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| issue date = 09/23/2013
| issue date = 09/23/2013
| title = IR 05000346-13-007; on 07/22/2013 - 08/9/2013; Davis-Besse Nuclear Power Station; Biennial Problem Identification and Resolution (Pi&R) Inspection
| title = IR 05000346-13-007; on 07/22/2013 - 08/9/2013; Davis-Besse Nuclear Power Station; Biennial Problem Identification and Resolution (Pi&R) Inspection
| author name = Pelke P J
| author name = Pelke P
| author affiliation = NRC/RGN-III/DNMS/MLB
| author affiliation = NRC/RGN-III/DNMS/MLB
| addressee name = Lieb R
| addressee name = Lieb R
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=Text=
=Text=
{{#Wiki_filter:
{{#Wiki_filter:ber 23, 2013
[[Issue date::September 23, 2013]]


Mr. Raymond Lieb Site Vice President FirstEnergy Nuclear Operating Company Davis-Besse Nuclear Power Station 5501 North State Route 2, Mail Stop A-DB-3080 Oak Harbor, OH 43449-9760
==SUBJECT:==
 
DAVIS-BESSE NUCLEAR POWER STATION - NRC PROBLEM IDENTIFICATION AND RESOLUTION INSPECTION REPORT 05000346/2013007
SUBJECT: DAVIS-BESSE NUCLEAR POWER STATION - NRC PROBLEM IDENTIFICATION AND RESOLUTION INSPECTION REPORT 05000346/2013007


==Dear Mr. Lieb:==
==Dear Mr. Lieb:==
On August 9, 2013, the U.S. Nuclear Regulatory Commission (NRC) completed a Problem Identification and Resolution biennial inspection at your Davis-Besse Nuclear Power Station.
On August 9, 2013, the U.S. Nuclear Regulatory Commission (NRC) completed a Problem Identification and Resolution biennial inspection at your Davis-Besse Nuclear Power Station.


The enclosed inspection report documents the inspection results, which were discussed on August 9, 2013, with you and other members of your staff. This inspection was an examination of activities conducted under your license as they relate to problem identification and resolution and compliance with the Commission's rules and regulations and the conditions of your license. Within these areas, the inspection involved examination of selected procedures and representative records, observations of activities, and interviews with personnel.
The enclosed inspection report documents the inspection results, which were discussed on August 9, 2013, with you and other members of your staff.
 
This inspection was an examination of activities conducted under your license as they relate to problem identification and resolution and compliance with the Commissions rules and regulations and the conditions of your license. Within these areas, the inspection involved examination of selected procedures and representative records, observations of activities, and interviews with personnel.


Based on the inspection sample, the inspection team concluded that the implementation of the corrective action program and overall performance related to identifying, evaluating, and resolving problems at Davis-Besse Nuclear Power Station effectively supported nuclear safety.
Based on the inspection sample, the inspection team concluded that the implementation of the corrective action program and overall performance related to identifying, evaluating, and resolving problems at Davis-Besse Nuclear Power Station effectively supported nuclear safety.


Licensee-identified problems were entered into the corrective action program at a low threshold. Problems were prioritized and evaluated commensurate with the safety significance of the problems and corrective actions were generally implemented in a timely manner commensurate with their importance to safety and addressed the identified causes of the problems. Lessons learned from industry operating experience were generally reviewed and applied when appropriate. Audits and self-assessments were effectively used to identify site performance deficiencies, programmatic concerns, and improvement opportunities. Based on the interviews conducted, the inspectors did not identify any impediment to the establishment of a safety conscious work environment at Davis-Besse Nuclear Power Station. Licensee staff is willing to raise concerns related to nuclear safety through at least one of the several means available.
Licensee-identified problems were entered into the corrective action program at a low threshold.
 
Problems were prioritized and evaluated commensurate with the safety significance of the problems and corrective actions were generally implemented in a timely manner commensurate with their importance to safety and addressed the identified causes of the problems. Lessons learned from industry operating experience were generally reviewed and applied when appropriate. Audits and self-assessments were effectively used to identify site performance deficiencies, programmatic concerns, and improvement opportunities. Based on the interviews conducted, the inspectors did not identify any impediment to the establishment of a safety conscious work environment at Davis-Besse Nuclear Power Station. Licensee staff is willing to raise concerns related to nuclear safety through at least one of the several means available. Based on the results of this inspection, no findings of significance were identified.


Enclosure Based on the results of this inspection, no findings of significance were identified. In accordance with 10 CFR 2.390 of the NRC's "Rules of Practice," a copy of this letter, its enclosure, 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 NRC's Agencywide Document Access and Management System (ADAMS). ADAMS is accessible from the NRC Web site at http://www.nrc.gov/reading-rm/adams.html (the Public Electronic Reading Room).
In accordance with 10 CFR 2.390 of the NRC's "Rules of Practice," a copy of this letter, its enclosure, 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 NRC's Agencywide Document Access and Management System (ADAMS). ADAMS is accessible from the NRC Web site at http://www.nrc.gov/reading-rm/adams.html (the Public Electronic Reading Room).


Sincerely,/RA/
Sincerely,
Patricia J. Pelke, Acting Chief Branch 6 Division of Reactor Projects Docket No. 50-346 License No. NPF-3  
/RA/
Patricia J. Pelke, Acting Chief Branch 6 Division of Reactor Projects Docket No. 50-346 License No. NPF-3


===Enclosure:===
===Enclosure:===
Inspection Report 05000346/2013007  
Inspection Report 05000346/2013007 w/Attachment: Supplemental Information


===w/Attachment:===
REGION III==
Supplemental Information cc w/encl: Distribution via ListServTM Enclosure U.S. NUCLEAR REGULATORY COMMISSION REGION III Docket No: 50-346 License No: NPF-3  
Docket No: 50-346 License No: NPF-3 Report No: 05000346/2013007 Licensee: FirstEnergy Nuclear Operating Company (FENOC)
Facility: Davis-Besse Nuclear Power Station Location: Oak Harbor, OH Dates: July 22 through August 9, 2013 Inspectors: J. Rutkowski, Project Engineer, Team Lead M. Holmberg, Senior Reactor Inspector B. Winter, Reactor Engineer T. Briley, Resident Inspector Approved by: Patricia J. Pelke, Acting Chief Branch 6 Division of Reactor Projects Enclosure


Report No: 05000346/2013007 Licensee: FirstEnergy Nuclear Operating Company (FENOC) Facility: Davis-Besse Nuclear Power Station
=SUMMARY OF FINDINGS=
Inspection Report (IR) 05000346/2013007; 07/22/2013 - 08/9/2013; Davis-Besse Nuclear


Location: Oak Harbor, OH Dates: July 22 through August 9, 2013 Inspectors: J. Rutkowski, Project Engineer, Team Lead M. Holmberg, Senior Reactor Inspector B. Winter, Reactor Engineer T. Briley, Resident Inspector Approved by: Patricia J. Pelke, Acting Chief Branch 6 Division of Reactor Projects 1 Enclosure
Power Station; Biennial Problem Identification and Resolution (PI&R) Inspection.


=SUMMARY OF FINDINGS=
This inspection was performed by three regional based inspectors and the Davis-Besse Nuclear Power Station resident inspector. No findings of significance or violations of NRC requirements were identified during this inspection. The NRCs program for overseeing the safe operation of commercial nuclear power reactors is described in NUREG-1649, Reactor Oversight Process,
Inspection Report (IR) 05000346/2013007; 07/22/2013 - 08/9/2013; Davis-Besse Nuclear Power Station; Biennial Problem Identification and Resolution (PI&R) Inspection.
Revision 4, dated December 2006.


This inspection was performed by three regional based inspectors and the Davis-Besse Nuclear Power Station resident inspector. No findings of significance or violations of NRC requirements were identified during this inspection. The NRC's program for overseeing the safe operation of commercial nuclear power reactors is described in NUREG-1649, "Reactor Oversight Process," Revision 4, dated December 2006. Problem Identification and Resolution Based on the samples selected for review, the team concluded that implementation of the corrective action program (CAP) at Davis-Besse Nuclear Power Station was effective. The licensee had a low stated threshold for identifying problems and entering them in the CAP.
Problem Identification and Resolution Based on the samples selected for review, the team concluded that implementation of the corrective action program (CAP) at Davis-Besse Nuclear Power Station was effective. The licensee had a low stated threshold for identifying problems and entering them in the CAP.


Items entered into the CAP were generally screened and prioritized in a timely manner using established criteria, although the team identified timeliness issues for a small percentage of issues. Issues in the CAP were properly evaluated and corrective actions were generally implemented in a timely manner. The team noted that the licensee reviewed operating experience (OE) for applicability to station activities. Audits and self-assessments were performed at an appropriate level to identify deficiencies. Based on interviews conducted during the inspection, licensee staff expressed freedom to raise nuclear safety concerns and to enter nuclear safety concerns into the CAP.
Items entered into the CAP were generally screened and prioritized in a timely manner using established criteria, although the team identified timeliness issues for a small percentage of issues. Issues in the CAP were properly evaluated and corrective actions were generally implemented in a timely manner. The team noted that the licensee reviewed operating experience (OE) for applicability to station activities. Audits and self-assessments were performed at an appropriate level to identify deficiencies. Based on interviews conducted during the inspection, licensee staff expressed freedom to raise nuclear safety concerns and to enter nuclear safety concerns into the CAP.


===A. NRC-Identified===
===NRC-Identified===
and Self-Revealed Findings None.
and Self-Revealed Findings None.
 
===Licensee-Identified Violations===


===B. Licensee-Identified Violations===
None.
None.


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==4OA2 Problem Identification and Resolution==
==4OA2 Problem Identification and Resolution==
{{IP sample|IP=IP 71152B}}
{{IP sample|IP=IP 71152B}}
This inspection constituted one biennial sample of Problem Identification and Resolution (PI&R) as defined in Inspection Procedure (IP) 71152, "Problem Identification and Resolution.Documents reviewed are listed in the Attachment to this report.
This inspection constituted one biennial sample of Problem Identification and Resolution (PI&R) as defined in Inspection Procedure (IP) 71152, Problem Identification and Resolution. Documents reviewed are listed in the Attachment to this report.


===.1 Assessment of the Corrective Action Program Effectiveness===
===.1 Assessment of the Corrective Action Program Effectiveness===


====a. Inspection Scope====
====a. Inspection Scope====
The inspectors reviewed the licensee's Corrective Action Program (CAP) implementing procedures and attended CAP meetings to assess the implementation of the CAP by licensee staff. The inspectors also interviewed licensee staff about their use of the CAP. The inspectors reviewed risk and safety significant issues in the licensee's CAP since the last NRC PI&R inspection in March 2011. The selection of issues ensured an adequate review of issues across NRC cornerstones. The inspectors used issues identified through NRC generic communications, department self-assessments, licensee audits, OE reports, and NRC documented findings. The inspectors reviewed Condition Reports (CRs) that were generated and a selection of completed investigations from the licensee's various investigation methods, which included root cause, full apparent cause, limited apparent cause, and common cause investigations.
The inspectors reviewed the licensees Corrective Action Program (CAP) implementing procedures and attended CAP meetings to assess the implementation of the CAP by licensee staff. The inspectors also interviewed licensee staff about their use of the CAP.
 
The inspectors reviewed risk and safety significant issues in the licensees CAP since the last NRC PI&R inspection in March 2011. The selection of issues ensured an adequate review of issues across NRC cornerstones. The inspectors used issues identified through NRC generic communications, department self-assessments, licensee audits, OE reports, and NRC documented findings. The inspectors reviewed Condition Reports (CRs) that were generated and a selection of completed investigations from the licensees various investigation methods, which included root cause, full apparent cause, limited apparent cause, and common cause investigations.
 
The inspectors selected the instrument air and station air systems to review in detail because the system had numerous operational problems in recent years and was in Maintenance Rule (a)(1) category. The intent of the review was to determine whether the licensee staff were properly monitoring and evaluating the performance of these systems through effective implementation of station monitoring programs. A five-year review of the air systems was performed to assess the licensees efforts in monitoring for system degradation due to aging aspects. The inspectors also performed partial system walkdowns of the main feedwater system, service water system, and emergency diesel generators. A review of the use of the station maintenance rule program to help identify equipment issues was also conducted.


The inspectors selected the instrument air and station air systems to review in detail because the system had numerous operational problems in recent years and was in Maintenance Rule (a)(1) category. The intent of the review was to determine whether the licensee staff were properly monitoring and evaluating the performance of these systems through effective implementation of station monitoring programs. A five-year review of the air systems was performed to assess the licensee's efforts in monitoring for system degradation due to aging aspects. The inspectors also performed partial system walkdowns of the main feedwater system, service water system, and emergency diesel generators. A review of the use of the station maintenance rule program to help identify equipment issues was also conducted.
During the reviews, the inspectors determined whether the licensees actions were in compliance with the licensees CAP and 10 CFR Part 50, Appendix B requirements.


During the reviews, the inspectors determined whether the licensee's actions were in compliance with the licensee's CAP and 10 CFR Part 50, Appendix B requirements. Specifically, the inspectors determined whether licensee personnel were identifying plant issues at the proper threshold, entering the plant issues into the station's CAP in a timely manner, and assigning the appropriate prioritization for resolution of the issues. The inspectors also determined whether the licensee staff assigned the appropriate investigational method to ensure the correct determination of root, apparent, and contributing causes. The inspectors also evaluated the timeliness and effectiveness of corrective actions for selected issue reports, completed investigations, and eight NRC previously identified findings that included principally non-cited violations.
Specifically, the inspectors determined whether licensee personnel were identifying plant issues at the proper threshold, entering the plant issues into the stations CAP in a timely manner, and assigning the appropriate prioritization for resolution of the issues. The inspectors also determined whether the licensee staff assigned the appropriate investigational method to ensure the correct determination of root, apparent, and contributing causes. The inspectors also evaluated the timeliness and effectiveness of corrective actions for selected issue reports, completed investigations, and eight NRC previously identified findings that included principally non-cited violations.


Documents reviewed are listed in the Attachment to this report.
Documents reviewed are listed in the Attachment to this report.


b. Assessment (1) Effectiveness of Problem Identification Based on the information reviewed, including initiation rates of CRs and interviews, the inspectors concluded that the licensee has a low threshold for initiating CRs, and from the CRs reviewed, the threshold was appropriate. Some of the non-supervisory licensee staff interviewed believed the CAP was ineffective for items of low safety significance partially due to the large number of low safety significant issues in the CAP. Several of the individuals interviewed stated they refrained from using the CAP for perceived non- safety-significant issues. The same individuals also stated that they would report nuclear safety issues. The inspectors did not identify any safety significant item that was not entered into the CAP. The inspectors assessed the effectiveness of problem identification as adequate.
b. Assessment
: (1) Effectiveness of Problem Identification Based on the information reviewed, including initiation rates of CRs and interviews, the inspectors concluded that the licensee has a low threshold for initiating CRs, and from the CRs reviewed, the threshold was appropriate. Some of the non-supervisory licensee staff interviewed believed the CAP was ineffective for items of low safety significance partially due to the large number of low safety significant issues in the CAP. Several of the individuals interviewed stated they refrained from using the CAP for perceived non-safety-significant issues. The same individuals also stated that they would report nuclear safety issues. The inspectors did not identify any safety significant item that was not entered into the CAP. The inspectors assessed the effectiveness of problem identification as adequate.


Observations The inspectors found that issues were being identified and captured in the licensee's programs and particularly in the CAP. During a non-outage year, about 4000 to 5000 CRs are initiated with most being of low safety significance. The inspectors found through interviews that licensee staff understood the expectation to write CRs for issues and did write CRs. In several departments, licensee staff regularly passed issues on to their supervisors and the supervisors wrote the CRs. However, several non-supervisory licensee staff from the small groups interviewed said that they believed the CAP system was ineffective for less than significant nuclear safety issues and several of them said that that they would not use the CAP system for minor issues. However, the inspectors noted that all the small groups interviewed stated that they would not hesitate to bring problems and issues to their immediate supervisors. All licensee staff interviewed said they would raise nuclear safety issues. The inspectors did not identify any specific safety significant issues where it was clear that an individual should have written CRs and did not.
Observations The inspectors found that issues were being identified and captured in the licensees programs and particularly in the CAP. During a non-outage year, about 4000 to 5000 CRs are initiated with most being of low safety significance. The inspectors found through interviews that licensee staff understood the expectation to write CRs for issues and did write CRs. In several departments, licensee staff regularly passed issues on to their supervisors and the supervisors wrote the CRs. However, several non-supervisory licensee staff from the small groups interviewed said that they believed the CAP system was ineffective for less than significant nuclear safety issues and several of them said that that they would not use the CAP system for minor issues. However, the inspectors noted that all the small groups interviewed stated that they would not hesitate to bring problems and issues to their immediate supervisors. All licensee staff interviewed said they would raise nuclear safety issues. The inspectors did not identify any specific safety significant issues where it was clear that an individual should have written CRs and did not.


Based on a similar concern that had been previously identified to the licensee earlier this calendar year (2013) from a review performed by an external group, the licensee initiated CR 2013-12261, "Observation on Condition Reporting Effectiveness."
Based on a similar concern that had been previously identified to the licensee earlier this calendar year (2013) from a review performed by an external group, the licensee initiated CR 2013-12261, Observation on Condition Reporting Effectiveness.


Corrective actions were identified and scheduled; some of them were ongoing during the inspection in response to the external group's review.
Corrective actions were identified and scheduled; some of them were ongoing during the inspection in response to the external groups review.


The licensee has an established (but not proceduralized) expectation that CRs are initiated in the CAP within 24 hours after discovery of an adverse condition and subsequently initially reviewed within 24 hours. The inspectors reviewed the last nine months of CRs for timeliness of initiation. Of the approximately 4000 CRs that were documented in the CAP, approximately 80 (2 percent) of the CRs were initiated 4 days or more from discovery of the adverse condition and approximately 5 CRs were initiated greater than 30 days after discovery. In the last nine months, the licensee initiated at least 15 CRs to document untimely CR initiation and at least 10 CRs to document untimely supervisory review (24-hour expectation for supervisors to review CRs once initiated). Additionally, the inspectors identified that no CR had been written to document the untimely initiation of CR 2013-11691, which documented failure of an integrated head assembly vent fan, even though the CR was initiated 14 days after discovery of the condition and after actions to address the issue had already been taken.
The licensee has an established (but not proceduralized) expectation that CRs are initiated in the CAP within 24 hours after discovery of an adverse condition and subsequently initially reviewed within 24 hours. The inspectors reviewed the last nine months of CRs for timeliness of initiation. Of the approximately 4000 CRs that were documented in the CAP, approximately 80 (2 percent) of the CRs were initiated 4 days or more from discovery of the adverse condition and approximately 5 CRs were initiated greater than 30 days after discovery. In the last nine months, the licensee initiated at least 15 CRs to document untimely CR initiation and at least 10 CRs to document untimely supervisory review (24-hour expectation for supervisors to review CRs once initiated). Additionally, the inspectors identified that no CR had been written to document the untimely initiation of CR 2013-11691, which documented failure of an integrated head assembly vent fan, even though the CR was initiated 14 days after discovery of the condition and after actions to address the issue had already been taken.


To address this issue, the licensee initiated CR 2013-12110, "Condition Reports not submitted for Notifications associated with BF2129," to document the untimely initiation of CR 2013-11691.
To address this issue, the licensee initiated CR 2013-12110, Condition Reports not submitted for Notifications associated with BF2129, to document the untimely initiation of CR 2013-11691.


The timely initiation of CRs after an adverse condition is discovered appears inconsistent and was previously documented in various CRs and self-assessments. Although the CAP document (NOP-LP-2001, "Corrective Action Program") does not specify time requirements for initiating CRs, licensee staff interviewed during the inspection were aware of the site expectation. To address this issue, the licensee initiated CR 2013-12262, "Observation on Condition Report Timeliness."
The timely initiation of CRs after an adverse condition is discovered appears inconsistent and was previously documented in various CRs and self-assessments. Although the CAP document (NOP-LP-2001, Corrective Action Program) does not specify time requirements for initiating CRs, licensee staff interviewed during the inspection were aware of the site expectation. To address this issue, the licensee initiated CR 2013-12262, Observation on Condition Report Timeliness.


The inspectors noted that in addition to the CAP, the licensee had other systems that capture items or issues that require action. Specifically, the inspectors briefly reviewed procedure change tracking, mainly in Operations, and the simulator work tracking system. The inspectors did not identify any timeliness issues relative to reporting issues, but had questions on the number of Operations procedures change requests and simulator work issues. The Operations procedure backlog has approximately 900 open change requests.
The inspectors noted that in addition to the CAP, the licensee had other systems that capture items or issues that require action. Specifically, the inspectors briefly reviewed procedure change tracking, mainly in Operations, and the simulator work tracking system. The inspectors did not identify any timeliness issues relative to reporting issues, but had questions on the number of Operations procedures change requests and simulator work issues. The Operations procedure backlog has approximately 900 open change requests.


Findings No findings of significance were identified. (2) Effectiveness of Prioritization and Evaluation of Issues The inspectors reviewed the classification of CRs for resolution and determined that, in general, CRs were assigned appropriate prioritization and evaluation levels. Evaluations in apparent cause and root cause reports reviewed by the inspectors were adequate. In several CR cause evaluations, the inspectors identified some items they considered weaknesses in the evaluation of issues, such as failure to address a contributing cause for Pressurizer Code Safety Valve setpoint test failure and a contributing cause for a failure to properly control equipment configuration and status. The inspectors noted that other internal and external review groups identified issues with the quality of the licensee's limited apparent cause evaluations. The inspectors determined that the licensee's prioritization and evaluation of issues were sufficient to ensure that established corrective actions would be effective and that there was appropriate consideration of risk in prioritizing issues.
Findings No findings of significance were identified.
: (2) Effectiveness of Prioritization and Evaluation of Issues The inspectors reviewed the classification of CRs for resolution and determined that, in general, CRs were assigned appropriate prioritization and evaluation levels. Evaluations in apparent cause and root cause reports reviewed by the inspectors were adequate. In several CR cause evaluations, the inspectors identified some items they considered weaknesses in the evaluation of issues, such as failure to address a contributing cause for Pressurizer Code Safety Valve setpoint test failure and a contributing cause for a failure to properly control equipment configuration and status. The inspectors noted that other internal and external review groups identified issues with the quality of the licensees limited apparent cause evaluations. The inspectors determined that the licensees prioritization and evaluation of issues were sufficient to ensure that established corrective actions would be effective and that there was appropriate consideration of risk in prioritizing issues.
 
Observations Over the last two years (second half 2011 through August 2013) approximately 12,000 CRs were documented in the CAP. Ninety-five percent or more of the CRs from the second half of 2011 to the end of 2012 are listed either in a closed or archive status.


Observations Over the last two years (second half 2011 through August 2013) approximately 12,000 CRs were documented in the CAP. Ninety-five percent or more of the CRs from the second half of 2011 to the end of 2012 are listed either in a closed or archive status. The majority of those that remain open appear to be related to corrective actions requiring outage related repairs. Approximately 50 percent of the CRs from 2013 (3300 total) are listed in the CAP as closed or archive status. The inspectors determined that these numbers were generally consistent with an effective program.
The majority of those that remain open appear to be related to corrective actions requiring outage related repairs. Approximately 50 percent of the CRs from 2013 (3300 total) are listed in the CAP as closed or archive status. The inspectors determined that these numbers were generally consistent with an effective program.


In CR-2011-88100, "Root Cause - Pressurizer Code Safety Valves Setpoint Test Failure," the direct cause was identified as setpoint drift and it was concluded that the exact cause of the setpoint variance (drift) was indeterminate. Additionally, the licensee concluded that the different vendors and test conditions established for the as-left and as-found setpoint tests, were minor in nature, but may have affected the test results.
In CR-2011-88100, Root Cause - Pressurizer Code Safety Valves Setpoint Test Failure, the direct cause was identified as setpoint drift and it was concluded that the exact cause of the setpoint variance (drift) was indeterminate. Additionally, the licensee concluded that the different vendors and test conditions established for the as-left and as-found setpoint tests, were minor in nature, but may have affected the test results.


However, a corrective action (CA) was not assigned to control future test conditions or to maintain a single test vendor to eliminate this potential contributing cause. This example illustrated a weakness in identification of a potential contributing cause for a significant condition adverse to quality. If a contributing cause was not identified, the effectiveness of the CAs taken could be less than fully effective. The inspectors did not identify any CAs that were less than effective as a result of the licensee's failure to identify a contributing cause.
However, a corrective action (CA) was not assigned to control future test conditions or to maintain a single test vendor to eliminate this potential contributing cause. This example illustrated a weakness in identification of a potential contributing cause for a significant condition adverse to quality. If a contributing cause was not identified, the effectiveness of the CAs taken could be less than fully effective. The inspectors did not identify any CAs that were less than effective as a result of the licensees failure to identify a contributing cause.


In CR-2012-08422, "Root Cause- DC (Direct Current) Motor Control Center Busses Not Supplied by Operable DC Sources," the licensee identified that the root cause was less than adequate administrative controls for equipment and system configuration control during maintenance and testing activities. DC battery maintenance work had been field completed, but not through a final post maintenance test, but this status was not properly identified and the system was declared operable. However, no CA was identified to determine if the total population of backlogged work orders of field completed work, waiting for final post maintenance testing, contributed to the cause of this issue. The inspectors noted in self-assessment (SN-SA-2012-0311) the licensee identified a backlog of 57 work orders with a field complete or awaiting testing status. This example illustrated a weakness in identification of a potential contributing cause for a condition adverse to quality. If a contributing cause was not identified, the effectiveness of the CAs taken could be less than fully effective. The licensee initiated CR 2013-12263, "Observation on Weakness in Condition Report Evaluation" to capture the inspectors' observations. The inspectors did not identify any CAs that were less than effective as a result of the licensee's failure to identify a contributing cause.
In CR-2012-08422, Root Cause- DC (Direct Current) Motor Control Center Busses Not Supplied by Operable DC Sources, the licensee identified that the root cause was less than adequate administrative controls for equipment and system configuration control during maintenance and testing activities. DC battery maintenance work had been field completed, but not through a final post maintenance test, but this status was not properly identified and the system was declared operable. However, no CA was identified to determine if the total population of backlogged work orders of field completed work, waiting for final post maintenance testing, contributed to the cause of this issue. The inspectors noted in self-assessment (SN-SA-2012-0311) the licensee identified a backlog of 57 work orders with a field complete or awaiting testing status. This example illustrated a weakness in identification of a potential contributing cause for a condition adverse to quality. If a contributing cause was not identified, the effectiveness of the CAs taken could be less than fully effective. The licensee initiated CR 2013-12263, Observation on Weakness in Condition Report Evaluation to capture the inspectors observations. The inspectors did not identify any CAs that were less than effective as a result of the licensees failure to identify a contributing cause.


Findings No findings of significance were identified.
Findings No findings of significance were identified.
: (3) Effectiveness of Corrective Actions In general, the corrective actions reviewed addressed the cause of the identified problem, and appeared to have been effective in the majority of samples reviewed, although some weaknesses were observed but did not preclude the inspectors from assessing corrective actions as generally effective.
The licensee used the CAP to identify problems and utilized the Maintenance Rule Program and the System Health Report to develop plans for Station and Instrument Air system improvement. The plans included replacement with new parts and equipment, refurbishment of components, and fine-tuning the operating band of the Station and Instrument Air system. The inspectors concluded that the licensee placed appropriate attention and actions to improve the system performance.
Observations The inspectors did not identify any new recurrent issues of significance, though CRs initiated by the licensee identified several recurrent issues. The inspectors noted that the licensee had activities to address recurring human performance issues that were identified and that were self-revealing. The inspectors also noted that during this assessment period, there was a violation associated with the seismic monitoring system that was essentially the same as a violation in 2007 for which a root cause evaluation was performed. This violation was documented in a quarterly integrated inspection report developed by the resident inspector office. The inspectors did not identify any additional issues regarding this violation beyond those previously documented in the inspection report.


(3) Effectiveness of Corrective Actions In general, the corrective actions reviewed addressed the cause of the identified problem, and appeared to have been effective in the majority of samples reviewed, although some weaknesses were observed but did not preclude the inspectors from assessing corrective actions as generally effective. The licensee used the CAP to identify problems and utilized the Maintenance Rule Program and the System Health Report to develop plans for Station and Instrument Air system improvement. The plans included replacement with new parts and equipment, refurbishment of components, and fine-tuning the operating band of the Station and Instrument Air system. The inspectors concluded that the licensee placed appropriate attention and actions to improve the system performance.
In CR-2012-18831, Root Cause-Decay Heat Pump Cyclone Separator Configuration Control, the licensee concluded that an effectiveness review was not warranted for the CA to preclude the recurrence of the root cause identified as an inadequate design interface review. The conclusion was based on the assumption that the revisions made to the current procedure for control of the design interface reviews would prevent a similar error and in part based upon a CAP data base key word search completed using the terms of DIE and Design Interface. However, a similar design interface review error would not likely be identified in the CAP data base search using these key words unless it had resulted in a substantial issue that required an apparent or root cause investigation. The inspectors determined that this example illustrated a potential weakness in evaluating the effectiveness of a CA.


Observations The inspectors did not identify any new recurrent issues of significance, though CRs initiated by the licensee identified several recurrent issues. The inspectors noted that the licensee had activities to address recurring human performance issues that were identified and that were self-revealing. The inspectors also noted that during this assessment period, there was a violation associated with the seismic monitoring system that was essentially the same as a violation in 2007 for which a root cause evaluation was performed. This violation was documented in a quarterly integrated inspection report developed by the resident inspector office. The inspectors did not identify any additional issues regarding this violation beyond those previously documented in the inspection report. In CR-2012-18831, "Root Cause-Decay Heat Pump Cyclone Separator Configuration Control," the licensee concluded that an effectiveness review was not warranted for the CA to preclude the recurrence of the root cause identified as an inadequate design interface review. The conclusion was based on the assumption that the revisions made to the current procedure for control of the design interface reviews would prevent a similar error and in part based upon a CAP data base key word search completed using the terms of "DIE" and "Design Interface."  However, a similar design interface review error would not likely be identified in the CAP data base search using these key words unless it had resulted in a substantial issue that required an apparent or root cause investigation. The inspectors determined that this example illustrated a potential weakness in evaluating the effectiveness of a CA. In CR-2011-88100, "Root Cause - Pressurizer Code Safety Valves Setpoint Test Failure," the licensee completed an effectiveness review of the CA that implemented a revised (lowered) setpoint test band to gain additional margin to accommodate for setpoint drift. The scope of the effectiveness review included an evaluation of the subsequent test results for pressurizer Code safety relief valve tests after implementing the revised setpoint test band. These test results included one Code safety relief valve that failed low out of specification (i.e. 3.4 percent below setpoint). The cause of this test failure was setpoint drift but may have occurred, in part, due to the lowered setpoint test band established as the CA for the root cause. However, the licensee's effectiveness review did not include an evaluation to determine if the CA for the root cause (e.g.
In CR-2011-88100, Root Cause - Pressurizer Code Safety Valves Setpoint Test Failure, the licensee completed an effectiveness review of the CA that implemented a revised (lowered) setpoint test band to gain additional margin to accommodate for setpoint drift. The scope of the effectiveness review included an evaluation of the subsequent test results for pressurizer Code safety relief valve tests after implementing the revised setpoint test band. These test results included one Code safety relief valve that failed low out of specification (i.e. 3.4 percent below setpoint). The cause of this test failure was setpoint drift but may have occurred, in part, due to the lowered setpoint test band established as the CA for the root cause. However, the licensees effectiveness review did not include an evaluation to determine if the CA for the root cause (e.g.


lowered setpoint band) contributed to this low setpoint lift failure. The inspectors assessed the licensee's decision not to investigate the potential negative impacts or unintended consequences of this CA as appearing inconsistent with the recommended actions for conducting effectiveness reviews as discussed in Section 4.7.5.2 of NOPBP-LP-2011 "FENOC Cause
lowered setpoint band) contributed to this low setpoint lift failure. The inspectors assessed the licensees decision not to investigate the potential negative impacts or unintended consequences of this CA as appearing inconsistent with the recommended actions for conducting effectiveness reviews as discussed in Section 4.7.5.2 of NOPBP-LP-2011 FENOC Cause


=====Analysis.=====
=====Analysis.=====
This example illustrated a potential weakness in the conduct of a CA effectiveness review. However, the inspectors did not identify an inappropriate corrective action.
This example illustrated a potential weakness in the conduct of a CA effectiveness review. However, the inspectors did not identify an inappropriate corrective action.


The inspectors reviewed the results of CRs used to document some areas of concern identified in the 2012 Safety Conscious Work Environment (SCWE) Surveys.
The inspectors reviewed the results of CRs used to document some areas of concern identified in the 2012 Safety Conscious Work Environment (SCWE) Surveys.


Specifically the inspectors reviewed CRs written for Regulatory Compliance, Operations, and Maintenance departments. The CRs for Maintenance and Operations had each listed a CA that did not appear to correct any issues but were for additional investigations. Both CRs were closed with no indication of any additional actions to be taken to address the identified issues. Discussions with Maintenance and Operations revealed that the management of those departments did have additional plans to document and address the issues, but that these plans were not written down in any CR documents or any other document provided to the inspectors. While those two CRs were classified as adverse fix (AF), and did not require any detailed analysis under the CAP, the actions listed did not address correcting the identified issues. The inspectors did not identify any non-compliance with licensee's procedural requirements associated with the reviewed CRs. Findings No findings of significance were identified.
Specifically the inspectors reviewed CRs written for Regulatory Compliance, Operations, and Maintenance departments. The CRs for Maintenance and Operations had each listed a CA that did not appear to correct any issues but were for additional investigations. Both CRs were closed with no indication of any additional actions to be taken to address the identified issues. Discussions with Maintenance and Operations revealed that the management of those departments did have additional plans to document and address the issues, but that these plans were not written down in any CR documents or any other document provided to the inspectors. While those two CRs were classified as adverse fix (AF), and did not require any detailed analysis under the CAP, the actions listed did not address correcting the identified issues. The inspectors did not identify any non-compliance with licensees procedural requirements associated with the reviewed CRs.
 
Findings No findings of significance were identified.


===.2 Assessment of the Use of Operating Experience===
===.2 Assessment of the Use of Operating Experience===


====a. Inspection Scope====
====a. Inspection Scope====
The inspectors reviewed the licensee's implementation of the facility's Operating Experience (OE) program. Specifically, the inspectors reviewed implementing OE program procedures, attended CAP meetings to observe the use of OE information, completed evaluations of OE issues and events, and selected monthly assessments of the OE composite performance indicators. The intent of the review was to: (1) determine whether the licensee was effectively integrating OE experience into the performance of daily activities; (2) determine whether evaluations of issues were appropriate and conducted by qualified individuals; (3) determine whether the licensee's program was sufficient to prevent future occurrences of previous industry events; and (4) determine whether the licensee effectively used the information in developing departmental assessments and facility audits. The inspectors also assessed if corrective actions, as a result of OE experience, were identified and implemented effectively and timely. Assessment Overall, the inspectors determined that the licensee was adequately evaluating industry OE for relevance to the facility. The licensee had entered all applicable items in the CAP in accordance with the licensee's procedures. Both internal and external OE was being incorporated into lessons learned for training and pre-job briefs. System Engineers utilized industry OE to resolve equipment operational problems. The inspectors concluded that the licensee was evaluating industry OE when performing root cause and apparent cause evaluations. The inspectors noted that the licensee had identified a small number of OE evaluations where the evaluation time was longer than the procedure NOBP-LP-2100, "FENOC Operating Experience Process," requirement of 150 days. However, this did not affect the overall assessment and the inspectors concluded that the licensee used operating experience appropriately.
The inspectors reviewed the licensees implementation of the facilitys Operating Experience (OE) program. Specifically, the inspectors reviewed implementing OE program procedures, attended CAP meetings to observe the use of OE information, completed evaluations of OE issues and events, and selected monthly assessments of the OE composite performance indicators. The intent of the review was to: (1)determine whether the licensee was effectively integrating OE experience into the performance of daily activities;
: (2) determine whether evaluations of issues were appropriate and conducted by qualified individuals;
: (3) determine whether the licensees program was sufficient to prevent future occurrences of previous industry events; and (4)determine whether the licensee effectively used the information in developing departmental assessments and facility audits. The inspectors also assessed if corrective actions, as a result of OE experience, were identified and implemented effectively and timely.
 
Assessment Overall, the inspectors determined that the licensee was adequately evaluating industry OE for relevance to the facility. The licensee had entered all applicable items in the CAP in accordance with the licensees procedures. Both internal and external OE was being incorporated into lessons learned for training and pre-job briefs. System Engineers utilized industry OE to resolve equipment operational problems. The inspectors concluded that the licensee was evaluating industry OE when performing root cause and apparent cause evaluations. The inspectors noted that the licensee had identified a small number of OE evaluations where the evaluation time was longer than the procedure NOBP-LP-2100, FENOC Operating Experience Process, requirement of 150 days. However, this did not affect the overall assessment and the inspectors concluded that the licensee used operating experience appropriately.


Observations The inspectors identified a weakness resulting in backlogged 10 CFR Part 21 notifications when the 10 CFR Part 21 Coordinator was transferred to another group.
Observations The inspectors identified a weakness resulting in backlogged 10 CFR Part 21 notifications when the 10 CFR Part 21 Coordinator was transferred to another group.


After the team's discovery, the licensee initiated CR-2013-12246, "The Review of 10 CFR Part 21 Notices of D-B Applicability is Backlogged," and initiated actions to distribute the backlogged 10 CFR Part 21 notifications.
After the teams discovery, the licensee initiated CR-2013-12246, The Review of 10 CFR Part 21 Notices of D-B Applicability is Backlogged, and initiated actions to distribute the backlogged 10 CFR Part 21 notifications.


====b. Findings====
====b. Findings====
Line 137: Line 162:


====a. Inspection Scope====
====a. Inspection Scope====
The inspectors assessed the licensee staff's ability to identify and enter issues into the CAP, prioritize and evaluate issues, and implement effective corrective actions, through efforts from departmental assessments and audits. The inspectors reviewed audit reports and completed assessments. Assessment The inspectors concluded that self-assessments and audits were typically accurate, thorough, and effective at identifying most issues and enhancement opportunities at an appropriate threshold. The inspectors concluded that personnel knowledgeable in the subject area completed audits and self-assessments. In many cases, self-assessments and audits identified issues that were not previously recognized by the licensee. Observations The inspectors reviewed some documents that implied or stated the licensee was behind schedule in completing some assessments; however, the inspectors did not identify any issues where the licensee's assessments missed issues or were not of sufficient depth. The inspectors did question the licensee's recent assessment of the Self-Assessment process or program. That assessment appeared to be primarily a "compliance" assessment and did not evaluate the effectiveness of the licensee's assessment process. The inspectors were not provided with a document that evaluated the effectiveness of the assessment process over the two-year period of the inspection. The licensee stated that an assessment, to evaluate effectiveness, was planned but had not been done.
The inspectors assessed the licensee staffs ability to identify and enter issues into the CAP, prioritize and evaluate issues, and implement effective corrective actions, through efforts from departmental assessments and audits. The inspectors reviewed audit reports and completed assessments.


The licensee completed a number of self-assessments in the Operations and Maintenance Departments over the past two years. In response to repeat Quality Assurance Department findings of marginal performance in the conduct of operations, the Operation Department had increased the frequency of "snapshot" type self-assessments with a focus on adverse trend identification. Overall, the assessments and trending for maintenance and operations issues appeared to be thorough and included acceptance criteria to determine when a trend was no longer of concern.
Assessment The inspectors concluded that self-assessments and audits were typically accurate, thorough, and effective at identifying most issues and enhancement opportunities at an appropriate threshold. The inspectors concluded that personnel knowledgeable in the subject area completed audits and self-assessments. In many cases, self-assessments and audits identified issues that were not previously recognized by the licensee.
 
Observations The inspectors reviewed some documents that implied or stated the licensee was behind schedule in completing some assessments; however, the inspectors did not identify any issues where the licensees assessments missed issues or were not of sufficient depth.
 
The inspectors did question the licensees recent assessment of the Self-Assessment process or program. That assessment appeared to be primarily a compliance assessment and did not evaluate the effectiveness of the licensees assessment process. The inspectors were not provided with a document that evaluated the effectiveness of the assessment process over the two-year period of the inspection. The licensee stated that an assessment, to evaluate effectiveness, was planned but had not been done.
 
The licensee completed a number of self-assessments in the Operations and Maintenance Departments over the past two years. In response to repeat Quality Assurance Department findings of marginal performance in the conduct of operations, the Operation Department had increased the frequency of snapshot type self-assessments with a focus on adverse trend identification. Overall, the assessments and trending for maintenance and operations issues appeared to be thorough and included acceptance criteria to determine when a trend was no longer of concern.


====b. Findings====
====b. Findings====
Line 147: Line 178:


====a. Inspection Scope====
====a. Inspection Scope====
The inspectors assessed the licensee's SCWE through the review of the licensee's employee concern program (ECP), implementing procedures, discussions with the coordinator of the ECP, interviews with personnel from various departments, and reviews of issue reports. The inspectors also reviewed the results from SCWE surveys conducted in 2011 and 2012. As part of the overall inspection effort, inspectors discussed department and station programs with a variety of staff members. In addition, the inspectors interviewed approximately 44 individuals, who were placed in twelve groups, each of which was composed of three to five individuals from various departments, to assess their willingness to raise nuclear safety issues. The individuals were non-supervisory personnel and were selected in a manner that provided a distribution across the various departments at the site. In addition to assessing individuals' willingness to raise nuclear safety issues, the interviews also addressed changes in the CAP and plant environment over the past 2 years. Other items discussed included:
The inspectors assessed the licensees SCWE through the review of the licensees employee concern program (ECP), implementing procedures, discussions with the coordinator of the ECP, interviews with personnel from various departments, and reviews of issue reports. The inspectors also reviewed the results from SCWE surveys conducted in 2011 and 2012.
 
As part of the overall inspection effort, inspectors discussed department and station programs with a variety of staff members. In addition, the inspectors interviewed approximately 44 individuals, who were placed in twelve groups, each of which was composed of three to five individuals from various departments, to assess their willingness to raise nuclear safety issues. The individuals were non-supervisory personnel and were selected in a manner that provided a distribution across the various departments at the site. In addition to assessing individuals willingness to raise nuclear safety issues, the interviews also addressed changes in the CAP and plant environment over the past 2 years. Other items discussed included:
* knowledge and understanding of the CAP;
* knowledge and understanding of the CAP;
* effectiveness and efficiency of the CAP; and
* effectiveness and efficiency of the CAP; and
* willingness to use the CAP.
* willingness to use the CAP.


Assessment Interviews indicated that the licensee has an environment where people are free to raise nuclear safety issues without fear of retaliation. Documents provided to the inspectors regarding the SCWE surveys generally supported the conclusions from the interviews. All interviewees indicated that personnel would raise nuclear safety issues, although several interviewed groups said they might refrain from raising issues of low safety significance. All of the individuals interviewed knew that in addition to the CAP, they could raise issues to their immediate supervisor, the ECP, or the NRC. Several of the individuals interviewed stated they would not use the ECP due to concerns regarding the effectiveness of the program or the anonymity provided by the program; however, these individuals also stated that they had never used the ECP.
Assessment Interviews indicated that the licensee has an environment where people are free to raise nuclear safety issues without fear of retaliation. Documents provided to the inspectors regarding the SCWE surveys generally supported the conclusions from the interviews.
 
All interviewees indicated that personnel would raise nuclear safety issues, although several interviewed groups said they might refrain from raising issues of low safety significance. All of the individuals interviewed knew that in addition to the CAP, they could raise issues to their immediate supervisor, the ECP, or the NRC. Several of the individuals interviewed stated they would not use the ECP due to concerns regarding the effectiveness of the program or the anonymity provided by the program; however, these individuals also stated that they had never used the ECP.
 
The licensee had ongoing actions in place to address the individuals that would not use the CAP or believed that it was not effective for low safety significant items. All of the individuals interviewed stated that they would report nuclear safety issues. The inspectors concluded that the licensees SCWE was acceptable. In addition, the licensee indicated that they were aware of issues with ECP and initiated a CR to address the issues that were identified by the inspectors during interviews with staff.
 
Based on this information as well as the low number of allegations received by the NRC, the inspectors determined that the ECP process was implemented adequately.


The licensee had ongoing actions in place to address the individuals that would not use the CAP or believed that it was not effective for low safety significant items. All of the individuals interviewed stated that they would report nuclear safety issues. The inspectors concluded that the licensee's SCWE was acceptable. In addition, the licensee indicated that they were aware of issues with ECP and initiated a CR to address the issues that were identified by the inspectors during interviews with staff.
Observations The inspectors reviewed the ECP log and three case files. No issues were identified.


Based on this information as well as the low number of allegations received by the NRC, the inspectors determined that the ECP process was implemented adequately. Observations The inspectors reviewed the ECP log and three case files. No issues were identified. It was also noted that over the last twelve months, there were only two allegations received by the NRC. The inspectors talked with the groups interviewed for SCWE about their use of the ECP. Personnel in several groups stated that they would not use the ECP either because of trust issues or effectiveness of the process. The inspectors noted that many of the interviewed personnel that stated they would not use the program had never used the program. Some other individuals said that it was their personal preference not to use the program. Many said that they had never had the need to use the program. The interview results were consistent with trends shown in SCWE surveys conducted by the licensee. The licensee initiated CR 2013-12258, "ECP Program Observation," which as classified requires a limited apparent cause investigation. That CR also documented that the licensee was aware of the issues some station personnel had with the ECP.
It was also noted that over the last twelve months, there were only two allegations received by the NRC. The inspectors talked with the groups interviewed for SCWE about their use of the ECP. Personnel in several groups stated that they would not use the ECP either because of trust issues or effectiveness of the process. The inspectors noted that many of the interviewed personnel that stated they would not use the program had never used the program. Some other individuals said that it was their personal preference not to use the program. Many said that they had never had the need to use the program. The interview results were consistent with trends shown in SCWE surveys conducted by the licensee. The licensee initiated CR 2013-12258, ECP Program Observation, which as classified requires a limited apparent cause investigation. That CR also documented that the licensee was aware of the issues some station personnel had with the ECP.


All of the twelve groups interviewed identified that one of the organizational issues was staffing. This was identified as an employee concern in previous assessments conducted by the licensee. Individuals stated that they have mentioned this issue to their supervisor, and in many cases, to their management. The inspectors did not identify any CAP issues specifically attributable to the interviewed individual's belief that staffing was inadequate. The licensee was aware of the staff's beliefs related to staffing.
All of the twelve groups interviewed identified that one of the organizational issues was staffing. This was identified as an employee concern in previous assessments conducted by the licensee. Individuals stated that they have mentioned this issue to their supervisor, and in many cases, to their management. The inspectors did not identify any CAP issues specifically attributable to the interviewed individuals belief that staffing was inadequate. The licensee was aware of the staffs beliefs related to staffing.


Several groups stated that it is harder now to get work done than it was in the past.
Several groups stated that it is harder now to get work done than it was in the past.


Complexity of requirements and additional requirements has complicated the work process. Several of these groups stated that, while important equipment is being maintained when necessary, because of the more complex processes and lack of resources, some equipment and systems are not being maintained the way staff think it should or consistent with the licensee's stated standards of excellence. The inspectors did not identify any CAP issues specifically related to the perceived complexity of work processes. Several individuals interviewed stated that while the CAP worked for safety significant items, they believed it did not work for less significant items. Some individuals stated that the effectiveness of the program was impacted by the requirement to document all the issues. The inspectors noted that this issue had been previously identified and did not identify any issue that was not captured in the CAP.
Complexity of requirements and additional requirements has complicated the work process. Several of these groups stated that, while important equipment is being maintained when necessary, because of the more complex processes and lack of resources, some equipment and systems are not being maintained the way staff think it should or consistent with the licensees stated standards of excellence. The inspectors did not identify any CAP issues specifically related to the perceived complexity of work processes.
 
Several individuals interviewed stated that while the CAP worked for safety significant items, they believed it did not work for less significant items. Some individuals stated that the effectiveness of the program was impacted by the requirement to document all the issues. The inspectors noted that this issue had been previously identified and did not identify any issue that was not captured in the CAP.


====b. Findings====
====b. Findings====
No findings of significance were identified.
No findings of significance were identified.
{{a|4OA6}}
{{a|4OA6}}
==4OA6 Management Meetings==
==4OA6 Management Meetings==


===.1 Exit Meeting Summary On August 9, 2013, the inspectors presented the inspection results to Mr. R. Lieb, Site Vice President, and other members of the licensee staff.===
===.1 Exit Meeting Summary===
The licensee acknowledged the issues presented. The inspectors confirmed that none of the potential report input discussed was considered proprietary. ATTACHMENT:
 
On August 9, 2013, the inspectors presented the inspection results to Mr. R. Lieb, Site Vice President, and other members of the licensee staff. The licensee acknowledged the issues presented. The inspectors confirmed that none of the potential report input discussed was considered proprietary.
 
ATTACHMENT:  


=SUPPLEMENTAL INFORMATION=
=SUPPLEMENTAL INFORMATION=
Line 177: Line 221:


===Licensee Personnel===
===Licensee Personnel===
: [[contact::R. Lieb]], Site Vice President  
: [[contact::R. Lieb]], Site Vice President
: [[contact::T. Summers]], Manager - Site Operations  
: [[contact::T. Summers]], Manager - Site Operations
: [[contact::G. Wolf]], Supervisor - Regulatory Compliance  
: [[contact::G. Wolf]], Supervisor - Regulatory Compliance
: [[contact::J. Sturdavant]], Senior Specialist - Regulatory Compliance  
: [[contact::J. Sturdavant]], Senior Specialist - Regulatory Compliance
: [[contact::P. McCloskey]], Manager - Regulatory Compliance  
: [[contact::P. McCloskey]], Manager - Regulatory Compliance
: [[contact::D. Missig]], Superintendent - Maintenance
: [[contact::D. Missig]], Superintendent - Maintenance
 
===NRC Personnel===
===NRC Personnel===
: [[contact::P. Pelke]], Acting Chief, Branch 6, Division of Reactor Projects  
: [[contact::P. Pelke]], Acting Chief, Branch 6, Division of Reactor Projects
: [[contact::D. Kimble]], Senior Resident Inspector  
: [[contact::D. Kimble]], Senior Resident Inspector
Attachment


Attachment
==LIST OF ITEMS==
==LIST OF ITEMS==
OPENED, CLOSED AND DISCUSSED  
 
===OPENED, CLOSED AND DISCUSSED===
 
===Opened===
===Opened===
None  
 
None


===Closed===
===Closed===
: None  
 
: Attachment
None Attachment
 
==LIST OF DOCUMENTS REVIEWED==
==LIST OF DOCUMENTS REVIEWED==
The following is a list of documents reviewed during the inspection.
: Inclusion on this list does not imply that the NRC inspectors reviewed the documents in their entirety, but rather, that selected sections of portions of the documents were evaluated as part of the overall inspection effort.
: Inclusion of a document on this list does not imply NRC acceptance of the document or any part of it, unless this is stated in the body of the inspection report.
: PLANT PROCEDURES Number Description or Title Date or RevisionDBBP-RC-0009 Site Continuous Performance Improvement 5
: DB-OP-06241 Auxiliary Boiler Operating Procedure 24-27
: DB-OP-06251 Station Air and Instrument Air System Operating Procedure 37
: DB-OP-06261 Service Water Operating System
: 57
: NOBP-LP-2001 FENOC Self-Assessment and Benchmarking 19
: NOBP-LP-2011 FENOC Cause Analysis 15
: NOBP-LP-2018 Integrated Performance Assessment and Trending 10
: NOBP-LP-2034 FENOC Assessment Strategy 4
: NOBP-LP-2100 FENOC Operating Experience Program 8
: NOP-CC-2004 Design Interface Reviews and Evaluations 1
: NOP-LP-1105 Security Organization and Personnel Duties 2
: NOP-LP-2001 Corrective Action Program 31
: NOP-LP-2011 FENOC Cause Analysis 15
: NOP-LP-2100 Operating Experience Program 6
: NOP-OP-3300 Conduct of Chemistry 3
: NOP-OP-4002 Conduct of Radiation Protection 5
: NOP-WM-0001 Work Management Process 7
: NOP-WM-4006 Conduct of Maintenance 6
: CORRECTIVE ACTION PROGRAM DOCUMENTS REVIEWED Number Description or Title Date or Revision2008-41216
: SAC 2 Tripped June 4, 2008 2008-47689
: Inadvertent Start-Up of
: EIAC During Maintenance
: October 10, 20082009-63253
: Unexpected Instrument Air Header Low Pressure Alarm August 14, 2009 2009-63547
: SAC 1 Tripped on High Air Temperature August 21, 2009 G201-2009-66291
: SAC 1 Will Exceed Its Maintenance Rule Unavailability Allowance
: August 21, 2009 2010-79458
: Station Air Compressor #2 Performance Issue
: July 8, 2010
: CA-2010-87048-001 Past Operability January 11, 2011
: Attachment CORRECTIVE ACTION PROGRAM DOCUMENTS REVIEWED Number Description or Title Date or Revision2011-88100 Root Cause - Pressurizer Code Safety Valves Setpoint Test Failure January 12, 20112011-88594 Clearance Issue Results in SW1358 Found in Failed Open Position January 23, 20112011-88594 Clearance Issue Results in SW1358 Found in Failed Open
: January 23, 20112011-89900 Incomplete Closure of
: CA 09-57849-07 for Rev. to
: NOP-OP-3300 Conduct of Chemistry February 21, 20112011-90403 Received Unexpected Annunciator Alarms 14-4-E and 14-4-F March 3, 2011 2011-90438 10 CFR Part 21- Areva Notification March 4, 2011 2011-90553 Housekeeping Issues 585 Level Turbine BLD March 7, 2011 2011-91665
: MS-C-11-02-22: Actions not Generated to Track Gap Analysis Requirements March 24, 2011 2011-91735 Preventative Action for CR Not Adequate March 25, 2011 2011-92199 10 CFR Part 21-
: NH 90 Hydramotor March 31, 2011 2011-92525 CNRB Concerns with Events at Site April 8, 2011 2011-95212 Unexpected Trend in Component Failures May 20, 2011 2011-96501 10 CFR Part 21- Velan Valves June 16, 2011 G201-2011-96726
: SAC 2 Reduced Operating Margin Due To High Cooling Water And Air Temperature
: June 21, 2011 G201-2011-97309
: EIAC Tripped Unexpectedly on High 3rd Stage Inlet Temperature July 6, 2011 G201-2011-97881 SAC1 Trip During High Ambient Temperature Condition July 18, 2011 G201-2011-97930
: Unable to Maintain Requested MVAR Output Due To Limitations On the System July 19, 2011 2011-00204
: Station Air Compressor #2 Exceed MR Unavailability Criteria
: August 4, 2011 2011-00385 NRC: Timeliness of Corrective Actions for a Nuclear Safety Related Component August 9, 2011 2011-00503
: SAC 2 Will Not Load
: August 11, 2011 2011-00622
: SAC 2 Discharge Check Valve Sticking Closed
: August 15, 2011 2011-00739 10 CFR Part 21- Fisher Information Notice August 18, 2011 2011-01563
: Station Air Compressor #1 Tripped During 1 Hour Loaded Run September 4, 20112011-01673 Self-assessment Deficiency Not Documented in Corrective Action Program September 8, 20112011-04078 Unexpected Loss of CCW Surge Tank Level October 20, 20112011-05456 E11C Water Intrusion/Fire November 16, 20112011-05542 Unexpected Drop in CCW Surge Tank Level November 17, 20112011-05831 CCW Pump Suction Pipe UT November 22, 20112011-06565 10 CFR Part 21- NUS Instruments December 8, 20112011-06662 Reschedule Corrective Order-S14 Heating
: December 10, 2011
: Attachment CORRECTIVE ACTION PROGRAM DOCUMENTS REVIEWED Number Description or Title Date or Revision2011-06778
: As-Found Condition of Station Air Compressor #1 Intercooler (DB-C101-1) December 13, 20112011-07195 DH Pump 1-1 O/B BRG Oil Temp Element Damaged December 22, 20112012-00765 Backlog of Condition Report and Corrective Action Closure Reviews January 17, 20122012-01007 Untimely Initiation of Condition Reports January 20, 20122012-01360 Unclear Expectations for Housekeeping January 26, 20122012-01651 Oversight Rejection of
: CA 10-82780-009 Response February 1, 2012 2012-01950 Inadequate Tracking of Seismic System Status February 6, 2012 2012-01929 Untimely Initiation of Condition Report February 6, 2012 2012-01975 Apparent Cause- Marginal Operations Effective Rating for 3rd Trimester of 2011 February 15, 20122012-02830 Apparent Cause- Adverse Trend in Error Rate I&C February 22, 20122012-03972 Untimely Initiation of a Condition Report March 14, 2012 2012-03970
: PA-DB-12-01: Radiation Protection Administration of the ALARA program March 14, 2012 2012-04226 10 CFR Part 21- Arvan Electrical Terminal March 19, 2012 2012-04305 Degrading Performance in Plant Status Control March 20, 2012 2012-04731 DB Mid-Cycle Assessment Performance Deficiency:
: CY.1 Chemistry Improvement Plan March 28, 2012 2012-04838 Potential
: NRC-NCV: Inadequate Tracking of Seismic System Status (Full Apparent Cause) March 30, 2012 2012-06759 Late Manager Approval of a Condition Report April 27, 2012 2012-08422 Root Cause -DC MCC Busses Not Supplied by Operable DC Sources May 22, 2012 2012-08725 EIAC Found in the Unloaded Standby Condition with a Cooling Pump Running May 25, 2012 2012-11039 10 CFR Part 21- 6.9 KV ABB Breakers July 13, 2012 2012-11294 Backlog of Condition Report Closure Reviews Continues to Increase July 19, 2012 2012-11361 Integrated Performance Assessment and Trending Chemistry Improvement Item July 20, 2012 2012-11889 Poor Progress in Completing Full Apparent Cause Evaluations July 31, 2012 2012-13249
: NRCRRCH2011 Failure to Revise USAR to Remove Yield Strength Values for Design Basis Structural Evaluations August 29, 2012 2012-13710
: Instrument Air Dryers 1 And 2 Continuously Blowing Down September 6, 20122012-09749 Root Cause- Insufficient Progress to Improve Operations September 14, 2012 
: Attachment CORRECTIVE ACTION PROGRAM DOCUMENTS REVIEWED Number Description or Title Date or Revision2011-02200 Unscheduled Low Level Deficiencies September 21, 2012 2012-14639 Vibration Monitoring System in Poor State September 23, 2012 2012-15422 EIAC Discharge Pressure Surging During Test October 3, 2012 2012-16087 Maintenance Trend Analysis of Their Work Management Performance October 11, 20122012-17219 Interim Effectiveness Review for AFI October 13, 20122012-16545 Timeliness of Condition Report Origination and Initial Reviews Needs Improvement October 19, 20122012-16559 Corrective Action Adequacy and Timeliness Needs Improvement October 19, 20122012-16833 After Placing Rod Control Panel into Manual an Unexpected Power Rise was Observed by the
: ATC RO NRC NCV - Full Apparent Cause October 24, 20122012-16863
: Auto Start Of SAC 1 And Sac 2 Due To Low Instrument Air Header Pressure With The EIAC
: In Lead October 25, 20122012-17419
: Operating Crew Performance Critique for ICS Transient on October 24, 2012 November 2, 20122012-17662
: MS-C-12-10-19:
: Finding: Protected Area Vehicle Search Observation Requirements Not Identified or Met. November 7, 20122012-17719
: MS-C-12-10-19:
: Finding, Communication System Testing Not Fully Performed November 8, 20122012-17767 Train 2 Battery Charger
: DBC-2N Scheduled Return Delayed Due To Resource Availability November 9, 20122012-17995 Taking ICS to Track Results in a 5 MW Rise in Power November 14, 20122012-18301 10 CFR Part 21- Fisher Commercial Grade November 20, 20122012-18474
: Repeat Instances of 9-1-F (Instrument Air Header Pressure Low Annunciator) Alarming in the Control Room November 27, 20122012-18495 August 2012 SCWE Survey Results - Identified 12 Negative Areas Within Operations November 27, 20122012-18513 August 2012 SCWE Survey Results - Identified 11 Negative Areas within Maintenance November 27, 20122012-18584 EDG 1 - Multiple Repair Attempts Required to Eliminate Leaking on Lube Oil Cooler O-Ring Seal November 28, 20122012-18605 EDG 1 Safety Start Blue Light did not Illuminate When EDG 1 was Started from the Control Room During Testing November 28, 20122012-18831 Root Cause -Decay Heat Pump Cyclone December 3, 2012
: Attachment CORRECTIVE ACTION PROGRAM DOCUMENTS REVIEWED Number Description or Title Date or RevisionSeparator Configuration Control 2012-19102 Time Delay Between Condition Report Initiation and Completion of Supervisor Review December 7, 20122012-19289 10 CFR Part 21- EPRI EQ Test Report December 12, 20122012-19355 10 CFR Part 21- Fisher Commercial Grade December 13, 20122012-19746
: PA-DB-12-03 Chemistry Section Trend Identified December 21, 20122013-00017 1A Metal Detector has Removed from Service Due to Continuously Alarming January 2, 2013 2013-00124 Radio Tracking January 4, 2013 2013-00542 Procedure Violation
: NOP-SS-3300 January 14, 20132013-00720 Condition Report Not Processed in a Timely Manner January 17, 20132013-00782 Trend in Human Performance Events January 18, 20132013-00808
: IP-SA-2012-0209, Chemistry 2nd Half 2012 IPAT, New Area Placed in Monitoring Status:
: Human Performance - Administrative Attention to Detail January 18, 20132013-00808
: IP-SA-2012-0209, Chemistry 2nd Half 2012 IPAT, New Area Placed in Monitoring Status:
: Human Performance - Administrative Attention to Detail January 18, 20132013-01128 CR Not Timely Reviewed by Supervisor January 30, 20132013-01450 CR Not Timely Reviewed by Supervisor January 30, 20132013-01798 Supervisor Review of Condition Report not Processed in Timely Manner February 5, 2013 2013-02253
: Unexpected Instrument Air Header Pressure Low Annunciator
: February 14, 20132013-02263 Station and Instrument Air System Degradation February 14, 20132013-02678 Factory Sealed Material Excepted from Search (NOP-LP-1202) February 22, 20132013-03423 BACC - A Flange Connection Leak Was Found On FE4952 March 8, 2013 2013-03594
: MS-C-13-02-22:
===Condition Report===
: 2012-08883 Generation Not Timely March 12, 2013   
: Attachment 2013-03599 BACC - Untimely Initiation of
: CR 2013-03423 March 12, 2013 2013-03596
: MS-C-02-22:
: CR-2012-0981 Root Cause Prevent Recurrence Actions Not Appropriately Entered Into the Corrective Action Plan and
: CAP Database March 13, 2013 2013-03669 Station and Instrument Air Recommended Improvements Tracking
: March 13, 2013 2013-04619 Corrective Action Review Board (CARB) Rejection of
: CR 2013-02094 Apparent Cause March 27, 2013 2013-05457 Control of Unopened, Sealed in the Manufacturing Process Material Inside the PA April 9, 2013 2013-05569 Condition Report 2103-04457 Initiation and Supervisor Review not Timely April 11, 2013 2013-05634
: PA-DB-13-01:
===Operating Experience===
: Program Oversight and Monitoring April 11, 2013 2013-05829
: PA-DB-13-01:
: Plant Engineering Operating Experience Evaluation Completion
: April 15, 2013 2013-05810
: PA-DB-13-01:
: Operations Operating Experience Evaluation Completion April 15, 2013 2013-05878 Untimely Initiation of a Condition Report April 16, 2013 2013-05935 Protected Area Searches of Bulk Liquids April 16, 2013 2013-04093 Untimely Initiation of a CR April 19, 2013 2013-06231 Violation of
: NOP-LP-1202 April 19, 2013 2013-06523
: PA-DB-13-01:
: OPS Performance Indicator for Procedure Backlog Does Not Have a GAP
: Closure Plan Return to Green Performance April 25, 2013 2013-06705 Low Level Trend Skill Based Rework April 29, 2013 2013-06834 Decreasing Rating in Work Groups Observed May 2, 2013 2013-07006 Trending of the High Performance Indicator Hours for Physical Protection Protected Area Equipment May 3, 2013 2013-07167 Security Equipment Technical Oversight Needs Improvement May 6, 2013 2013-07146 Adverse Trend in Events Due to Failure to Self-Check Properly May 6, 2013 2013-07548 Six Red Areas for Operations Ad-Hoc SCWE Survey May 14, 2013 2013-07613 Low Level Trend of Lack of Situational Awareness in Maintenance Department May 15, 2013 2013-08225 Use of Adjustable Wrenches or Improvised Tools May 28, 2013 2013-08434
: ODMI - Station and Instrument Air Summer Operations
: May 31, 2013 2013-08565 INPO 2013:
: AFI
: PI.2-1 Initiation of Condition Reports June 3, 2013 2013-09602
: SAC#2 Was Surging
: June 21, 2013 2011-09381 Failure to Control ECCS Valve Position June 21, 2013 
: Attachment 2013-02697 10 CFR Part 21- GOTHIC Error Report June 22, 2013 2013-10533 Post Trip Plant Response Not as Expected July 10, 2013 2013-10645 Pressurizer Level Transient Not Timely Documented via Condition Report July 12, 2013 2013-10873 Gaps Identified in OBSR 2013-19075 (Officer Patrol of Auxiliary Building) July 16, 2013 2013-11191 SAC#1 Auto Start Due to SAC#2 Surging
: July 22, 2013 2013-11201 Timeliness of Condition Report Supervisory Review July 22, 2013 2013-11201 Timeliness of Condition Report Supervisory Review July 22, 2013 2013-11218 Untimely Documentation of Observations July 22, 2013 2013-11476
: IP-SA-DB-2013-0022, Chemistry 1st Half 2013 IPAT, New Trend, Human Performance - Procedure Use and Adherence - Timeliness July 25, 2013 2013-11475
: IP-SA-DB-2013-0022, Chemistry 1st Half 2013 IPAT, New Trend: Human Performance, Worker Practices - Clear Communication July 25, 2013 2013-11691 IHA Fan
: DB-C141-6 Failure August 4, 2013
: OTHER DOCUMENTS Number Description or Title Date or RevisionSystem Health Report 2008-4 System -18-01 - Station and Instrument Air 4th Quarter January 2009 System Health Report 2009-4 System -18-01 - Station and Instrument Air 4th Quarter January 2010 System Health Report 2010-4 System -18-01 - Station and Instrument Air 4th Quarter January 2011 System Health Report 2011-1 System Health Report- Station and Instrument Air April 2011 System Health Report 2011-2 System Health Report- Station Lighting
: April 2011 System Health Report 2011-2 System Health Report- Station and Instrument Air July 2011 System Health Report 2012-3 System Health Report- Plant Computer October 2011 System Health Report 2011-4 System Health Report-CRD January 2012 System Health Report 2011-4 System Health Report-
: ICS-NNI January 2012 System Health Report 2011-4 System -18-01 - Station and Instrument Air 4th Quarter January 2012 System Health Report 2012-4 System 36-01 - Main Feedwater System Health Report January 2012 System Health Report 2012-1 System Health Report-CRD April 2012 
: Attachment OTHER DOCUMENTS Number Description or Title Date or RevisionSystem Health Report 2012-1 System Health Report-ICS-NNI April 2012 System Health Report 2012-4 System Health Report- Plant Computer October 2012 System Health Report 2011-1 System Health Report- Station Lighting January 2013 System Health Report 2012-4 System Health Report- Service Water January 2013 System Health Report 2012-4 System -18-01 - Station and Instrument Air 4th Quarter January 2013
: Open Work Orders for Main Feedwater July 25, 2013
: Operations Performance Improvement Action Plan 1
: Maintenance Rule (a)(1) Evaluation Form for Station and Instrument Air System September 22, 2011
: Maintenance Rule (a)(1) Action Plan and Goals for Station and Instrument Air System January 23, 2012 Revised Maintenance Rule (a)(1) Action Plan and Goals for Station and Instrument Air System April 11, 2013 D-12-014 Employee Concerns Case May 2012 D-13-005 Employee Concerns Case March 2013 D-13-012 Employee Concerns Case June 2013
: AUDITS, ASSESSMENTS AND
: SELF-ASSESSMENTS Number Description or Title Date or Revision
: Davis Besse SCWE Survey Results For August 2012 No Date
: CA-SA-DB-2012-02 Davis-Besse Safety Culture Assessment No Date
: SN-SA-2013-0074 Status of Davis-Besse Assessment/Benchmarking Program No Date
: SN-SA-11-191
: GL 2008-01 - Managing Gas Accumulation Reliability of Heat Exchangers Cooled by Service Water May 17, 2011
: SN-SA-2011-0017 Work Group Clearance Assessment August 1, 2011
: PA-DB-2011-0029
: DB-PA-11-03:
: Corrective Action Program February 2, 2012
: IP-SA-2012-0035
: IPAT-Site Integrated Performance Assessment & Trending (2011) May 30, 2012
: IP-SA-2012-0032 2011 Integrated Performance Assessment and Trending for Site Protection May 30, 2012
: IP-SA-2011-0029 Radiation Protection 2nd Half 2011 IPAT May 30, 2012
: IP-SA-2012-0026 Chemistry 2nd Half 2011 IPAT May 30, 2012 
: Attachment AUDITS, ASSESSMENTS AND
: SELF-ASSESSMENTS Number Description or Title Date or Revision
: IP-SA-2012-0035 CAP IPAT Second Half 2011 May 30, 2012
: PA-DB-2012-0005
: DB-PA-12-01:
: Radiation Protection Functional Area Assessment July 6, 2012
: PA-DB-2012-0009
: DB-PA-12-01:
: Chemistry Assessment for the 1st Trimester of 2012 July 17, 2012
: IP-SA-2012-0134 DB Maintenance IPAT August 3, 2012
: IP-SA-2012-0135 First Half 2012 - DB Site Protection IPAT August 3, 2012
: IP-SA-2012-0096 First Half 2012 - DB Radiation Protection IPAT August 6, 2012
: IP-SA-2012-0129 First Half 2012 - DB Corrective Action Program IPAT August 8, 2012
: SN-SA-2012-0119 Review DB Performance with Respect to
: October 17, 2012
: FO-SA-2012-0026 Objective 5 Team Identified Finding (TIF) Effectiveness Review
: November 26, 2012SN-SA-2012-0303 Davis-Besse Nuclear Safety Culture Monitoring Panel 2012 4th Quarter Assessment December 7, 2012
: IP-SA-2012-0188 3rd Quarter 2012 DB Corrective Action Program IPAT December 16, 2012IP-SA-2012-0176 3rd Quarter Ops IPAT December 19, 2012SA-DB-2012-0208 Site Integrated PA and Trending February 5, 2013
: IP-SA-DB-2012-0223 2nd Half 2012 DB Site Protection IPAT February 5, 2013
: IP-SA-DB-2012-0220 2nd Half 2012 DB Corrective Action Program IPAT February 5, 2013
: PA-DB-2012-0035
: PA-DB-12-03:
: Chemistry Assessment 3rd Trimester 2012 February 22, 2013
: SN-SA-2012-0311 Semi-Annual Backlog Assessment February 25, 2013
: SN-SA-2013-0150 Davis-Besse Nuclear Safety Culture Monitoring Panel 2013 1st Quarter Assessment April 3, 2013
: FO-SA-2013-0003 Problem Identification and Resolution Assessment May 15, 2013
: SN-SA-2012-0125 Willingness of SROs and SMs to Raise Issues With Confidence they will be Addressed June 18, 2013   
: Attachment
: SN-SA-2012-0104 Final Effectiveness Review- Ops Perf Imp June 24, 2013
: PA-DB-2012-0046
: PA-DB-13-01:
: Security Functional Area Assessment June 24, 2013
: PA-DB-2013-0010
: PA-DB-13-01:
: Radiation Protection Functional Area Assessment June 24, 2013
: SN-SA-2012-0125 Effective Job Feedback June 26, 2013
: PA-DB-2013-0007
: PA-DB-13-01:
: Chemistry 1st Trimester for 2013 June 26, 2013
: SA-DB-2013-0016 Corrective Action Program July 10, 2013
: IP-SA-DB-2013-0006 DB Radiation Protection 1st Quarter 2013 IPAT Report July 10, 2013
: IP-SA-DB-2013-0005 DB Chemistry 1st Quarter 2013 IPAT Report July 10, 2013
: IP-SA-DB-2013-0016 DB Corrective Action Program 1st Quarter 2013 IPAT Report July 10, 2013
: FO-SA-2013-004 Focused Self Assessment of Work Instruction Quality July 15, 2013
: FO-SA-2013-0002 Assessment of the Design and Implementation of the Safeguards Protection Program at Davis-Besse Nuclear Power Station July 26, 2013
: DRAWINGS Number Description or Title Date or Revision E-58B, Sh 2A Containment Ventilation System 15 E-58B, Sh 2C Containment Ventilation System 13
: OS-0119A Operational Schematic Instrument Air 30
: OS-0119B Operational Schematic Station Air 24
: OS-018, Sh 1 Operation Schematic Auxiliary Steam System 27
: OS-020, Sh 1 Operational Schematic Service Water System 89
: OS-026 Operational Schematic Main Generator Stator Winding Cooling Water System 34
: OS-045 Operation Schematic Primary and Demineralized Water System 46
: CONDITION REPORTS GENERATED DURING INSPECTION Number Description or Title Date or Revision2013-12110 Condition Reports not Submitted for Notifications Associated with BF2129 August 6, 2013 2013-12209 Apparent Error with Discovery Date as Documented in
: CR 2012-17767 August 8, 2013 2013-12246 The Review of 10CFR Part 21 Notices of D-B Applicability is Backlogged August 8, 2013 
: Attachment CONDITION REPORTS GENERATED DURING INSPECTION Number Description or Title Date or Revision2013-12258 ECP Program Observation August 8, 2013 2013-12261 Observation on Condition Reporting Effectiveness August 8, 2013 2013-12262 Observation on Condition Report Timeliness August 8, 2013 2013-12263 NRC PI&R Observation on Weakness in Condition Report Cause Evaluation August 8, 2013 2012-12301 Observation on Lack of Self-Assessment on Overall Effectiveness of Self-Assessment Program August 9, 2013 2013-12569 Condition Report Initiation by Individuals Questioned August 14, 2013
===Work Orders===
and Notifications Number Description or Title Date or Revision200009025 CC4:
: Disassemble and Inspect Valve Actuator 0
: 200099230
: SW 1356 Op Eval 04-0017 0
: 200165513 RPLC Strainer Cable 0
: 200333328 MV1380-Relube, Replace Worm Gear 0
: 200336387
: SW 1379 Replace Worn Worm Gear 0
: 200411842
: SW 276,
: SW 277 Replace Leaking Valves 0
: 200483784 DW8 Demineralized Water to Condensate Storage 0
: 200483786 PW56 - Replace Diaphragm 0
: 600719854
: DB-OP-06241
: CA 11-05454-1 November 15, 2011
: 600719886 Replace Diaphragm PW56 November 17, 2011
: 600797587
: DB-OP-06401
: CA-2012-16833-3 November 14, 2012
: 600802338
: DB-OP-06401 December 17, 2012
: OPERATING EXPERIENCE Number Description or Title Date or Revision
: OE-2012-0500 Scratches Found on Reactor Vessel Head O-Ring Seating Surface April 4, 2012
: OE-2012-0718 Manual Reactor Scram Caused By Human Performance Errors During Feedwater Flow Manipulation April 20, 2012 
: Attachment
: OE-2012-0736 At Brown's Ferry a 120 Vac Lighting Circuit was not Separated from Their Reactor Protection System in the Relay Room.
: A Fire Hot Short was postulated to Affect Control Rods From Inserting. June 27, 2012
: OE 2012-1313 IN12-11, Age Related Capacitor Degradation July 25, 2012
: OE 2012-1529
: Local Leak Rate Test Boundary Invalidated by Performing the Backfill Process of Instrument and Sensing Lines
: August 1, 2012
: OE 2012-1551 IN2012-17, Concrete Compressive Strength Design Calculation September 6, 2012
: OE-2012-1611 NRC
: TI 177 Consider Newer PWROG Gas Management Guidance HHSI Pump Suction Piping Acceptance Criteria October 10, 2012
: OE-2012-1720 Manual Reactor Scrams Caused By Load Center Transformer Faults October 30, 2012
: OE-2013-0177 Weld Leak in Essential Raw Cooling Water (ERCW) for Containment Spray Heat Exchanger Vibration Induced Fatigue Caused Crack. February 6, 2013
: OE 2013-0483 IN2013-05, Battery Expected Life and its Potential Impact on Surveillance Requirements March 22, 2013
: ROOT CAUSES AND APPARENT CAUSES Number Description or Title Date or Revision
: CR-2011-00078 ODMI:
: TPCW System Flow Margin August 8, 2011
: CR-2012-01563
: Station Air Compressor #1 Tripped During
: 1 Hour Loaded Run
: September 4, 2011
: CR-2012-02091 Fourth Quarter 2011 System Health Report
: Overall Rating White February 9, 2012
: CR-2012-09381 During
: DB-PF - 03010 NOP/NOT:
: Active Leak1st Seal Cavity Vent Line June 6, 2012
: CR-2012-11519 Station Air Compressor #2 Will Not Load
: July 24, 2012
: CR-2011-05456 E11C Water Intrusion / Fire January 16, 2013     
: Attachment
==LIST OF ACRONYMS==
: [[USED]] [[]]
: [[ADAMS]] [[Agencywide Document Access and Management System]]
: [[AF]] [[Adverse Fix]]
: [[CA]] [[Corrective Action]]
: [[CAP]] [[Corrective Action Program]]
: [[CARB]] [[Corrective Action Review Board]]
: [[CFR]] [[Code of Federal Regulations]]
: [[CR]] [[Condition Report]]
: [[ECP]] [[Employee Concerns Program]]
: [[OE]] [[Operating Experience]]
: [[PARS]] [[Publicly Available Records]]
PI&R  Problem Identification and Resolution
: [[SCWE]] [[Safety Conscious Work Environment]]
: [[R.]] [[Lieb -2-  Based on the results of this inspection, no findings of significance were identified. In accordance with 10]]
: [[CFR]] [[2.390 of the NRC's "Rules of Practice," a copy of this letter, its enclosure, 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 NRC's Agencywide Document Access and Management System (ADAMS).]]
: [[ADAMS]] [[is accessible from the]]
NRC Web site at http://www.nrc.gov/reading-rm/adams.html (the Public Electronic Reading Room).
Sincerely,  /RA/
Patricia J. Pelke, Acting Chief  Branch 6  Division of Reactor Projects


Docket No. 50-346
License No. NPF-3  Enclosure:  Inspection Report 05000346/2011008  w/Attachment: Supplemental Information
cc w/encl:  Distribution via ListServTM 
}}
}}

Latest revision as of 14:58, 20 December 2019

IR 05000346-13-007; on 07/22/2013 - 08/9/2013; Davis-Besse Nuclear Power Station; Biennial Problem Identification and Resolution (Pi&R) Inspection
ML13266A431
Person / Time
Site: Davis Besse Cleveland Electric icon.png
Issue date: 09/23/2013
From: Patricia Pelke
NRC/RGN-III/DNMS/MLB
To: Lieb R
FirstEnergy Nuclear Operating Co
References
IR-13-007
Download: ML13266A431 (30)


Text

ber 23, 2013

SUBJECT:

DAVIS-BESSE NUCLEAR POWER STATION - NRC PROBLEM IDENTIFICATION AND RESOLUTION INSPECTION REPORT 05000346/2013007

Dear Mr. Lieb:

On August 9, 2013, the U.S. Nuclear Regulatory Commission (NRC) completed a Problem Identification and Resolution biennial inspection at your Davis-Besse Nuclear Power Station.

The enclosed inspection report documents the inspection results, which were discussed on August 9, 2013, with you and other members of your staff.

This inspection was an examination of activities conducted under your license as they relate to problem identification and resolution and compliance with the Commissions rules and regulations and the conditions of your license. Within these areas, the inspection involved examination of selected procedures and representative records, observations of activities, and interviews with personnel.

Based on the inspection sample, the inspection team concluded that the implementation of the corrective action program and overall performance related to identifying, evaluating, and resolving problems at Davis-Besse Nuclear Power Station effectively supported nuclear safety.

Licensee-identified problems were entered into the corrective action program at a low threshold.

Problems were prioritized and evaluated commensurate with the safety significance of the problems and corrective actions were generally implemented in a timely manner commensurate with their importance to safety and addressed the identified causes of the problems. Lessons learned from industry operating experience were generally reviewed and applied when appropriate. Audits and self-assessments were effectively used to identify site performance deficiencies, programmatic concerns, and improvement opportunities. Based on the interviews conducted, the inspectors did not identify any impediment to the establishment of a safety conscious work environment at Davis-Besse Nuclear Power Station. Licensee staff is willing to raise concerns related to nuclear safety through at least one of the several means available. Based on the results of this inspection, no findings of significance were identified.

In accordance with 10 CFR 2.390 of the NRC's "Rules of Practice," a copy of this letter, its enclosure, 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 NRC's Agencywide Document Access and Management System (ADAMS). ADAMS is accessible from the NRC Web site at http://www.nrc.gov/reading-rm/adams.html (the Public Electronic Reading Room).

Sincerely,

/RA/

Patricia J. Pelke, Acting Chief Branch 6 Division of Reactor Projects Docket No. 50-346 License No. NPF-3

Enclosure:

Inspection Report 05000346/2013007 w/Attachment: Supplemental Information

REGION III==

Docket No: 50-346 License No: NPF-3 Report No: 05000346/2013007 Licensee: FirstEnergy Nuclear Operating Company (FENOC)

Facility: Davis-Besse Nuclear Power Station Location: Oak Harbor, OH Dates: July 22 through August 9, 2013 Inspectors: J. Rutkowski, Project Engineer, Team Lead M. Holmberg, Senior Reactor Inspector B. Winter, Reactor Engineer T. Briley, Resident Inspector Approved by: Patricia J. Pelke, Acting Chief Branch 6 Division of Reactor Projects Enclosure

SUMMARY OF FINDINGS

Inspection Report (IR) 05000346/2013007; 07/22/2013 - 08/9/2013; Davis-Besse Nuclear

Power Station; Biennial Problem Identification and Resolution (PI&R) Inspection.

This inspection was performed by three regional based inspectors and the Davis-Besse Nuclear Power Station resident inspector. No findings of significance or violations of NRC requirements were identified during this inspection. 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.

Problem Identification and Resolution Based on the samples selected for review, the team concluded that implementation of the corrective action program (CAP) at Davis-Besse Nuclear Power Station was effective. The licensee had a low stated threshold for identifying problems and entering them in the CAP.

Items entered into the CAP were generally screened and prioritized in a timely manner using established criteria, although the team identified timeliness issues for a small percentage of issues. Issues in the CAP were properly evaluated and corrective actions were generally implemented in a timely manner. The team noted that the licensee reviewed operating experience (OE) for applicability to station activities. Audits and self-assessments were performed at an appropriate level to identify deficiencies. Based on interviews conducted during the inspection, licensee staff expressed freedom to raise nuclear safety concerns and to enter nuclear safety concerns into the CAP.

NRC-Identified

and Self-Revealed Findings None.

Licensee-Identified Violations

None.

REPORT DETAILS

OTHER ACTIVITIES

4OA2 Problem Identification and Resolution

This inspection constituted one biennial sample of Problem Identification and Resolution (PI&R) as defined in Inspection Procedure (IP) 71152, Problem Identification and Resolution. Documents reviewed are listed in the Attachment to this report.

.1 Assessment of the Corrective Action Program Effectiveness

a. Inspection Scope

The inspectors reviewed the licensees Corrective Action Program (CAP) implementing procedures and attended CAP meetings to assess the implementation of the CAP by licensee staff. The inspectors also interviewed licensee staff about their use of the CAP.

The inspectors reviewed risk and safety significant issues in the licensees CAP since the last NRC PI&R inspection in March 2011. The selection of issues ensured an adequate review of issues across NRC cornerstones. The inspectors used issues identified through NRC generic communications, department self-assessments, licensee audits, OE reports, and NRC documented findings. The inspectors reviewed Condition Reports (CRs) that were generated and a selection of completed investigations from the licensees various investigation methods, which included root cause, full apparent cause, limited apparent cause, and common cause investigations.

The inspectors selected the instrument air and station air systems to review in detail because the system had numerous operational problems in recent years and was in Maintenance Rule (a)(1) category. The intent of the review was to determine whether the licensee staff were properly monitoring and evaluating the performance of these systems through effective implementation of station monitoring programs. A five-year review of the air systems was performed to assess the licensees efforts in monitoring for system degradation due to aging aspects. The inspectors also performed partial system walkdowns of the main feedwater system, service water system, and emergency diesel generators. A review of the use of the station maintenance rule program to help identify equipment issues was also conducted.

During the reviews, the inspectors determined whether the licensees actions were in compliance with the licensees CAP and 10 CFR Part 50, Appendix B requirements.

Specifically, the inspectors determined whether licensee personnel were identifying plant issues at the proper threshold, entering the plant issues into the stations CAP in a timely manner, and assigning the appropriate prioritization for resolution of the issues. The inspectors also determined whether the licensee staff assigned the appropriate investigational method to ensure the correct determination of root, apparent, and contributing causes. The inspectors also evaluated the timeliness and effectiveness of corrective actions for selected issue reports, completed investigations, and eight NRC previously identified findings that included principally non-cited violations.

Documents reviewed are listed in the Attachment to this report.

b. Assessment

(1) Effectiveness of Problem Identification Based on the information reviewed, including initiation rates of CRs and interviews, the inspectors concluded that the licensee has a low threshold for initiating CRs, and from the CRs reviewed, the threshold was appropriate. Some of the non-supervisory licensee staff interviewed believed the CAP was ineffective for items of low safety significance partially due to the large number of low safety significant issues in the CAP. Several of the individuals interviewed stated they refrained from using the CAP for perceived non-safety-significant issues. The same individuals also stated that they would report nuclear safety issues. The inspectors did not identify any safety significant item that was not entered into the CAP. The inspectors assessed the effectiveness of problem identification as adequate.

Observations The inspectors found that issues were being identified and captured in the licensees programs and particularly in the CAP. During a non-outage year, about 4000 to 5000 CRs are initiated with most being of low safety significance. The inspectors found through interviews that licensee staff understood the expectation to write CRs for issues and did write CRs. In several departments, licensee staff regularly passed issues on to their supervisors and the supervisors wrote the CRs. However, several non-supervisory licensee staff from the small groups interviewed said that they believed the CAP system was ineffective for less than significant nuclear safety issues and several of them said that that they would not use the CAP system for minor issues. However, the inspectors noted that all the small groups interviewed stated that they would not hesitate to bring problems and issues to their immediate supervisors. All licensee staff interviewed said they would raise nuclear safety issues. The inspectors did not identify any specific safety significant issues where it was clear that an individual should have written CRs and did not.

Based on a similar concern that had been previously identified to the licensee earlier this calendar year (2013) from a review performed by an external group, the licensee initiated CR 2013-12261, Observation on Condition Reporting Effectiveness.

Corrective actions were identified and scheduled; some of them were ongoing during the inspection in response to the external groups review.

The licensee has an established (but not proceduralized) expectation that CRs are initiated in the CAP within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br /> after discovery of an adverse condition and subsequently initially reviewed within 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />. The inspectors reviewed the last nine months of CRs for timeliness of initiation. Of the approximately 4000 CRs that were documented in the CAP, approximately 80 (2 percent) of the CRs were initiated 4 days or more from discovery of the adverse condition and approximately 5 CRs were initiated greater than 30 days after discovery. In the last nine months, the licensee initiated at least 15 CRs to document untimely CR initiation and at least 10 CRs to document untimely supervisory review (24-hour expectation for supervisors to review CRs once initiated). Additionally, the inspectors identified that no CR had been written to document the untimely initiation of CR 2013-11691, which documented failure of an integrated head assembly vent fan, even though the CR was initiated 14 days after discovery of the condition and after actions to address the issue had already been taken.

To address this issue, the licensee initiated CR 2013-12110, Condition Reports not submitted for Notifications associated with BF2129, to document the untimely initiation of CR 2013-11691.

The timely initiation of CRs after an adverse condition is discovered appears inconsistent and was previously documented in various CRs and self-assessments. Although the CAP document (NOP-LP-2001, Corrective Action Program) does not specify time requirements for initiating CRs, licensee staff interviewed during the inspection were aware of the site expectation. To address this issue, the licensee initiated CR 2013-12262, Observation on Condition Report Timeliness.

The inspectors noted that in addition to the CAP, the licensee had other systems that capture items or issues that require action. Specifically, the inspectors briefly reviewed procedure change tracking, mainly in Operations, and the simulator work tracking system. The inspectors did not identify any timeliness issues relative to reporting issues, but had questions on the number of Operations procedures change requests and simulator work issues. The Operations procedure backlog has approximately 900 open change requests.

Findings No findings of significance were identified.

(2) Effectiveness of Prioritization and Evaluation of Issues The inspectors reviewed the classification of CRs for resolution and determined that, in general, CRs were assigned appropriate prioritization and evaluation levels. Evaluations in apparent cause and root cause reports reviewed by the inspectors were adequate. In several CR cause evaluations, the inspectors identified some items they considered weaknesses in the evaluation of issues, such as failure to address a contributing cause for Pressurizer Code Safety Valve setpoint test failure and a contributing cause for a failure to properly control equipment configuration and status. The inspectors noted that other internal and external review groups identified issues with the quality of the licensees limited apparent cause evaluations. The inspectors determined that the licensees prioritization and evaluation of issues were sufficient to ensure that established corrective actions would be effective and that there was appropriate consideration of risk in prioritizing issues.

Observations Over the last two years (second half 2011 through August 2013) approximately 12,000 CRs were documented in the CAP. Ninety-five percent or more of the CRs from the second half of 2011 to the end of 2012 are listed either in a closed or archive status.

The majority of those that remain open appear to be related to corrective actions requiring outage related repairs. Approximately 50 percent of the CRs from 2013 (3300 total) are listed in the CAP as closed or archive status. The inspectors determined that these numbers were generally consistent with an effective program.

In CR-2011-88100, Root Cause - Pressurizer Code Safety Valves Setpoint Test Failure, the direct cause was identified as setpoint drift and it was concluded that the exact cause of the setpoint variance (drift) was indeterminate. Additionally, the licensee concluded that the different vendors and test conditions established for the as-left and as-found setpoint tests, were minor in nature, but may have affected the test results.

However, a corrective action (CA) was not assigned to control future test conditions or to maintain a single test vendor to eliminate this potential contributing cause. This example illustrated a weakness in identification of a potential contributing cause for a significant condition adverse to quality. If a contributing cause was not identified, the effectiveness of the CAs taken could be less than fully effective. The inspectors did not identify any CAs that were less than effective as a result of the licensees failure to identify a contributing cause.

In CR-2012-08422, Root Cause- DC (Direct Current) Motor Control Center Busses Not Supplied by Operable DC Sources, the licensee identified that the root cause was less than adequate administrative controls for equipment and system configuration control during maintenance and testing activities. DC battery maintenance work had been field completed, but not through a final post maintenance test, but this status was not properly identified and the system was declared operable. However, no CA was identified to determine if the total population of backlogged work orders of field completed work, waiting for final post maintenance testing, contributed to the cause of this issue. The inspectors noted in self-assessment (SN-SA-2012-0311) the licensee identified a backlog of 57 work orders with a field complete or awaiting testing status. This example illustrated a weakness in identification of a potential contributing cause for a condition adverse to quality. If a contributing cause was not identified, the effectiveness of the CAs taken could be less than fully effective. The licensee initiated CR 2013-12263, Observation on Weakness in Condition Report Evaluation to capture the inspectors observations. The inspectors did not identify any CAs that were less than effective as a result of the licensees failure to identify a contributing cause.

Findings No findings of significance were identified.

(3) Effectiveness of Corrective Actions In general, the corrective actions reviewed addressed the cause of the identified problem, and appeared to have been effective in the majority of samples reviewed, although some weaknesses were observed but did not preclude the inspectors from assessing corrective actions as generally effective.

The licensee used the CAP to identify problems and utilized the Maintenance Rule Program and the System Health Report to develop plans for Station and Instrument Air system improvement. The plans included replacement with new parts and equipment, refurbishment of components, and fine-tuning the operating band of the Station and Instrument Air system. The inspectors concluded that the licensee placed appropriate attention and actions to improve the system performance.

Observations The inspectors did not identify any new recurrent issues of significance, though CRs initiated by the licensee identified several recurrent issues. The inspectors noted that the licensee had activities to address recurring human performance issues that were identified and that were self-revealing. The inspectors also noted that during this assessment period, there was a violation associated with the seismic monitoring system that was essentially the same as a violation in 2007 for which a root cause evaluation was performed. This violation was documented in a quarterly integrated inspection report developed by the resident inspector office. The inspectors did not identify any additional issues regarding this violation beyond those previously documented in the inspection report.

In CR-2012-18831, Root Cause-Decay Heat Pump Cyclone Separator Configuration Control, the licensee concluded that an effectiveness review was not warranted for the CA to preclude the recurrence of the root cause identified as an inadequate design interface review. The conclusion was based on the assumption that the revisions made to the current procedure for control of the design interface reviews would prevent a similar error and in part based upon a CAP data base key word search completed using the terms of DIE and Design Interface. However, a similar design interface review error would not likely be identified in the CAP data base search using these key words unless it had resulted in a substantial issue that required an apparent or root cause investigation. The inspectors determined that this example illustrated a potential weakness in evaluating the effectiveness of a CA.

In CR-2011-88100, Root Cause - Pressurizer Code Safety Valves Setpoint Test Failure, the licensee completed an effectiveness review of the CA that implemented a revised (lowered) setpoint test band to gain additional margin to accommodate for setpoint drift. The scope of the effectiveness review included an evaluation of the subsequent test results for pressurizer Code safety relief valve tests after implementing the revised setpoint test band. These test results included one Code safety relief valve that failed low out of specification (i.e. 3.4 percent below setpoint). The cause of this test failure was setpoint drift but may have occurred, in part, due to the lowered setpoint test band established as the CA for the root cause. However, the licensees effectiveness review did not include an evaluation to determine if the CA for the root cause (e.g.

lowered setpoint band) contributed to this low setpoint lift failure. The inspectors assessed the licensees decision not to investigate the potential negative impacts or unintended consequences of this CA as appearing inconsistent with the recommended actions for conducting effectiveness reviews as discussed in Section 4.7.5.2 of NOPBP-LP-2011 FENOC Cause

Analysis.

This example illustrated a potential weakness in the conduct of a CA effectiveness review. However, the inspectors did not identify an inappropriate corrective action.

The inspectors reviewed the results of CRs used to document some areas of concern identified in the 2012 Safety Conscious Work Environment (SCWE) Surveys.

Specifically the inspectors reviewed CRs written for Regulatory Compliance, Operations, and Maintenance departments. The CRs for Maintenance and Operations had each listed a CA that did not appear to correct any issues but were for additional investigations. Both CRs were closed with no indication of any additional actions to be taken to address the identified issues. Discussions with Maintenance and Operations revealed that the management of those departments did have additional plans to document and address the issues, but that these plans were not written down in any CR documents or any other document provided to the inspectors. While those two CRs were classified as adverse fix (AF), and did not require any detailed analysis under the CAP, the actions listed did not address correcting the identified issues. The inspectors did not identify any non-compliance with licensees procedural requirements associated with the reviewed CRs.

Findings No findings of significance were identified.

.2 Assessment of the Use of Operating Experience

a. Inspection Scope

The inspectors reviewed the licensees implementation of the facilitys Operating Experience (OE) program. Specifically, the inspectors reviewed implementing OE program procedures, attended CAP meetings to observe the use of OE information, completed evaluations of OE issues and events, and selected monthly assessments of the OE composite performance indicators. The intent of the review was to: (1)determine whether the licensee was effectively integrating OE experience into the performance of daily activities;

(2) determine whether evaluations of issues were appropriate and conducted by qualified individuals;
(3) determine whether the licensees program was sufficient to prevent future occurrences of previous industry events; and (4)determine whether the licensee effectively used the information in developing departmental assessments and facility audits. The inspectors also assessed if corrective actions, as a result of OE experience, were identified and implemented effectively and timely.

Assessment Overall, the inspectors determined that the licensee was adequately evaluating industry OE for relevance to the facility. The licensee had entered all applicable items in the CAP in accordance with the licensees procedures. Both internal and external OE was being incorporated into lessons learned for training and pre-job briefs. System Engineers utilized industry OE to resolve equipment operational problems. The inspectors concluded that the licensee was evaluating industry OE when performing root cause and apparent cause evaluations. The inspectors noted that the licensee had identified a small number of OE evaluations where the evaluation time was longer than the procedure NOBP-LP-2100, FENOC Operating Experience Process, requirement of 150 days. However, this did not affect the overall assessment and the inspectors concluded that the licensee used operating experience appropriately.

Observations The inspectors identified a weakness resulting in backlogged 10 CFR Part 21 notifications when the 10 CFR Part 21 Coordinator was transferred to another group.

After the teams discovery, the licensee initiated CR-2013-12246, The Review of 10 CFR Part 21 Notices of D-B Applicability is Backlogged, and initiated actions to distribute the backlogged 10 CFR Part 21 notifications.

b. Findings

No findings of significance were identified.

.3 Assessment of Self-Assessments and Audits

a. Inspection Scope

The inspectors assessed the licensee staffs ability to identify and enter issues into the CAP, prioritize and evaluate issues, and implement effective corrective actions, through efforts from departmental assessments and audits. The inspectors reviewed audit reports and completed assessments.

Assessment The inspectors concluded that self-assessments and audits were typically accurate, thorough, and effective at identifying most issues and enhancement opportunities at an appropriate threshold. The inspectors concluded that personnel knowledgeable in the subject area completed audits and self-assessments. In many cases, self-assessments and audits identified issues that were not previously recognized by the licensee.

Observations The inspectors reviewed some documents that implied or stated the licensee was behind schedule in completing some assessments; however, the inspectors did not identify any issues where the licensees assessments missed issues or were not of sufficient depth.

The inspectors did question the licensees recent assessment of the Self-Assessment process or program. That assessment appeared to be primarily a compliance assessment and did not evaluate the effectiveness of the licensees assessment process. The inspectors were not provided with a document that evaluated the effectiveness of the assessment process over the two-year period of the inspection. The licensee stated that an assessment, to evaluate effectiveness, was planned but had not been done.

The licensee completed a number of self-assessments in the Operations and Maintenance Departments over the past two years. In response to repeat Quality Assurance Department findings of marginal performance in the conduct of operations, the Operation Department had increased the frequency of snapshot type self-assessments with a focus on adverse trend identification. Overall, the assessments and trending for maintenance and operations issues appeared to be thorough and included acceptance criteria to determine when a trend was no longer of concern.

b. Findings

No findings of significance were identified.

.4 Assessment of Safety Conscious Work Environment (SCWE)

a. Inspection Scope

The inspectors assessed the licensees SCWE through the review of the licensees employee concern program (ECP), implementing procedures, discussions with the coordinator of the ECP, interviews with personnel from various departments, and reviews of issue reports. The inspectors also reviewed the results from SCWE surveys conducted in 2011 and 2012.

As part of the overall inspection effort, inspectors discussed department and station programs with a variety of staff members. In addition, the inspectors interviewed approximately 44 individuals, who were placed in twelve groups, each of which was composed of three to five individuals from various departments, to assess their willingness to raise nuclear safety issues. The individuals were non-supervisory personnel and were selected in a manner that provided a distribution across the various departments at the site. In addition to assessing individuals willingness to raise nuclear safety issues, the interviews also addressed changes in the CAP and plant environment over the past 2 years. Other items discussed included:

  • knowledge and understanding of the CAP;
  • effectiveness and efficiency of the CAP; and
  • willingness to use the CAP.

Assessment Interviews indicated that the licensee has an environment where people are free to raise nuclear safety issues without fear of retaliation. Documents provided to the inspectors regarding the SCWE surveys generally supported the conclusions from the interviews.

All interviewees indicated that personnel would raise nuclear safety issues, although several interviewed groups said they might refrain from raising issues of low safety significance. All of the individuals interviewed knew that in addition to the CAP, they could raise issues to their immediate supervisor, the ECP, or the NRC. Several of the individuals interviewed stated they would not use the ECP due to concerns regarding the effectiveness of the program or the anonymity provided by the program; however, these individuals also stated that they had never used the ECP.

The licensee had ongoing actions in place to address the individuals that would not use the CAP or believed that it was not effective for low safety significant items. All of the individuals interviewed stated that they would report nuclear safety issues. The inspectors concluded that the licensees SCWE was acceptable. In addition, the licensee indicated that they were aware of issues with ECP and initiated a CR to address the issues that were identified by the inspectors during interviews with staff.

Based on this information as well as the low number of allegations received by the NRC, the inspectors determined that the ECP process was implemented adequately.

Observations The inspectors reviewed the ECP log and three case files. No issues were identified.

It was also noted that over the last twelve months, there were only two allegations received by the NRC. The inspectors talked with the groups interviewed for SCWE about their use of the ECP. Personnel in several groups stated that they would not use the ECP either because of trust issues or effectiveness of the process. The inspectors noted that many of the interviewed personnel that stated they would not use the program had never used the program. Some other individuals said that it was their personal preference not to use the program. Many said that they had never had the need to use the program. The interview results were consistent with trends shown in SCWE surveys conducted by the licensee. The licensee initiated CR 2013-12258, ECP Program Observation, which as classified requires a limited apparent cause investigation. That CR also documented that the licensee was aware of the issues some station personnel had with the ECP.

All of the twelve groups interviewed identified that one of the organizational issues was staffing. This was identified as an employee concern in previous assessments conducted by the licensee. Individuals stated that they have mentioned this issue to their supervisor, and in many cases, to their management. The inspectors did not identify any CAP issues specifically attributable to the interviewed individuals belief that staffing was inadequate. The licensee was aware of the staffs beliefs related to staffing.

Several groups stated that it is harder now to get work done than it was in the past.

Complexity of requirements and additional requirements has complicated the work process. Several of these groups stated that, while important equipment is being maintained when necessary, because of the more complex processes and lack of resources, some equipment and systems are not being maintained the way staff think it should or consistent with the licensees stated standards of excellence. The inspectors did not identify any CAP issues specifically related to the perceived complexity of work processes.

Several individuals interviewed stated that while the CAP worked for safety significant items, they believed it did not work for less significant items. Some individuals stated that the effectiveness of the program was impacted by the requirement to document all the issues. The inspectors noted that this issue had been previously identified and did not identify any issue that was not captured in the CAP.

b. Findings

No findings of significance were identified.

4OA6 Management Meetings

.1 Exit Meeting Summary

On August 9, 2013, the inspectors presented the inspection results to Mr. R. Lieb, Site Vice President, and other members of the licensee staff. The licensee acknowledged the issues presented. The inspectors confirmed that none of the potential report input discussed was considered proprietary.

ATTACHMENT:

SUPPLEMENTAL INFORMATION

KEY POINTS OF CONTACT

Licensee Personnel

R. Lieb, Site Vice President
T. Summers, Manager - Site Operations
G. Wolf, Supervisor - Regulatory Compliance
J. Sturdavant, Senior Specialist - Regulatory Compliance
P. McCloskey, Manager - Regulatory Compliance
D. Missig, Superintendent - Maintenance

NRC Personnel

P. Pelke, Acting Chief, Branch 6, Division of Reactor Projects
D. Kimble, Senior Resident Inspector

Attachment

LIST OF ITEMS

OPENED, CLOSED AND DISCUSSED

Opened

None

Closed

None Attachment

LIST OF DOCUMENTS REVIEWED