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See also: [[see also::IR 05000440/2005014]]


=Text=
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{{#Wiki_filter:U- I FENOC Perry Nuclear Power Station ,% 10 Center Road FirstEnergy  
{{#Wiki_filter:U-   I FENOC           ,%
Nuclear Operating  
Perry Nuclear Power Station 10 Center Road FirstEnergy Nuclear Operating Company                                                                               Perry Ohio 44081 L. William Pearce                                                                                                       440-280-5382 Vice President                                                                                                   Fax: 440-280-8029 January 27, 2006 PY-CEI/NRR-2935L United States Nuclear Regulatory Commission Document Control Desk Washington, DC 20555 Perry Nuclear Power Plant Docket No. 50-440 License No. NPF-58
Company Perry Ohio 44081 L. William Pearce 440-280-5382
 
Vice President  
==Subject:==
Fax: 440-280-8029
Response to NRC Confirmatory Action Letter (CAL) Followup Inspection Phase 2 Performance Improvement Initiative Review Inspection Report 05000440/2005014 Ladies and Gentlemen:
January 27, 2006 PY-CEI/NRR-2935L
This letter provides the FirstEnergy Nuclear Operating Company (FENOC) response to the NRC Inspection Report 05000440/2005014 for the Perry Nuclear Power Plant (PNPP). The NRC letter provided the results of your review of Phase 2 of the Performance Improvement Initiative. In your letter you requested that FENOC respond within 30 days of receipt of the letter describing the specific actions that PNPP plans to take to address the observations identified in this inspection report. There were six (6) observations contained in the report. The FENOC responses to these observations are contained in an attachment to this letter. No commitments are contained in this letter or the attachment.
United States Nuclear Regulatory  
If you have questions or require additional information, please contact Mr. Jeffrey Lausberg -
Commission
Manager, Regulatory Compliance at (440) 280-5940.
Document Control Desk Washington, DC 20555 Perry Nuclear Power Plant Docket No. 50-440 License No. NPF-58 Subject: Response to NRC Confirmatory  
Very truly yours, nx r> e         ft             -PC,?-4C   -                                 -
Action Letter (CAL) Followup Inspection  
Attachment cc:     NRC Region III Administrator NRC Project Manager NRC Resident Inspector
Phase 2 Performance  
 
Improvement  
Attachment I
Initiative  
Issue 1: The inspectors noted that some issues identified in the Perry IP 95003 inspection report were not specifically addressed by Commitments and/or Action Items in the licensee's August 8 and August 17 response letters. However, upon detailed review, the inspectors identified that although specific actions to address the issues in the IP 95003 inspection report were not addressed in these letters, actions were contained in some form in either the revised P11, the correction action program, or through departmental initiatives independent of a formal program.
Review Inspection  
The following specific examples were identified:
Report 05000440/2005014
PNPP Response: This issue is centered on assuring a concise reconciliation and ultimately a complete resolution of all findings and key observations detailed in the Perry 95003 Inspection Report. To that end, a 95003 Inspection Report "gap analysis" is under development which will track all findings and key observations noted in the inspection report in a matrix. This "gap analysis" will be monitored by the Perry Performance Improvement Initiative staff to provide additional assurance of integrated issue resolution.
Ladies and Gentlemen:
A specific response to each of the supporting observations is provided below.
This letter provides the FirstEnergy  
Observation: The licensee's response letters addressed an observation in the IP 95003 inspection report that corrective actions for issues entered into the corrective action program were frequently narrowly focused.
Nuclear Operating  
Resolution: The inspectors noted that the action items listed in the response letters did not specifically address the issue of narrowly focused corrective actions. The licensee credited a corrective action associated with CR 05-0722 3 to address the issue. This corrective action prescribed a 5-day root cause training course. It was unclear to the inspectors or to interviewed licensee personnel how the addition of this root cause class to the licensee's training program addressed the issue of narrowly focused corrective actions. Through interviews, the inspectors determined that the revised PlI Human Performance and Corrective Action Program initiatives generally addressed improvement of standards associated with the corrective action process and therefore indirectly addressed the issue.
Company (FENOC) response to the NRC Inspection  
PNPP Response: Addressing the issue of narrowly focused corrective actions is one specific and substantive action necessary to achieve improvement in the implementation of the Corrective Action Program. The approach taken in the Phase 2 PII to improve implementation of the Corrective Action program has been to address the basic fundamental causes and in so doing, encompass the specific issues identified in the 95QQ3Irtspection.ReporL.                                   -         - _____-
Report 05000440/2005014  
Specific to this observation, there are several actions that provide the details for resolution of this issue. As noted in the inspection report, CR 05-07223 and additionally, the Detailed Action Monitoring Plan (DAMP) section 1.4 which are focused on improving the quality of evaluations and corrective actions primarily through training, provide the basis for this action closure. In addition, actions focused on reviews and feedback provided by the Corrective Action Closure Board (Action 1.6.1 and 1.6.2) and the Corrective Action Review Board (Actions 1.7.2,1.7.4 and 1.7.5) further support the resolution of this issue. Collectively, these actions focus on training to improve the quality of investigations and corrective actions, and the review and feedback process to assure effective resolution of plant issues.
for the Perry Nuclear Power Plant (PNPP). The NRC letter provided the results of your review of Phase 2 of the Performance  
 
Improvement  
Attachment 2
Initiative.  
Observation: The licensee's response letters addressed an observation in the IP 95003 inspection report of a lack of a questioning attitude for off-normal conditions.
In your letter you requested  
Resolution: The inspectors noted that the action items listed in the response letters did not specifically address a lack of a questioning altitude for off-normal conditions. The licensee identified four condition reports that were associated with events related to the issue. The inspectors noted that these condition reports lacked corrective actions that addressed questioning attitude. Through interviews, the inspectors determined that the revised Pil Human Performance and Corrective Action Program initiative actions included training that generally addressed improvement of standards associated with problem identification and therefore indirectly addressed the issue.
that FENOC respond within 30 days of receipt of the letter describing  
PNPP Response: Our 95003 Supplemental Inspection response letter included four bulleted actions which address the root cause of procedure adherence issues, including questioning attitude. Additionally, site training on the error prevention tools of effective communication and questioning attitude was provided in April, 2005. During the 4th quarter of 2005 and 1 st quarter of 2006 human performance fundamentals training is being provided which addresses the use of the error prevention tool of questioning attitude.
the specific actions that PNPP plans to take to address the observations  
These actions, when completed will address the root cause of questioning attitude and ultimately will address the more specific case of lack of questioning attitude for off normal conditions by engineering personnel.
identified  
Observation: The licensee's response letters addressed an observation in the IP 95003 inspection report that a lack of technical rigor in engineering products resulted in incorrect conclusions, and that a weakness in the communications between engineering and other organizations hindered the resolution of problems.
in this inspection  
Resolution: The Phase 2 P1I Detailed Action and Monitoring Plan included general action items for training on engineering rigor and conduct; however, the inspectors noted that more substantial action items, including the development of engineering procedures to address the specific issues, were being accomplished outside of the Phase 2 Pll and the corrective action program. As such, actions that more substantially addressed IP 95003 issues were not formally tracked by the Phase 2 P11 or by the corrective action program. The licensee entered this issue into their oCR                                 05-eR675.         -
report. There were six (6) observations  
PNPP Response: The issue of techn cal rigor identified in the 95003 Inspection Report will be addressed through implementation of the P11. The transition review from Phase 1 to Phase 2 of the P11 identified Phase 1 technical rigor actions requiring inclusion in the Phase 2 DAMP Appendix. Specifically actions A.5.3.1, A.5.4.1, A.5.5.1 were included in the DAMP as specific actions to address technical rigor.
contained  
In addition to the actions specified in the DAMP, the Perry Engineering Department undertook further action that will be captured through the implementation of PYBP-PNED-0004 Perry Nuclear Engineering Department Conduct of Engineering document.
in the report. The FENOC responses  
Effective implementation of this document will provide additional basis to assure an adequate and sustained resolution of the issue of technical rigor. This action has been added to the Phase 2 P11 DAMP Appendix as action A.5.6.1 as a result of condition report 05-07675.
to these observations  
 
are contained  
Attachment 3
in an attachment  
Observation: The IP 95003 inspection report identified the following issues related to the use of the corrective action program to address action items in the Phase 1 P11: (1) while P11 action items may be considered closed, the corrective actions to address the problems may not have been fully identified or implemented; and (2) in some cases the corrective action program had not been adequately implemented to address the concerns identified during the Phase 1 P11 reviews.
to this letter. No commitments  
Because closed Phase 1 P11 action items were not reviewed by licensee staff to determine whether the items had been adequately accomplished and because the IP 95003 inspection identified that some action items were not adequately addressed, the inspectors questioned whether the completed Phase 1 PI1 action items had been adequately accomplished.
are contained  
Resolution: In response to the inspectors' concerns, the licensee reviewed a sample of closed Phase 1 P11 action items to assess whether there were items that were not captured in the transfer process due to inappropriate Phase 1 closure. The licensee found no issues with the sample of Phase 1 closed items that were reviewed. The NRC planned to conduct independent reviews of closed Phase 1 P11 action items and determine whether those actions had been adequately accomplished during future CAL ftllow up inspection activities.
in this letter or the attachment.
PNPP Response: This observation notes the Phase 2 P11 dependency on the adequate review and closure of the Phase 1 P11 and questions whether additional reviews need to be completed to assure the adequacy of the closed Phase 1 P11 actions. As noted in the Inspection Report, for the Phase 1 actions which were not closed a comprehensive approach was taken to assure proper transition and integration into Phase 2.
If you have questions  
The Phase 1 P11 was in part, a broad-based discovery process, developed to ensure a full understanding of all key issues associated with Perry performance. Much of this effort was focused on reviews (latent issues, system health and programs). Each of these assessments reached a conclusion with regard to overall adequacy/health of each area.
or require additional  
These assessments would also identify other issues that typically were entered into the corrective action process and not tracked by the PII. This is consistent with the current Phase 2 Pil approach. As defined in PYBP-PII-0006 section 4.6:
information, please contact Mr. Jeffrey Lausberg -Manager, Regulatory  
Fundamentally, the Pll is aimed at strengthening execution of existing process. As a result, unless P11 effectiveness reviews and performance assessments reveal continuing significant performance gaps, problems identified in these reviews will be handled through existing processes such as the Corrective Action Program.
Compliance  
As notedin the inspection report, as part of this PIHinspection PNPP performed a sampling of these closure packages to determine if any actions identified affected the fundamental conclusion of each assessment that should have been further tracked by the P11. None were identified.
at (440) 280-5940.Very truly yours, nx r> e ft -PC,?-4C --Attachment
In response to this observation a review of past condition reports on Phase 1 P11 action closure was performed. CR 05-02940 documents an issue identified by the Corrective Action Assessment Board that identities that several Phase 1 P11 closure validation packages did not meet the requirements for closure under PYBP-PII-0005 'Closure and Validation of P11 Actions". Specifically it identified two of eleven closure packages did not meet the criteria for closure and five of the eleven packages did not meet the requirements for documentation of "results achieved."
cc: NRC Region III Administrator
A review of this CR indicates that the issues identified focused on the adequacy of the "results achieved" section of the closure package. As defined in Phase 2 of the PII, "results achieved" are now generally segregated from the closure package for individual action item closure packages and are follow-up steps in each initiative, typically in the form of self-assessments and effectiveness reviews. It is recognized that in some cases,
NRC Project Manager NRC Resident Inspector  
 
Attachment
Attachment 4
I Issue 1: The inspectors  
the Phase 1 P11 actions did not achieve the desired results. The Phase 2 P11 was developed to focus on achievement of results. Tools such as results based performance metrics, self-assessments and effectiveness reviews are now integrated into the P1I to assure that the desired results are achieved.
noted that some issues identified  
For the two other closure issues identified, the CR investigation determined them to be of an administrative nature that did not affect the ultimate closure disposition and no additional actions were determined to be necessary.
in the Perry IP 95003 inspection  
Issue 2: The inspectors identified that, in some cases, corrective action items for issues were flexible in nature and relied heavily upon particularly high standards or rigor of implementation, which was considered a potential vulnerability.The-following specific examples were identified:
report were not specifically  
Observation: The licensee's response letters addressed an observation in the IP 95003 inspection report that multi-disciplinary assessment teams were not required for root cause evaluations, leading to potential inadequate reviews.
addressed  
Resolution: The inspectors noted that as part of one of the licensee's completed actions in the response letters, licensee personnel revised procedure NOP-LP-2001, "Corrective Action Program," to address multi-disciplinary root cause teams. The inspectors noted that although NOP-LP-2001, Revision 12, addressed multi-disciplined Corrective Action Review Board membership and Management Review Board membership, this procedure did not address multi-disciplinary root cause evaluation teams. Subsequently, the inspectors determined that the procedure change addressing multi-disciplinary root cause team members had been relocated to business practice NOBP-LP-201 1, "FENOC Cause Analysis," Revision 3. NOBP-LP-2011 included a statement to provide multi-disciplined team members as needed. The business practice also stated that members may serve more than one role. As a result, NOBP-LP-2011 provided flexibility that allowed a single-member root cause team. At the end of the inspection, licensee management planned to consider what additional actions, if any, should be implemented to address this issue.
by Commitments  
PNPP Response: In response to this observation, Perry personnel have reviewed the situation and discussed it with the Fleet Program Manager for the Corrective Action Program process. As a result, the Nuclear Operating Business Practice (NOBP-LP-2011) FENOC Cause Analysis has been revised. This revision, effective December 16, 2005, eliminated the qualifiers of "if a team is used" (or similar variation) from the Business Practice.
and/or Action Items in the licensee's  
Additional actions are also contained within the CAP P11 that will strengthen the overall effectiveness of cause evaluations. Specifically, Items 1.4.1,1.4.2, 1.4.3, 1.4.4,1.4.5, and 1.4.6 all target the area of improving the quality of evaluations and corrective actions to ensure corrective actions are smarter and solve the cause of the identified problem.
August 8 and August 17 response letters. However, upon detailed review, the inspectors  
Observation: The licensee's response letters addressed an observation in the IP 95003 inspection report that corrective actions to address identified problems were not always properly prioritized, leading to untimely implementation.
identified  
Resolution: An action item established corrective action program performance as a standing agenda item at the senior management team meetings. An additional action item prescribed an improvement in the timeliness of corrective action program actions. Through procedure review and interviews, the inspectors determined that actual corrective action prioritization was left to the
that although specific actions to address the issues in the IP 95003 inspection  
 
report were not addressed  
Attachment S
in these letters, actions were contained  
discretion of the action owner. The licensee's expectation was that problems should be prioritized by safety significance. The inspectors noted that this expectation, with the lack of additional guidance for implementation, was extremely subjective.
in some form in either the revised P11, the correction  
PNPP Response: A number of Performance Improvement Initiative Action Items address the issue of appropriate prioritization of Corrective Actions. The long-term resolution of this issue is anchored in the program fundamentals that have been communicated and reiterated to all site personnel through the development of PYBP-SITE-0046, Corrective Action Program Implementation Expectations. This action is a result of CAP P1l Actions 1.1.1, 1.2.1 and 1.2.2. Specifically, this document states:
action program, or through departmental  
Expectation: Condition report investigations and corrective action completion are to be based upon risk significance (not due dates).
initiatives  
 
independent  
==Purpose:==
of a formal program.The following  
- Assignments based upon risk significance and not default due dates.
specific examples were identified:
Each activity evaluated and communicated with supervisionAheprority and work schedule.
PNPP Response:  
Expectation: The individual assigned the activity is to complete the assignment in a quality and efficient manner such that the review and approval resources have sufficient time to complete the activity prior to the due date.
This issue is centered on assuring a concise reconciliation  
 
and ultimately  
==Purpose:==
a complete resolution  
Activities are actively worked based upon their risk significance.
of all findings and key observations  
Communication between the individual assigned, their supervisor and the reviewer are occurring to discuss the schedule.
detailed in the Perry 95003 Inspection  
To facilitate the implementation of these expectations there is a focus (via CAP P11 Actions 1.7.1 through 1.7.6) on identifying the appropriate corrective actions in the cause determinations being performed. This is implemented via the Correction Action Review Board and Corrective Action Closure Board that ensure high quality cause evaluations are performed. Ensuring the appropriate focused corrective actions are defined will also control the workload of corrective actions. Maintaining control of the corrective action workload also facilitates the prioritization of actions to be completed based on their significance.
Report. To that end, a 95003 Inspection  
To ensure the desired results are being achieved and the appropriate performance oversight is maintained, several Performance Indicators have been established. These indicators monitor important attributes of the Corrective Action Program including completion of Condition Reports and Corrective Actions on time, quality of evaluations, median age of CRs, and CA work off rates. These PIs are reviewed monthly to ensure the desired results are achieved. Should the expected level of performance not be realized in any given month a recovery plan is developed to restore performance to the expected level.
Report "gap analysis" is under development  
The collective effect of the actions described above (as implemented by the CAP P11) address the issue described in the observation of corrective actions not always being properly prioritized leading to untimely implementation. Accordingly, no additional action is required at this time}}
which will track all findings and key observations  
noted in the inspection
report in a matrix. This "gap analysis" will be monitored  
by the Perry Performance
Improvement  
Initiative  
staff to provide additional  
assurance  
of integrated  
issue resolution.
A specific response to each of the supporting  
observations  
is provided below.Observation:  
The licensee's  
response letters addressed  
an observation  
in the IP 95003 inspection  
report that corrective  
actions for issues entered into the corrective  
action program were frequently  
narrowly focused.Resolution:  
The inspectors  
noted that the action items listed in the response letters did not specifically  
address the issue of narrowly focused corrective  
actions. The licensee credited a corrective  
action associated  
with CR 05-0722 3 to address the issue. This corrective  
action prescribed  
a 5-day root cause training course. It was unclear to the inspectors  
or to interviewed
licensee personnel  
how the addition of this root cause class to the licensee's  
training program addressed  
the issue of narrowly focused corrective  
actions. Through interviews, the inspectors
determined  
that the revised PlI Human Performance  
and Corrective  
Action Program initiatives
generally  
addressed  
improvement  
of standards  
associated  
with the corrective  
action process and therefore  
indirectly  
addressed  
the issue.PNPP Response:  
Addressing  
the issue of narrowly focused corrective  
actions is one specific and substantive  
action necessary  
to achieve improvement  
in the implementation
of the Corrective  
Action Program. The approach taken in the Phase 2 PII to improve implementation  
of the Corrective  
Action program has been to address the basic fundamental  
causes and in so doing, encompass  
the specific issues identified  
in the 95QQ3Irtspection.ReporL.  
--_____-Specific to this observation, there are several actions that provide the details for resolution  
of this issue. As noted in the inspection  
report, CR 05-07223 and additionally, the Detailed Action Monitoring  
Plan (DAMP) section 1.4 which are focused on improving the quality of evaluations  
and corrective  
actions primarily  
through training, provide the basis for this action closure. In addition, actions focused on reviews and feedback provided by the Corrective  
Action Closure Board (Action 1.6.1 and 1.6.2) and the Corrective  
Action Review Board (Actions 1.7.2,1.7.4  
and 1.7.5) further support the resolution  
of this issue. Collectively, these actions focus on training to improve the quality of investigations  
and corrective  
actions, and the review and feedback process to assure effective  
resolution  
of plant issues.  
Attachment
2 Observation:  
The licensee's  
response letters addressed  
an observation  
in the IP 95003 inspection  
report of a lack of a questioning  
attitude for off-normal  
conditions.
Resolution:  
The inspectors  
noted that the action items listed in the response letters did not specifically  
address a lack of a questioning  
altitude for off-normal  
conditions.  
The licensee identified  
four condition  
reports that were associated  
with events related to the issue. The inspectors  
noted that these condition  
reports lacked corrective  
actions that addressed  
questioning
attitude.  
Through interviews, the inspectors  
determined  
that the revised Pil Human Performance
and Corrective  
Action Program initiative  
actions included training that generally  
addressed improvement  
of standards  
associated  
with problem identification  
and therefore  
indirectly
addressed  
the issue.PNPP Response:  
Our 95003 Supplemental  
Inspection  
response letter included four bulleted actions which address the root cause of procedure  
adherence  
issues, including questioning  
attitude.  
Additionally, site training on the error prevention  
tools of effective communication  
and questioning  
attitude was provided in April, 2005. During the 4th quarter of 2005 and 1 st quarter of 2006 human performance  
fundamentals  
training is being provided which addresses  
the use of the error prevention  
tool of questioning
attitude.These actions, when completed  
will address the root cause of questioning  
attitude and ultimately  
will address the more specific case of lack of questioning  
attitude for off normal conditions  
by engineering  
personnel.
Observation:  
The licensee's  
response letters addressed  
an observation  
in the IP 95003 inspection  
report that a lack of technical  
rigor in engineering  
products resulted in incorrect conclusions, and that a weakness in the communications  
between engineering  
and other organizations  
hindered the resolution  
of problems.Resolution:  
The Phase 2 P1I Detailed Action and Monitoring  
Plan included general action items for training on engineering  
rigor and conduct; however, the inspectors  
noted that more substantial
action items, including  
the development  
of engineering  
procedures  
to address the specific issues, were being accomplished  
outside of the Phase 2 Pll and the corrective  
action program. As such, actions that more substantially  
addressed  
IP 95003 issues were not formally tracked by the Phase 2 P11 or by the corrective  
action program. The licensee entered this issue into their oCR 05-eR675.  
-PNPP Response:  
The issue of techn cal rigor identified  
in the 95003 Inspection  
Report will be addressed  
through implementation  
of the P11. The transition  
review from Phase 1 to Phase 2 of the P11 identified  
Phase 1 technical  
rigor actions requiring  
inclusion  
in the Phase 2 DAMP Appendix.  
Specifically  
actions A.5.3.1, A.5.4.1, A.5.5.1 were included in the DAMP as specific actions to address technical  
rigor.In addition to the actions specified  
in the DAMP, the Perry Engineering  
Department
undertook  
further action that will be captured through the implementation  
of PYBP-PNED-0004  
Perry Nuclear Engineering  
Department  
Conduct of Engineering  
document.Effective  
implementation  
of this document will provide additional  
basis to assure an adequate and sustained  
resolution  
of the issue of technical  
rigor. This action has been added to the Phase 2 P11 DAMP Appendix as action A.5.6.1 as a result of condition  
report 05-07675.  
Attachment
3 Observation:  
The IP 95003 inspection  
report identified  
the following  
issues related to the use of the corrective  
action program to address action items in the Phase 1 P11: (1) while P11 action items may be considered  
closed, the corrective  
actions to address the problems may not have been fully identified  
or implemented;  
and (2) in some cases the corrective  
action program had not been adequately  
implemented  
to address the concerns identified  
during the Phase 1 P11 reviews.Because closed Phase 1 P11 action items were not reviewed by licensee staff to determine whether the items had been adequately  
accomplished  
and because the IP 95003 inspection
identified  
that some action items were not adequately  
addressed, the inspectors  
questioned
whether the completed  
Phase 1 PI1 action items had been adequately  
accomplished.
Resolution:  
In response to the inspectors'  
concerns, the licensee reviewed a sample of closed Phase 1 P11 action items to assess whether there were items that were not captured in the transfer process due to inappropriate  
Phase 1 closure. The licensee found no issues with the sample of Phase 1 closed items that were reviewed.  
The NRC planned to conduct independent
reviews of closed Phase 1 P11 action items and determine  
whether those actions had been adequately  
accomplished  
during future CAL ftllow up inspection  
activities.
PNPP Response:  
This observation  
notes the Phase 2 P11 dependency  
on the adequate review and closure of the Phase 1 P11 and questions  
whether additional  
reviews need to be completed  
to assure the adequacy of the closed Phase 1 P11 actions. As noted in the Inspection  
Report, for the Phase 1 actions which were not closed a comprehensive
approach was taken to assure proper transition  
and integration  
into Phase 2.The Phase 1 P11 was in part, a broad-based  
discovery  
process, developed  
to ensure a full understanding  
of all key issues associated  
with Perry performance.  
Much of this effort was focused on reviews (latent issues, system health and programs).  
Each of these assessments  
reached a conclusion  
with regard to overall adequacy/health  
of each area.These assessments  
would also identify other issues that typically  
were entered into the corrective  
action process and not tracked by the PII. This is consistent  
with the current Phase 2 Pil approach.  
As defined in PYBP-PII-0006  
section 4.6: Fundamentally, the Pll is aimed at strengthening  
execution  
of existing process. As a result, unless P11 effectiveness  
reviews and performance  
assessments  
reveal continuing  
significant  
performance  
gaps, problems identified  
in these reviews will be handled through existing processes  
such as the Corrective  
Action Program.As notedin the inspection  
report, as part of this PIH inspection
PNPP performed  
a sampling of these closure packages to determine  
if any actions identified  
affected the fundamental  
conclusion  
of each assessment  
that should have been further tracked by the P11. None were identified.
In response to this observation  
a review of past condition  
reports on Phase 1 P11 action closure was performed.  
CR 05-02940 documents  
an issue identified  
by the Corrective
Action Assessment  
Board that identities  
that several Phase 1 P11 closure validation
packages did not meet the requirements  
for closure under PYBP-PII-0005  
'Closure and Validation  
of P11 Actions".  
Specifically  
it identified  
two of eleven closure packages did not meet the criteria for closure and five of the eleven packages did not meet the requirements  
for documentation  
of "results achieved." A review of this CR indicates  
that the issues identified  
focused on the adequacy of the"results achieved" section of the closure package. As defined in Phase 2 of the PII,"results achieved" are now generally  
segregated  
from the closure package for individual
action item closure packages and are follow-up  
steps in each initiative, typically  
in the form of self-assessments  
and effectiveness  
reviews. It is recognized  
that in some cases,  
Attachment
4 the Phase 1 P11 actions did not achieve the desired results. The Phase 2 P11 was developed  
to focus on achievement  
of results. Tools such as results based performance
metrics, self-assessments  
and effectiveness  
reviews are now integrated  
into the P1I to assure that the desired results are achieved.For the two other closure issues identified, the CR investigation  
determined  
them to be of an administrative  
nature that did not affect the ultimate closure disposition  
and no additional  
actions were determined  
to be necessary.
Issue 2: The inspectors  
identified  
that, in some cases, corrective  
action items for issues were flexible in nature and relied heavily upon particularly  
high standards  
or rigor of implementation, which was considered  
a potential  
vulnerability.The-following  
specific examples were identified:
Observation:  
The licensee's  
response letters addressed  
an observation  
in the IP 95003 inspection  
report that multi-disciplinary  
assessment  
teams were not required for root cause evaluations, leading to potential  
inadequate  
reviews.Resolution:  
The inspectors  
noted that as part of one of the licensee's  
completed  
actions in the response letters, licensee personnel  
revised procedure  
NOP-LP-2001, "Corrective  
Action Program," to address multi-disciplinary  
root cause teams. The inspectors  
noted that although NOP-LP-2001, Revision 12, addressed  
multi-disciplined  
Corrective  
Action Review Board membership  
and Management  
Review Board membership, this procedure  
did not address multi-disciplinary  
root cause evaluation  
teams. Subsequently, the inspectors  
determined  
that the procedure  
change addressing  
multi-disciplinary  
root cause team members had been relocated  
to business practice NOBP-LP-201  
1, "FENOC Cause Analysis," Revision 3. NOBP-LP-2011
included a statement  
to provide multi-disciplined  
team members as needed. The business practice also stated that members may serve more than one role. As a result, NOBP-LP-2011
provided flexibility  
that allowed a single-member  
root cause team. At the end of the inspection, licensee management  
planned to consider what additional  
actions, if any, should be implemented
to address this issue.PNPP Response:  
In response to this observation, Perry personnel  
have reviewed the situation  
and discussed  
it with the Fleet Program Manager for the Corrective  
Action Program process. As a result, the Nuclear Operating  
Business Practice (NOBP-LP-2011) FENOC Cause Analysis has been revised. This revision, effective  
December 16, 2005, eliminated  
the qualifiers  
of "if a team is used" (or similar variation)  
from the Business Practice.Additional  
actions are also contained  
within the CAP P11 that will strengthen  
the overall effectiveness  
of cause evaluations.  
Specifically, Items 1.4.1,1.4.2, 1.4.3, 1.4.4,1.4.5, and 1.4.6 all target the area of improving  
the quality of evaluations  
and corrective  
actions to ensure corrective  
actions are smarter and solve the cause of the identified  
problem.Observation:  
The licensee's  
response letters addressed  
an observation  
in the IP 95003 inspection  
report that corrective  
actions to address identified  
problems were not always properly prioritized, leading to untimely implementation.
Resolution:  
An action item established  
corrective  
action program performance  
as a standing agenda item at the senior management  
team meetings.  
An additional  
action item prescribed  
an improvement  
in the timeliness  
of corrective  
action program actions. Through procedure  
review and interviews, the inspectors  
determined  
that actual corrective  
action prioritization  
was left to the  
Attachment
S discretion  
of the action owner. The licensee's  
expectation  
was that problems should be prioritized
by safety significance.  
The inspectors  
noted that this expectation, with the lack of additional
guidance for implementation, was extremely  
subjective.
PNPP Response:  
A number of Performance  
Improvement  
Initiative  
Action Items address the issue of appropriate  
prioritization  
of Corrective  
Actions. The long-term  
resolution  
of this issue is anchored in the program fundamentals  
that have been communicated  
and reiterated  
to all site personnel  
through the development  
of PYBP-SITE-0046, Corrective
Action Program Implementation  
Expectations.  
This action is a result of CAP P1l Actions 1.1.1, 1.2.1 and 1.2.2. Specifically, this document states: Expectation:  
Condition  
report investigations  
and corrective  
action completion  
are to be based upon risk significance (not due dates).Purpose: -Assignments  
based upon risk significance  
and not default due dates.Each activity evaluated  
and communicated  
with supervisionAheprority  
and work schedule.Expectation:  
The individual  
assigned the activity is to complete the assignment  
in a quality and efficient  
manner such that the review and approval resources  
have sufficient  
time to complete the activity prior to the due date.Purpose: Activities  
are actively worked based upon their risk significance.
Communication  
between the individual  
assigned, their supervisor  
and the reviewer are occurring  
to discuss the schedule.To facilitate  
the implementation  
of these expectations  
there is a focus (via CAP P11 Actions 1.7.1 through 1.7.6) on identifying  
the appropriate  
corrective  
actions in the cause determinations  
being performed.  
This is implemented  
via the Correction  
Action Review Board and Corrective  
Action Closure Board that ensure high quality cause evaluations
are performed.  
Ensuring the appropriate  
focused corrective  
actions are defined will also control the workload of corrective  
actions. Maintaining  
control of the corrective  
action workload also facilitates  
the prioritization  
of actions to be completed  
based on their significance.
To ensure the desired results are being achieved and the appropriate  
performance
oversight  
is maintained, several Performance  
Indicators  
have been established.  
These indicators  
monitor important  
attributes  
of the Corrective  
Action Program including completion  
of Condition  
Reports and Corrective  
Actions on time, quality of evaluations, median age of CRs, and CA work off rates. These PIs are reviewed monthly to ensure the desired results are achieved.  
Should the expected level of performance  
not be realized in any given month a recovery plan is developed  
to restore performance  
to the expected level.The collective  
effect of the actions described  
above (as implemented  
by the CAP P11)address the issue described  
in the observation  
of corrective  
actions not always being properly prioritized  
leading to untimely implementation.  
Accordingly, no additional  
action is required at this time
}}

Latest revision as of 21:59, 7 December 2019

Response to NRC CAL Followup Inspection Phase 2 Performance Improvement Initiative Review Inspection Report 0500440-05-014
ML060380531
Person / Time
Site: Perry FirstEnergy icon.png
Issue date: 01/27/2006
From: Pearce L
FirstEnergy Nuclear Operating Co
To:
Document Control Desk, Office of Nuclear Reactor Regulation
References
PY-CEI/NRR-2935L
Download: ML060380531 (6)


Text

U- I FENOC ,%

Perry Nuclear Power Station 10 Center Road FirstEnergy Nuclear Operating Company Perry Ohio 44081 L. William Pearce 440-280-5382 Vice President Fax: 440-280-8029 January 27, 2006 PY-CEI/NRR-2935L United States Nuclear Regulatory Commission Document Control Desk Washington, DC 20555 Perry Nuclear Power Plant Docket No. 50-440 License No. NPF-58

Subject:

Response to NRC Confirmatory Action Letter (CAL) Followup Inspection Phase 2 Performance Improvement Initiative Review Inspection Report 05000440/2005014 Ladies and Gentlemen:

This letter provides the FirstEnergy Nuclear Operating Company (FENOC) response to the NRC Inspection Report 05000440/2005014 for the Perry Nuclear Power Plant (PNPP). The NRC letter provided the results of your review of Phase 2 of the Performance Improvement Initiative. In your letter you requested that FENOC respond within 30 days of receipt of the letter describing the specific actions that PNPP plans to take to address the observations identified in this inspection report. There were six (6) observations contained in the report. The FENOC responses to these observations are contained in an attachment to this letter. No commitments are contained in this letter or the attachment.

If you have questions or require additional information, please contact Mr. Jeffrey Lausberg -

Manager, Regulatory Compliance at (440) 280-5940.

Very truly yours, nx r> e ft -PC,?-4C - -

Attachment cc: NRC Region III Administrator NRC Project Manager NRC Resident Inspector

Attachment I

Issue 1: The inspectors noted that some issues identified in the Perry IP 95003 inspection report were not specifically addressed by Commitments and/or Action Items in the licensee's August 8 and August 17 response letters. However, upon detailed review, the inspectors identified that although specific actions to address the issues in the IP 95003 inspection report were not addressed in these letters, actions were contained in some form in either the revised P11, the correction action program, or through departmental initiatives independent of a formal program.

The following specific examples were identified:

PNPP Response: This issue is centered on assuring a concise reconciliation and ultimately a complete resolution of all findings and key observations detailed in the Perry 95003 Inspection Report. To that end, a 95003 Inspection Report "gap analysis" is under development which will track all findings and key observations noted in the inspection report in a matrix. This "gap analysis" will be monitored by the Perry Performance Improvement Initiative staff to provide additional assurance of integrated issue resolution.

A specific response to each of the supporting observations is provided below.

Observation: The licensee's response letters addressed an observation in the IP 95003 inspection report that corrective actions for issues entered into the corrective action program were frequently narrowly focused.

Resolution: The inspectors noted that the action items listed in the response letters did not specifically address the issue of narrowly focused corrective actions. The licensee credited a corrective action associated with CR 05-0722 3 to address the issue. This corrective action prescribed a 5-day root cause training course. It was unclear to the inspectors or to interviewed licensee personnel how the addition of this root cause class to the licensee's training program addressed the issue of narrowly focused corrective actions. Through interviews, the inspectors determined that the revised PlI Human Performance and Corrective Action Program initiatives generally addressed improvement of standards associated with the corrective action process and therefore indirectly addressed the issue.

PNPP Response: Addressing the issue of narrowly focused corrective actions is one specific and substantive action necessary to achieve improvement in the implementation of the Corrective Action Program. The approach taken in the Phase 2 PII to improve implementation of the Corrective Action program has been to address the basic fundamental causes and in so doing, encompass the specific issues identified in the 95QQ3Irtspection.ReporL. - - _____-

Specific to this observation, there are several actions that provide the details for resolution of this issue. As noted in the inspection report, CR 05-07223 and additionally, the Detailed Action Monitoring Plan (DAMP) section 1.4 which are focused on improving the quality of evaluations and corrective actions primarily through training, provide the basis for this action closure. In addition, actions focused on reviews and feedback provided by the Corrective Action Closure Board (Action 1.6.1 and 1.6.2) and the Corrective Action Review Board (Actions 1.7.2,1.7.4 and 1.7.5) further support the resolution of this issue. Collectively, these actions focus on training to improve the quality of investigations and corrective actions, and the review and feedback process to assure effective resolution of plant issues.

Attachment 2

Observation: The licensee's response letters addressed an observation in the IP 95003 inspection report of a lack of a questioning attitude for off-normal conditions.

Resolution: The inspectors noted that the action items listed in the response letters did not specifically address a lack of a questioning altitude for off-normal conditions. The licensee identified four condition reports that were associated with events related to the issue. The inspectors noted that these condition reports lacked corrective actions that addressed questioning attitude. Through interviews, the inspectors determined that the revised Pil Human Performance and Corrective Action Program initiative actions included training that generally addressed improvement of standards associated with problem identification and therefore indirectly addressed the issue.

PNPP Response: Our 95003 Supplemental Inspection response letter included four bulleted actions which address the root cause of procedure adherence issues, including questioning attitude. Additionally, site training on the error prevention tools of effective communication and questioning attitude was provided in April, 2005. During the 4th quarter of 2005 and 1 st quarter of 2006 human performance fundamentals training is being provided which addresses the use of the error prevention tool of questioning attitude.

These actions, when completed will address the root cause of questioning attitude and ultimately will address the more specific case of lack of questioning attitude for off normal conditions by engineering personnel.

Observation: The licensee's response letters addressed an observation in the IP 95003 inspection report that a lack of technical rigor in engineering products resulted in incorrect conclusions, and that a weakness in the communications between engineering and other organizations hindered the resolution of problems.

Resolution: The Phase 2 P1I Detailed Action and Monitoring Plan included general action items for training on engineering rigor and conduct; however, the inspectors noted that more substantial action items, including the development of engineering procedures to address the specific issues, were being accomplished outside of the Phase 2 Pll and the corrective action program. As such, actions that more substantially addressed IP 95003 issues were not formally tracked by the Phase 2 P11 or by the corrective action program. The licensee entered this issue into their oCR 05-eR675. -

PNPP Response: The issue of techn cal rigor identified in the 95003 Inspection Report will be addressed through implementation of the P11. The transition review from Phase 1 to Phase 2 of the P11 identified Phase 1 technical rigor actions requiring inclusion in the Phase 2 DAMP Appendix. Specifically actions A.5.3.1, A.5.4.1, A.5.5.1 were included in the DAMP as specific actions to address technical rigor.

In addition to the actions specified in the DAMP, the Perry Engineering Department undertook further action that will be captured through the implementation of PYBP-PNED-0004 Perry Nuclear Engineering Department Conduct of Engineering document.

Effective implementation of this document will provide additional basis to assure an adequate and sustained resolution of the issue of technical rigor. This action has been added to the Phase 2 P11 DAMP Appendix as action A.5.6.1 as a result of condition report 05-07675.

Attachment 3

Observation: The IP 95003 inspection report identified the following issues related to the use of the corrective action program to address action items in the Phase 1 P11: (1) while P11 action items may be considered closed, the corrective actions to address the problems may not have been fully identified or implemented; and (2) in some cases the corrective action program had not been adequately implemented to address the concerns identified during the Phase 1 P11 reviews.

Because closed Phase 1 P11 action items were not reviewed by licensee staff to determine whether the items had been adequately accomplished and because the IP 95003 inspection identified that some action items were not adequately addressed, the inspectors questioned whether the completed Phase 1 PI1 action items had been adequately accomplished.

Resolution: In response to the inspectors' concerns, the licensee reviewed a sample of closed Phase 1 P11 action items to assess whether there were items that were not captured in the transfer process due to inappropriate Phase 1 closure. The licensee found no issues with the sample of Phase 1 closed items that were reviewed. The NRC planned to conduct independent reviews of closed Phase 1 P11 action items and determine whether those actions had been adequately accomplished during future CAL ftllow up inspection activities.

PNPP Response: This observation notes the Phase 2 P11 dependency on the adequate review and closure of the Phase 1 P11 and questions whether additional reviews need to be completed to assure the adequacy of the closed Phase 1 P11 actions. As noted in the Inspection Report, for the Phase 1 actions which were not closed a comprehensive approach was taken to assure proper transition and integration into Phase 2.

The Phase 1 P11 was in part, a broad-based discovery process, developed to ensure a full understanding of all key issues associated with Perry performance. Much of this effort was focused on reviews (latent issues, system health and programs). Each of these assessments reached a conclusion with regard to overall adequacy/health of each area.

These assessments would also identify other issues that typically were entered into the corrective action process and not tracked by the PII. This is consistent with the current Phase 2 Pil approach. As defined in PYBP-PII-0006 section 4.6:

Fundamentally, the Pll is aimed at strengthening execution of existing process. As a result, unless P11 effectiveness reviews and performance assessments reveal continuing significant performance gaps, problems identified in these reviews will be handled through existing processes such as the Corrective Action Program.

As notedin the inspection report, as part of this PIHinspection PNPP performed a sampling of these closure packages to determine if any actions identified affected the fundamental conclusion of each assessment that should have been further tracked by the P11. None were identified.

In response to this observation a review of past condition reports on Phase 1 P11 action closure was performed. CR 05-02940 documents an issue identified by the Corrective Action Assessment Board that identities that several Phase 1 P11 closure validation packages did not meet the requirements for closure under PYBP-PII-0005 'Closure and Validation of P11 Actions". Specifically it identified two of eleven closure packages did not meet the criteria for closure and five of the eleven packages did not meet the requirements for documentation of "results achieved."

A review of this CR indicates that the issues identified focused on the adequacy of the "results achieved" section of the closure package. As defined in Phase 2 of the PII, "results achieved" are now generally segregated from the closure package for individual action item closure packages and are follow-up steps in each initiative, typically in the form of self-assessments and effectiveness reviews. It is recognized that in some cases,

Attachment 4

the Phase 1 P11 actions did not achieve the desired results. The Phase 2 P11 was developed to focus on achievement of results. Tools such as results based performance metrics, self-assessments and effectiveness reviews are now integrated into the P1I to assure that the desired results are achieved.

For the two other closure issues identified, the CR investigation determined them to be of an administrative nature that did not affect the ultimate closure disposition and no additional actions were determined to be necessary.

Issue 2: The inspectors identified that, in some cases, corrective action items for issues were flexible in nature and relied heavily upon particularly high standards or rigor of implementation, which was considered a potential vulnerability.The-following specific examples were identified:

Observation: The licensee's response letters addressed an observation in the IP 95003 inspection report that multi-disciplinary assessment teams were not required for root cause evaluations, leading to potential inadequate reviews.

Resolution: The inspectors noted that as part of one of the licensee's completed actions in the response letters, licensee personnel revised procedure NOP-LP-2001, "Corrective Action Program," to address multi-disciplinary root cause teams. The inspectors noted that although NOP-LP-2001, Revision 12, addressed multi-disciplined Corrective Action Review Board membership and Management Review Board membership, this procedure did not address multi-disciplinary root cause evaluation teams. Subsequently, the inspectors determined that the procedure change addressing multi-disciplinary root cause team members had been relocated to business practice NOBP-LP-201 1, "FENOC Cause Analysis," Revision 3. NOBP-LP-2011 included a statement to provide multi-disciplined team members as needed. The business practice also stated that members may serve more than one role. As a result, NOBP-LP-2011 provided flexibility that allowed a single-member root cause team. At the end of the inspection, licensee management planned to consider what additional actions, if any, should be implemented to address this issue.

PNPP Response: In response to this observation, Perry personnel have reviewed the situation and discussed it with the Fleet Program Manager for the Corrective Action Program process. As a result, the Nuclear Operating Business Practice (NOBP-LP-2011) FENOC Cause Analysis has been revised. This revision, effective December 16, 2005, eliminated the qualifiers of "if a team is used" (or similar variation) from the Business Practice.

Additional actions are also contained within the CAP P11 that will strengthen the overall effectiveness of cause evaluations. Specifically, Items 1.4.1,1.4.2, 1.4.3, 1.4.4,1.4.5, and 1.4.6 all target the area of improving the quality of evaluations and corrective actions to ensure corrective actions are smarter and solve the cause of the identified problem.

Observation: The licensee's response letters addressed an observation in the IP 95003 inspection report that corrective actions to address identified problems were not always properly prioritized, leading to untimely implementation.

Resolution: An action item established corrective action program performance as a standing agenda item at the senior management team meetings. An additional action item prescribed an improvement in the timeliness of corrective action program actions. Through procedure review and interviews, the inspectors determined that actual corrective action prioritization was left to the

Attachment S

discretion of the action owner. The licensee's expectation was that problems should be prioritized by safety significance. The inspectors noted that this expectation, with the lack of additional guidance for implementation, was extremely subjective.

PNPP Response: A number of Performance Improvement Initiative Action Items address the issue of appropriate prioritization of Corrective Actions. The long-term resolution of this issue is anchored in the program fundamentals that have been communicated and reiterated to all site personnel through the development of PYBP-SITE-0046, Corrective Action Program Implementation Expectations. This action is a result of CAP P1l Actions 1.1.1, 1.2.1 and 1.2.2. Specifically, this document states:

Expectation: Condition report investigations and corrective action completion are to be based upon risk significance (not due dates).

Purpose:

- Assignments based upon risk significance and not default due dates.

Each activity evaluated and communicated with supervisionAheprority and work schedule.

Expectation: The individual assigned the activity is to complete the assignment in a quality and efficient manner such that the review and approval resources have sufficient time to complete the activity prior to the due date.

Purpose:

Activities are actively worked based upon their risk significance.

Communication between the individual assigned, their supervisor and the reviewer are occurring to discuss the schedule.

To facilitate the implementation of these expectations there is a focus (via CAP P11 Actions 1.7.1 through 1.7.6) on identifying the appropriate corrective actions in the cause determinations being performed. This is implemented via the Correction Action Review Board and Corrective Action Closure Board that ensure high quality cause evaluations are performed. Ensuring the appropriate focused corrective actions are defined will also control the workload of corrective actions. Maintaining control of the corrective action workload also facilitates the prioritization of actions to be completed based on their significance.

To ensure the desired results are being achieved and the appropriate performance oversight is maintained, several Performance Indicators have been established. These indicators monitor important attributes of the Corrective Action Program including completion of Condition Reports and Corrective Actions on time, quality of evaluations, median age of CRs, and CA work off rates. These PIs are reviewed monthly to ensure the desired results are achieved. Should the expected level of performance not be realized in any given month a recovery plan is developed to restore performance to the expected level.

The collective effect of the actions described above (as implemented by the CAP P11) address the issue described in the observation of corrective actions not always being properly prioritized leading to untimely implementation. Accordingly, no additional action is required at this time