Inspection.

The augmented inspection was conducted by a team consisting of inspectors from the NRCs Region I office, special agents from the Office of Investigation, and a security specialist from Nuclear Security and Incident Response (NSIR). The NRCs program for overseeing the safe operation of commercial nuclear power reactors is described in NUREG-1649, Reactor Oversight Process, Revision 4, dated December 2006. An Augmented Inspection Team (AIT)was initiated in accordance with NRC Management Directive 8.3, NRC Incident Investigation Program, and Inspection Manual Chapter 0309, Reactive Inspection Decision Basis for Reactors, and implemented using Inspection Procedure (IP) 93800, Augmented Inspection Team.

Cornerstone: Physical Protection

The team concluded that Exelons prompt compensatory measures and corrective actions in response to the videotaped inattentive security officers at PBAPS were appropriate and ensured the stations ability to satisfy the Security Plan. Overall, Security Plan implementation provided assurance that the health and safety of the public was adequately protected at all times.

Notwithstanding, the security officer inattentiveness adversely impacted elements of the defense-in-depth security strategy. In addition, actions by security guard force supervision were not effective in ensuring that unacceptable security officer behavior was promptly identified and properly addressed.

AIT Inspection Follow-Up Issues In accordance with guidance in IP 93800, the AIT was principally a fact-finding inspection and the team did not make a determination whether NRC rules or requirements were violated.

However, based on the teams observations, the following issues warrant additional NRC follow-up and review:

1) Corrective actions for identified security officer concerns (Section 2.4)2) Security officer attentiveness and extent of condition (Section 2.5)3) Effectiveness of security management and supervisory oversight (Section 2.6)4) Behavioral Observation Program effectiveness (Section 2.7)5) Root cause analysis and extent of condition (Section 2.9)ii iii

REPORT DETAILS

1.0 Inspection Background Information On September 10, 2007, the NRC was contacted by representatives of WCBS-TV (New York City), stating that videotapes of inattentive security officers (SOs) at the Peach Bottom Atomic Power Station (PBAPS) were in their possession. Based upon this information, the Region I Regional Administrator directed implementation of enhanced inspection oversight of security activities by the resident inspectors at PBAPS. That same day, the NRC verbally informed Exelon management of the information received, whereupon Exelon commenced an internal investigation. During the subsequent days before the NRC staff made arrangements to view the videotapes, Region I engaged Exelon several times to discuss the status of their investigation, results achieved, and actions taken to address the alleged security officer inattentiveness issues. On September 19, 2007, the videos were made available by WCBS-TV and viewed by the NRC staff. Based on the viewing of these videos and NRC knowledge of Exelons investigation details, it was determined on September 19, 2007, that an augmented inspection team was warranted. A charter was developed on September 20, 2007, and the NRC commenced an Augmented Inspection Team at PBAPS on September 21, 2007.

The NRC staff learned that the videos were taken by a station SO on-shift using a personal video device and a cell phone video camera on four different occasions between March and August 2007. Video images depicted multiple SOs inattentive to duty in the stations ready room during security shifts on March 12, June 9, June 20, and August 10, 2007. The ready room is a location within the protected area boundary where officers are staged for response functions, while not conducting security patrols.

The videos showed a total of ten SOs all working on Security Team No. 1 that appeared to be inattentive. The video clips were taken at various times during both day and night shifts.

Exelon formed an issues management team based upon NRC information passed verbally on September 10, 2007. One of Exelons initial actions was to re-emphasize to the PBAPS security guard force and Exelon fleet security staffs the need for continued fitness for duty (FFD), with emphasis in the area of fatigue, and their responsibilities to remain alert on duty and report any inattentiveness to supervision. On September 19, 2007, Exelon management and Wackenhut established enhanced security staff oversight at PBAPS, including Wackenhut corporate management providing 24-hour oversight and observation of the security officers. On September 20, 2007, Wackenhut implemented 24-hour on-site security supervision in the ready room. By letter to the Regional Administrator, dated September 21, 2007, Exelon highlighted their immediate efforts to address security officer attentiveness concerns and their investigation findings, to date. Exelon removed site access privileges and placed the security officers, identified as being inattentive in the videotapes, on administrative hold, pending the outcome of Exelons internal investigation.

C contains the detailed chronology associated with this event.

1.1 Augmented Inspection Objectives (93800)

Based on the deterministic criteria specified in Management Directive 8.3, NRC Incident Investigation Program, and Inspection Manual Chapter 0309, Reactive Inspection Decision Basis for Reactors, an Augmented Inspection Team was initiated using the inspection guidance of IP 93800, Augmented Inspection Team.

As outlined in the AIT charter (Attachment B), the inspection teams objectives were to:

(1) review the facts surrounding the specific security events identified and Exelons corrective actions;

(2) understand Exelons short and long-term approach to address the observed performance issues;

(3) assess the Peach Bottom security program to assure that the current security program is effective and meeting the security plan; and

(4) identify any generic issues associated with the events.

2.1 Independent Review of Events (AIT Charter Items No. 2 and 3)

a. Inspection Scope

The team conducted 38 interviews to understand the circumstances and facts surrounding the events, including the probable causes and extent of inattentiveness of SOs at the site. The NRC interviewed security personnel from each of the four security teams, Wackenhut supervision, maintenance personnel, and Exelon management to gather information and evaluate the stations response to the event and current oversight of security. In addition to interviews, the team reviewed the videotapes of the inattentive SOs; and examined station documentation, procedures, and corrective actions associated with the security program and this event.

b. Observations Based on a review of the videos, the team confirmed what appeared to be inattentive, on-duty SOs on four separate occasions (March 12; June 9; June 20; and August 10, 2007). There were a total of ten SOs that appeared inattentive to duty while working on Security Team No. 1. Based upon interviews and documentation reviews, the team did not identify any additional inattentive officers working on teams other than Security Team No.1. The NRC review of inattentive SOs is on-going. The team noted that none of the ten videotaped SOs who were interviewed admitted to being inattentive to duty or seeing anyone inattentive to duty.

The team identified that a maintenance technician and maintenance supervisor were made aware of the videos prior to NRC becoming aware of the issues on September 10, 2007. The maintenance technician reported the issue to his supervisor who did not provide the information to site management. The maintenance supervisor informed the maintenance technician to have the SO report the issue to his security supervisor. The licensee had initiated corrective actions to address this issue.

2.2 Security Plan Impact (AIT Charter Item No. 6)

a. Inspection Scope

The team conducted interviews and observations of the security organization to determine current security program effectiveness and implementation. The team reviewed the Security Plan and verified that Peach Bottom was able to implement Security Plan requirements. The team performed walk downs of the sites protective strategy to evaluate the potential effect of degraded security officer response, due to inattentiveness, on Security Plan implementation. The team evaluated critical SO defensive position response times, for a variety of potential threats, to evaluate the potential significance of the SO performance issues on Security Plan effectiveness.

b. Observations The team concluded that inattentive SOs would have an adverse impact on elements of the defense-in-depth security strategy at PBAPS. SOs in response positions are required, by procedure, to remain alert and attentive. Based upon the information gathered by the team, it appears that the videotaped SOs allowed themselves to become inattentive and potentially compromised their ability to fulfill their duties regarding the sites protective strategy. However, based on the teams review of the Security Plan and security strategy, the level of security at PBAPS was not significantly degraded as a result of these SO performance issues. The following observations were used by the team to assess the significance of SO inattentiveness on station security:

• All inattentive SOs were inside the plants ready room and were in a response only function that did not involve surveillance or detection duties;

• Each of the identified SOs satisfactorily conducted patrols and rounds on the dates associated with the inattentive events;

• All the SOs in the ready room carried two communication devices at all times that could be used to alert the officers, if required to respond;

• SOs in the ready room and SOs at other posts were contacted via radio at 15 minute intervals on backshifts and 30 minute intervals on day shifts;

• All time-lines for these responders (estimated times to reach defensive positions)were determined to be conservative, with margin built into the response time, when compared to the time-lines associated with postulated threats; and

• The responders involved were part of the layered defense-in-depth strategy and were not credited as initial engagement responders.

2.3 Probable Causes (AIT Charter Items No. 2 and 3)

a. Inspection Scope

The team used formal and informal interviews, plant walkdowns, and unannounced observations during day and night shifts to independently assess the extent that inattentive SOs may go undetected at the station. The team reviewed the stations employee concern program files, Wackenhuts Safe-2-Say program, and corrective action documents to determine station effectiveness in addressing security program and personnel issues related to the behavior exhibited during these events. The team reviewed security corrective action documents, audits, surveillances, and drill documentation to determine station opportunities to identify an adverse trend in security performance prior to the videotaping events.

b. Observations The team determined the following causal factors contributed to inattentive behavior in the security organization:

• Adverse behavior had developed among SOs on Security Team No. 1 that treated inattentiveness in the ready room as an acceptable practice;

• The ready room was not accessible for adequate supervisory oversight.

Specifically, the room was locked and did not permit unannounced supervisory checks, and the single room window was blocked from supervisory observations by a file cabinet;

• Management failed to effectively communicate and reinforce station attentiveness expectations. Although generic briefings were given to security teams on alertness and behavior observations, the communications were not effectively received or specific to actual conditions at the plant;

• Security supervisors failed to properly address concerns involving inattentive SOs and were not receptive to these concerns being brought forward. At least two security supervisors were informed that SOs were inattentive and appropriate actions were not taken;

• The environmental conditions in the ready room were not conducive to attentiveness and station management failed to address these known adverse conditions. The ready room had high background noise, was dimly lit, and was poorly ventilated;

• Management failed to identify human factor issues related to 12-hour shifts spent, in part, at the ready room post with low physical activity. For some SOs, a significant portion of the shift could be spent sitting in the ready room when not on patrol or performing other duties; and

• Management failed to provide adequate attentiveness stimuli to the SOs in the ready room.

2.4 Corrective Actions and Compensatory Measures (AIT Charter Items No. 1, 8, and 9)

a. Inspection Scope

The team performed reviews to verify that compensatory measures implemented at PBAPS were appropriate, maintained, and consistent with the sites Security Plan. The team conducted interviews with the SOs and supervisors performing compensatory measures and conducted walkdowns of those measures. The team reviewed supervisory observation and coaching documentation. The team also reviewed Exelon initiated nuclear event reports and Exelons transition plan for the security guard force.

b. Observations The stations prompt compensatory measures and corrective actions implemented to address SOs inattentiveness were appropriate and assured Exelons ability to implement the security strategy. The following is a list of prompt measures implemented at PBAPS by Exelon:

• Briefed all SOs on fatigue and responsibilities for self-reporting;

• Enhanced Wackenhut Corporate oversight at the site for 24-hour coverage and a security supervisor was placed in the ready room 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> a day;

• Exelon senior site management and site security oversight observations performed daily;

• Security Team No. 1 removed from the security shift rotation, denied site access, and placed on administrative hold, pending investigation results;

• Exelon issued Nuclear Event Report (NER), NC-07-034, with fleet-wide actions and issued a generic communication to the industry;

• All SOs were interviewed;

• Exelon plans to terminate the Wackenhut security contract for security services, effective November 1, 2007; and

• Exelon implemented enhanced radio checks on September 27, 2007, based upon NRC observations.

The team identified one corrective action improvement associated with the predictability of radio communication checks for the various security posts. The team noted that a random order radio check would enhance alertness. Exelon implemented this change on September 27, 2007. In addition, Exelon communicated that any actions to change compensatory measures established would be discussed with the NRC, in advance.

The team identified one example where the corrective actions, prior to September 2007, were not effectively implemented. The security organization did not enter instances of inappropriate SO behavior from early 2007 into the station corrective action program (CAP). There was no indication that station corrective actions regarding unacceptable SO behavior were effectively received or acted upon by security supervisors or managers at PBAPS.

2.5 Extent of Inattentive Security Officers (AIT Charter item No. 5)

a. Inspection Scope

The team conducted 38 interviews to ascertain the extent of potential inattentive SO behavior at the site. The interview population included a sample of individuals from all security teams. The team reviewed Exelons interview results to understand their investigative findings which included an interview sample of nearly 100 percent of SOs.

Additionally, the team conducted unannounced backshift observations at various security posts, including the ready room.

b. Observations All security officers were interviewed at least once by either NRC or Exelon. Based on videos and interviews conducted, all ten SOs in the video, were working on Security Team No. 1. None of the SOs interviewed claimed to have ever been inattentive or witnessed inattentive behavior by fellow officers on duty. Seven of the SOs identified as inattentive by video were interviewed by the NRC during the AIT. These seven SOs denied being inattentive or seeing anybody inattentive.

2.6 Management and Supervisory Oversight (AIT Charter Item No. 7)

a. Inspection Scope

The team reviewed Exelons and Wackenhuts actions preceding the event to assess the effectiveness of management oversight and engagement with the PBAPS security organization. The team reviewed procedures, corrective actions, and nuclear event reports related to both Exelon and Wackenhut management oversight. The team reviewed Exelon and Wackenhut backshift and paired observation documentation to evaluate the frequency and quality of oversight activities.

b. Observations The team identified a lack of effective supervisory oversight on Security Team No. 1 that had a direct adverse impact on this event and prolonged identification. In addition, the team determined that station management failed to effectively engage the security personnel when adverse behavior occurred. The following examples were specific instances of ineffective management and supervisory oversight:

• Two individuals indicated that on-shift supervisors on Security Team No. 1 were provided information regarding inattentive SOs. Two supervisors took no action when notified and one supervisor discouraged bringing forward safety concerns;

• Station management failed to take appropriate corrective actions for environmental conditions in the ready room which contributed to inattentive behavior;

• Station management failed to take into consideration human factors when determining shift rotation of internal/external responders. Specifically, SOs were allowed to remain on the same security post for 12-hour shifts which was not conducive to attentiveness; and

• PBAPS security management staffing was not maintained to fleet standards. For a total period of approximately six months over the past year, Exelons fleet standard of a security manager and two security operations supervisors was not maintained. For that time period, Exelon maintained just one acting security manager and one operations security supervisor at the station.

2.7 Behavioral Observation Program (BOP) (AIT Charter Item No. 3)

a. Inspection Scope

The team reviewed Exelons FFD program procedures and the stations general employee training manual with regards to the BOP. The team conducted interviews with SOs and supervisors to determine the level of knowledge and willingness to participate in the reporting of SO behaviors potentially adverse to safety.

b. Observations The team identified the following examples where the station was not effective in promoting and supporting the BOP:

• Some SOs interviewed did not consider closing their eyes or putting their head down on a table for periods of time an example of inattentiveness or fatigue;

• There were multiple opportunities for several SOs to have reported inattentive SO behavior exhibited during the associated security events; and

• There were several opportunities for SOs to have reported aberrant or unacceptable SO behavior during previous security events in early 2007.

2.8 Overtime and Fatigue (AIT Charter Item No. 3)

a. Inspection Scope

The team reviewed schedules, payroll records, and work hour tracking documentation to identify if any security officers that appeared inattentive in the videotape had worked excessive hours or violated NRC work hour requirements.

b. Observations The team determined that the hours worked by the ten SOs, on the four events videotaped, did not exceed NRC individual work hour requirements. The most hours worked by any of these security officers was 12.5 hours5.787037e-5 days <br />0.00139 hours <br />8.267196e-6 weeks <br />1.9025e-6 months <br /> on the day of the event and 57 hours6.597222e-4 days <br />0.0158 hours <br />9.424603e-5 weeks <br />2.16885e-5 months <br /> total for the week of the event. NRC individual limits are 16 hours1.851852e-4 days <br />0.00444 hours <br />2.645503e-5 weeks <br />6.088e-6 months <br /> worked in 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> and 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> worked in seven days. The majority of the ten SOs were working the standard work schedule with little or no overtime. The inattentive behavior occurred on both weekdays and on weekends at various times of the day and night. Additionally, the inattentive behavior was exhibited at different times throughout the 12 hour1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br /> shifts, not just near the end of the shifts. The team did not find a strong correlation between inattentive behavior and work hours.

2.9 Root Cause Evaluation (AIT Charter Item No. 4)

a. Inspection Scope

The team reviewed Exelons root cause team charter and interviewed the root cause team to understand goals and milestones associated with the performance of their root cause evaluation, including determination of causal factors and extent of condition. The inspectors reviewed the scope and depth of the barrier analysis associated with the causal evaluation.

b. Observations Exelons root cause team and charter were established during the week of September 24, 2007. The Exelon team leader discussed their preliminary event chronology and scope of efforts with the team on September 28, 2007. Exelon has a completion milestone for the documented root cause evaluation by October 26, 2007.

The NRC AIT follow-up inspection will review Exelons root cause and extent of condition when this evaluation is completed.

2.10 Generic Issues and Implications (AIT Charter Item No. 11)

a. Inspection Scope

The team reviewed the methodology and content of Exelon communications to their fleet and to the industry regarding the security officer issues at PBAPS. The team also considered what potential NRC generic communications and lessons learned should be disseminated to the industry.

b. Observations Exelon issued an NER to the Exelon fleet with actions to address inattentiveness issues at each of their sites. This NER communicated information and directed actions for the other Exelon sites in order to ensure similar behaviors are not occurring fleet-wide.

Exelon has also submitted a generic communication to the industry about the event and actions taken, to date.

The NRC has submitted a security advisory (SA-07-06) to the industry regarding inattentive security officers. NRC Resident Inspectors conducted random, unannounced checks of ready rooms and security posts in all four Regions. Additionally, the team identified the following issues for generic communication consideration:

• Licensee SO shift rotation frequency and susceptibility to inattentive behavior;

• Licensee evaluation of attentiveness stimuli for security posts where it would be appropriate, based on the nature of their duties;

• Licensee supervision of SOs with regard to utilization of supervisory tools to detect inattentiveness; and

• Licensee environmental conditions for security posts.

3.0 Meetings

Exit Meeting Summary

On October 9, 2007, the inspection team presented the inspection results at a public exit meeting to Mr. Ron DeGregorio and other PBAPS staff. Exelon acknowledged the teams observations and issues for follow-up.

SUPPLEMENTAL INFORMATION

KEY POINTS OF CONTACT

Licensee Personnel

J. Grimes Site Vice President

P. Cowan Director, Licensing and Regulatory Affairs

S. Craig Security Manager

J. Mallon Licensing Manager

LIST OF ITEMS OPENED, CLOSED, AND DISCUSSED

None