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{{Adams|number = ML093100139}}
{{Adams
| number = ML093100139
| issue date = 11/05/2009
| title = IR 05000255-09-007, on 08/31/09 - 09/25/09; Palisades Nuclear Plant. Inspection Procedure 95001 Supplemental Inspection
| author name = Boland A T
| author affiliation = NRC/RGN-III/DRS
| addressee name = Schwarz C J
| addressee affiliation = Entergy Nuclear Operations, Inc
| docket = 05000255
| license number = DPR-020
| contact person =
| case reference number = EA-09-349
| document report number = IR-09-007
| document type = Inspection Report, Letter
| page count = 21
}}


{{IR-Nav| site = 05000255 | year = 2009 | report number = 007 }}
{{IR-Nav| site = 05000255 | year = 2009 | report number = 007 }}


=Text=
=Text=
{{#Wiki_filter:
{{#Wiki_filter:UNITED STATES NUCLEAR REGULATORY COMMISSION REGION III 2443 WARRENVILLE ROAD, SUITE 210 LISLE, IL 60532-4352
[[Issue date::November 5, 2009]]


EA-09-349 Mr. Christopher Vice President Operations Entergy Nuclear Operations, Inc.
November 5, 2009


Palisades Nuclear Plant 27780 Blue Star Memorial Highway Covert, MI 49043-9530
EA-09-349 Mr. Christopher Vice President Operations
 
Entergy Nuclear Operations, Inc.
 
Palisades Nuclear Plant  
 
27780 Blue Star Memorial Highway  
 
Covert, MI 49043-9530


SUBJECT: PALISADES NUCLEAR PLANT NRC SUPPLEMENTAL (95001) INSPECTION REPORT 05000255/2009007
SUBJECT: PALISADES NUCLEAR PLANT NRC SUPPLEMENTAL (95001) INSPECTION REPORT 05000255/2009007


==Dear Mr. Schwarz:==
==Dear Mr. Schwarz:==
On September 25, 2009, the U.S. Nuclear Regulatory Commission (NRC) completed a supplemental inspection at your Palisades Nuclear Plant. The enclosed report documents the inspection results which were discussed on September 25, 2009, with you and members of your staff. The NRC performed this supplemental inspection consistent with the NRC Action Matrix due to a White performance issue in the Occupational Radiation Safety Cornerstone. Specifically, on January 30, 2009, the NRC issued its Final Significance Determination and a Notice of Violation (NRC Inspection Report 05000255/2008011(DRS)) for a White finding that involved failures by your staff to perform adequate radiological evaluations necessary to properly identify the radiological hazards to assess the dose for workers performing demobilization of fuel reconstitution equipment. The NRC staff was informed on August 12, 2009, of your staff's readiness for this inspection. This supplemental inspection utilized NRC Inspection Procedure 95001, "Inspection for One or Two White Inputs in a Strategic Performance Area," and was conducted to provide assurance that: (1) the root and contributing causes of the White performance issue were understood; (2) the extent of condition and extent of cause were identified; and (3) your corrective actions were sufficient to address the root causes and contributing causes and to prevent recurrence. The inspection was an examination of activities conducted under your license as they relate to safety and to compliance with the Commission's Rules and Regulations and with the conditions of your license. Within these areas, the inspection focused on your staff's evaluation of the White performance issue and consisted of a selective review of procedures, documents and representative records, observation of activities, and interviews of personnel.
On September 25, 2009, the U.S. Nuclear Regulatory Commission (NRC) completed a supplemental inspection at your Palisades Nuclear Plant. The enclosed report documents the  
 
inspection results which were discussed on September 25, 2009, with you and members of your  
 
staff. The NRC performed this supplemental inspection c onsistent with the NRC Action Matrix due to a White performance issue in the Occupational Radi ation Safety Cornerstone. Specifically, on January 30, 2009, the NRC issued its Final Significance Determination and a Notice of Violation (NRC Inspection Report 05000255/2008011(DRS)) for a White finding that involved failures by  
 
your staff to perform adequate radiological eval uations necessary to properly identify the radiological hazards to assess the dose for workers performing demobilization of fuel  
 
reconstitution equipment. The NRC staff was informed on August 12, 2009, of your staff's  
 
readiness for this inspection.
 
This supplemental inspection utilized NRC Inspection Procedure 95001, "Inspection for One or Two White Inputs in a Strategic Performance Area," and was conducted to provide assurance  
 
that: (1) the root and contributing causes of the White performance issue were understood;  
 
(2) the extent of condition and extent of cause were identified; and (3) your corrective actions  
 
were sufficient to address the root causes and contributing causes and to prevent recurrence.
 
The inspection was an examination of activities conducted under your license as they relate to safety and to compliance with the Commission's Rules and Regulations and with the conditions  
 
of your license. Within these areas, the inspection focused on your staff's evaluation of the  
 
White performance issue and consisted of a selective review of procedures, documents and  
 
representative records, observation of activities, and interviews of personnel.
 
C. Schwartz -2-
Your staff's evaluation identified that the root cause of the issue was a lack of radiation protection management and supervisory oversight of the work activity that led to low standards
 
and complacency. As a result, the radiological hazards were underestimated. Based on the
 
results of this inspection, no findings associated with your staff's evaluation of this performance
 
issue were identified. The inspectors determined that your root cause evaluation and
 
associated self-assessment for the White finding were conducted using systematic techniques
 
and adequately identified the root and contributory causes for the specific performance issue.
 
Corrective actions were developed to address the identified cause and contributors, which included improvements to the radiation work permi ts that govern reactor cavity and spent fuel pool work, development of a work instruction for high risk activities, and expanded staffing for
 
the radiation protection organization. We concluded that your corrective actions were adequate
 
to address the causes that were identified in your evaluation so as to prevent recurrence.
 
Therefore, consistent with NRC Manual Chapter 0305, "Operating Reactor Assessment
 
Program," this issue has been removed from c onsideration of future agency actions because four quarters has elapsed following our input of the original finding in the assessment program (i.e., the end of the third quarter 2009). Based on our assessment of your performance, as of
 
the end of the third quarter 2009, Palisades is in the licensee response band (Column 1) of the
 
Action Matrix.
 
However, during the course of our inspection ac tivities the inspectors identified one Severity Level IV Non-Cited Violation (NCV) for the failure to include information pertinent to worker


C. Schwartz -2- Your staff's evaluation identified that the root cause of the issue was a lack of radiation protection management and supervisory oversight of the work activity that led to low standards and complacency. As a result, the radiological hazards were underestimated. Based on the results of this inspection, no findings associated with your staff's evaluation of this performance issue were identified. The inspectors determined that your root cause evaluation and associated self-assessment for the White finding were conducted using systematic techniques and adequately identified the root and contributory causes for the specific performance issue. Corrective actions were developed to address the identified cause and contributors, which included improvements to the radiation work permits that govern reactor cavity and spent fuel pool work, development of a work instruction for high risk activities, and expanded staffing for the radiation protection organization. We concluded that your corrective actions were adequate to address the causes that were identified in your evaluation so as to prevent recurrence.
radiation exposures as documented on NRC Form 5s, as required by 10 CFR 50.9,  
"Completeness and Accuracy of Information." No cross-cutting aspects were identified with this


Therefore, consistent with NRC Manual Chapter 0305, "Operating Reactor Assessment Program," this issue has been removed from consideration of future agency actions because four quarters has elapsed following our input of the original finding in the assessment program (i.e., the end of the third quarter 2009). Based on our assessment of your performance, as of the end of the third quarter 2009, Palisades is in the licensee response band (Column 1) of the Action Matrix. However, during the course of our inspection activities the inspectors identified one Severity Level IV Non-Cited Violation (NCV) for the failure to include information pertinent to worker radiation exposures as documented on NRC Form 5s, as required by 10 CFR 50.9,
violation. Because the violation was of very low safety-significance, neither was it repetitive nor  
"Completeness and Accuracy of Information." No cross-cutting aspects were identified with this violation. Because the violation was of very low safety-significance, neither was it repetitive nor willful, and was entered into the Palisades' corrective action program, this violation is being treated as an NCV, in accordance with the NRC's Enforcement Policy. If you contest the NCV in this report, you should provide a response within 30 days of the date of this inspection report, with the basis for your denial, to the Nuclear Regulatory Commission, ATTN.:
Document Control Desk, Washington DC 20555-0001; with copies to the Regional Administrator, Region III; the Director, Office of Enforcement, United States Nuclear Regulatory Commission, Washington, DC 20555-0001; and the NRC Resident Inspector at the Palisades Nuclear Plant.


C. Schwartz -3- 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 System (PARS) component of NRC's Agencywide Documents Access and Management System (ADAMS), accessible from the NRC Web site at http://www.nrc.gov/reading-rm/adams.html (the Public Electronic Reading Room).
willful, and was entered into the Palisades' corrective action program, this violation is being
 
treated as an NCV, in accordance with the NRC's Enforcement Policy. If you contest the NCV
 
in this report, you should provide a response within 30 days of the date of this inspection report, with the basis for your denial, to the Nuclear Regulatory Commission, ATTN.:
 
Document Control Desk, Washington DC 20555-0001; with copies to the Regional
 
Administrator, Region III; the Director, Office of Enforcement, United States Nuclear Regulatory
 
Commission, Washington, DC 20555-0001; and the NRC Resident Inspector at the Palisades Nuclear Plant.
 
C. Schwartz -3-
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 av ailable electronically for public inspection in the NRC Public Document Room or from the Publicly Available Records System (PARS)
component of NRC's Agencywide Documents Access and Management System (ADAMS), accessible from the NRC Web site at http://www.nrc.gov/reading-rm/adams.html (the Public Electronic Reading Room).
 
Sincerely,/RA/


Sincerely,/RA/
Anne T. Boland, Director Division of Reactor Safety  
Anne T. Boland, Director Division of Reactor Safety  


Docket Nos. 50-255 License Nos. DPR-20  
Docket Nos. 50-255  
 
License Nos. DPR-20  


===Enclosure:===
===Enclosure:===
Line 35: Line 128:
Supplemental Information cc w/encl: Distribution via ListServ Enclosure U.S. NUCLEAR REGULATORY COMMISSION REGION III Dockets: 50-255 Licenses Nos.: DPR-20 Reports Nos.: 05000255/2009007 Licensee: Entergy Nuclear Operations Company, Inc.
Supplemental Information cc w/encl: Distribution via ListServ Enclosure U.S. NUCLEAR REGULATORY COMMISSION REGION III Dockets: 50-255 Licenses Nos.: DPR-20 Reports Nos.: 05000255/2009007 Licensee: Entergy Nuclear Operations Company, Inc.


Facility: Palisades Nuclear Plant Location: Covert, MI Dates: August 31 through September 25, 2009 Inspectors: J. Cassidy, Senior Health Physicist M. Phalen, Health Physicist J. Ellegood, Senior Resident Inspector Technical P. Lee, PhD, Health Physics Specialists: R. Pedersen, Senior Technical Advisor for NRR Health Physics Program Office Approved By: Wayne Slawinski, Branch Chief (Acting) Plant Support Team Division of Reactor Safety, RIII Enclosure 1
Facility: Palisades Nuclear Plant Location: Covert, MI Dates: August 31 through September 25, 2009 Inspectors: J. Cassidy, Senior Health Physicist M. Phalen, Health Physicist J. Ellegood, Senior Resident Inspector Technical P. Lee, PhD, Health Physics Specialists: R. Pedersen, Senior Technical Advisor for NRR Health Physics Program Office Approved By: Wayne Slawinski, Branch Chief (Acting) Plant Support Team Division of Reactor Safety, RIII Enclosure 1  


=SUMMARY OF FINDINGS=
=SUMMARY OF FINDINGS=
IR 05000255/2009007; 08/31/09 - 09/25/09; Palisades Nuclear Plant. Inspection Procedure 95001 Supplemental Inspection. The report covers a supplemental inspection performed by regional health physics inspectors, the Palisades Nuclear Plant senior resident inspector, and assistance from NRC regional and headquarters personnel. One Severity Level IV NCV of 10 CFR 50.9 was identified. The significance of most findings is indicated by their color (Green, White, Yellow, Red) using Inspection Manual Chapter 0609, "Significance Determination Process" (SDP). Cross-cutting aspects are determined using Inspection Manual Chapter 0305 "Operating Reactor Assessment Program."  Findings for which the SDP does not apply may be Green or assigned a severity level after NRC management review. 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.
IR 05000255/2009007; 08/31/09 - 09/25/09; Palisades Nuclear Plant. Inspection Procedure 95001 Supplemental Inspection.
 
The report covers a supplemental inspection performed by regional health physics inspectors, the Palisades Nuclear Plant senior resident inspector, and assistance from NRC regional and headquarters personnel. One Severity Level IV NCV of 10 CFR 50.9 was identified. The significance of most findings is indicated by their color (Green, White, Yellow, Red) using  
 
Inspection Manual Chapter 0609, "Significance Determination Process" (SDP). Cross-cutting aspects are determined using Inspection Manual Chapter 0305 "Operating Reactor Assessment  
 
Program."  Findings for which the SDP does not apply may be Green or assigned a severity level after NRC management review. 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.
 
===Cornerstone: Occupational Radiation Safety===
 
The NRC performed this supplemental inspection in accordance with inspection procedure (IP) 95001, "Inspection for One or Two White Inputs in a Strategic Performance Area," to assess the licensee's evaluation associated with the failure to perform adequate radiological evaluations necessary to properly identify the radiological hazards and to assess the dose for workers that received unanticipated dose rate alarms on their electronic dosimeters while performing demobilization of fuel reconstitution equipment in October 2007. The NRC staff previously characterized this issue as having low to moderate safety-significance (White) as documented in NRC Inspection Report 05000225/2008011(DRS). During this supplemental inspection, the inspectors determined that the licensee performed an adequate evaluation of the specific performance issue and that comprehensive corrective actions addressed each of the root and contributing causes. The licensee identified one root cause in that Palisades under-
 
estimated the extent of radiological hazards that were present during the demobilization of the equipment due to the "lack of radiation protec tion management and supervisory oversight. This led to:  (a) low standards; (b) mindset; and (c) complacency associated with the work activity."


===Cornerstone: Occupational Radiation Safety The NRC performed this supplemental inspection in accordance with inspection procedure (IP) 95001, "Inspection for One or Two ===
Additionally, two contributing causes were identified. Specifically, inadequate communications and insufficient supervisory radiation protection (RP) staff resource was devoted to the work.
White Inputs in a Strategic Performance Area," to assess the licensee's evaluation associated with the failure to perform adequate radiological evaluations necessary to properly identify the radiological hazards and to assess the dose for workers that received unanticipated dose rate alarms on their electronic dosimeters while performing demobilization of fuel reconstitution equipment in October 2007. The NRC staff previously characterized this issue as having low to moderate safety-significance (White) as documented in NRC Inspection Report 05000225/2008011(DRS). During this supplemental inspection, the inspectors determined that the licensee performed an adequate evaluation of the specific performance issue and that comprehensive corrective actions addressed each of the root and contributing causes. The licensee identified one root cause in that Palisades under-estimated the extent of radiological hazards that were present during the demobilization of the equipment due to the "lack of radiation protection management and supervisory oversight. This led to:  (a) low standards; (b) mindset; and (c) complacency associated with the work activity."


Additionally, two contributing causes were identified. Specifically, inadequate communications and insufficient supervisory radiation protection (RP) staff resource was devoted to the work. Corrective actions as documented in the root cause evaluation included:
Corrective actions as documented in the root cause evaluation included:
* Enhancement to Radiation Work Permits (RWPs) for Spent Fuel Pool (SFP) and reactor cavity work to require the use of extremity dosimetry for the removal of equipment from the water, unless waived in writing by the Radiation Protection Manager.
* Enhancement to Radiation Work Permits (RWPs) for Spent Fuel Pool (SFP) and reactor cavity work to require the use of extremity dosimetry for the removal of equipment from the water, unless waived in writing by the Radiation Protection Manager.
* Development of a Work instruction (WI) RSD-H-019 for High Risk Assessment and Supervisory Oversight.
* Development of a Work instruction (WI) RSD-H-019 for High Risk Assessment and Supervisory Oversight.


2* Implementation of Entergy fleet procedure EN-OP-116 for Infrequently Performed Test and Evolution.
2* Implementation of Entergy fleet procedure EN-OP-116 for Infrequently Performed Test and Evolution.
* Expanded RP staffing to meet the Entergy Standard level for qualified technicians and supervisors. The station also provided supplemental information to the NRC regarding additional actions that have been taken to ensure that there is an appropriate level of radiation protection management and supervisory oversight associated with radiologically significant work activities, including the reconstitution of damaged fuel. Based on the licensee's progress in evaluating and correcting the issues associated with the failures to perform adequate radiological evaluations necessary to properly identify the radiological hazards to assess the dose for workers performing demobilization of fuel reconstitution equipment that resulted in the White finding, this occupational radiation safety cornerstone performance issue will not be held open beyond the normal four quarters provided in NRC Manual Chapter 0305, "Operating Reactor Assessment Program." Findings Severity Level IV. The inspectors identified a Severity Level IV NCV of 10 CFR 50.9, "Completeness and Accuracy of Information."  The inspectors identified that the licensee, on April 17, 2008, submitted to the NRC inadequate NRC Form 5s, "Occupational Dose Record for a Monitoring Period" for three individuals that were involved in the demobilization of spent fuel reconstitution equipment in October 2007. The NRC Form 5s were not complete and accurate in all material respects. Specifically, the NRC Form 5s did not include pertinent information relative to the radiological implications to these individuals regarding their personal involvement in the demobilization of spent fuel reconstitution equipment under circumstances when the licensee's ability to assess the worker's dose was compromised. In particular, the NRC Form 5s failed to document the uncertainties associated with the workers' radiation doses, as was necessary in this instance consistent with the instructions on the Form 5. When the NRC questioned the licensee on the accuracy of these NRC Form 5 submittals, the licensee submitted revised NRC Form 5s. The violation was more than minor because the missing information was material to the NRC. Specifically, this information is used by the NRC in its evaluation of the risk of radiation exposure associated with the licensed activity and in exercising its statutory authority to monitor and regulate the safety and health practices of its licensees. This Severity Level IV violation is of very low safety-significance because if the information had been complete and accurate when reviewed by the NRC, it likely would not have resulted in a reconsideration of a regulatory position or substantial further inquiry, such as an additional inspection or a formal request for information. Because this violation was of very low safety-significance, neither was it repetitive nor willful, and was entered into the licensee's corrective action program [Condition Report (CR)-PLP-2009-04213], the violation is being treated as an NCV, consistent with the NRC Enforcement Policy. No cross-cutting aspects were identified with this violation. (Section 03.01)   
* Expanded RP staffing to meet the Entergy Standard level for qualified technicians and supervisors.
 
The station also provided supplemental information to the NRC regarding additional actions that have been taken to ensure that there is an appropriate level of radiation protection management and supervisory oversight associated with radiologically significant work activities, including the reconstitution of damaged fuel.
 
Based on the licensee's progress in evaluating and correcting the issues associated with the failures to perform adequate radiological evaluations necessary to properly identify the radiological hazards to assess the dose for workers performing demobilization of fuel reconstitution equipment that resulted in the White finding, this occupational radiation safety cornerstone performance issue will not be held open beyond the normal four quarters provided in NRC Manual Chapter 0305, "Operating Reactor Assessment Program."
 
Findings Severity Level IV. The inspectors identified a Severity Level IV NCV of 10 CFR 50.9, "Completeness and Accuracy of Information."  The inspectors identified that the licensee, on April 17, 2008, submitted to the NRC inadequate NRC Form 5s, "Occupational Dose Record for a Monitoring Period" for three individuals that were involved in the demobilization of spent fuel reconstitution equipment in October 2007. The NRC Form 5s were not complete and accurate in all material respects. Specifically, the NRC Form 5s did not include pertinent information relative to the radiological implications to these individuals regarding their personal involvement in the demobilization of spent fuel reconstitution equipment under circumstances when the licensee's ability to assess the worker's dose was compromised. In particular, the NRC  
 
Form 5s failed to document the uncertainties associated with the workers' radiation doses, as was necessary in this instance consistent with the instructions on the Form 5. When the NRC questioned the licensee on the accuracy of these NRC Form 5 submittals, the licensee submitted revised NRC Form 5s.
 
The violation was more than minor because the missing information was material to the NRC.
 
Specifically, this information is used by the NRC in its evaluation of the risk of radiation exposure associated with the licensed activity and in exercising its statutory authority to monitor and regulate the safety and health practices of its licensees. This Severity Level IV violation is of very low safety-significance because if the information had been complete and accurate when reviewed by the NRC, it likely would not have resulted in a reconsideration of a regulatory position or substantial further inquiry, such as an additional inspection or a formal request for information. Because this violation was of very low safety-significance, neither was it repetitive nor willful, and was entered into the licensee's corrective action program [Condition Report (CR)-PLP-2009-04213], the violation is being treated as an NCV, consistent with the NRC  
 
Enforcement Policy. No cross-cutting aspects were identified with this violation. (Section 03.01)   


3
3


=REPORT DETAILS=
=REPORT DETAILS=
01. Inspection Scope The NRC staff performed this supplemental inspection in accordance with IP 95001 to assess the licensee's evaluation of a (White) finding, which affected the occupational radiation safety cornerstone in the radiation safety strategic performance area. The inspection objectives were to:
 
01. Inspection Scope The NRC staff performed this supplemental inspection in accordance with IP 95001 to assess the licensee's evaluation of a (White) finding, which affected the occupational  
 
radiation safety cornerstone in the radiation safety strategic performance area. The  
 
inspection objectives were to:
* provide assurance that the root and contributing causes of risk-significant issues were understood;
* provide assurance that the root and contributing causes of risk-significant issues were understood;
* provide assurance that the extent of condition and extent of cause of risk-significant issues were identified; and
* provide assurance that the extent of condition and extent of cause of risk-significant issues were identified; and
* provide assurance that the licensee's corrective actions for risk-significant issues were or will be sufficient to address the root and contributing causes to preclude repetition. The licensee entered the Regulatory Response Column of the NRC's Action Matrix in the fourth quarter of 2008 as a result of one inspection finding of low to moderate safety-significance (White). On October 04, 2007, during the demobilization of fuel reconstitution equipment, three supplemental employees received unanticipated dose rate alarms. The licensee's response to these alarms did not adequately recognize and assess the radiological hazards. As a result, the internal and extremity radiation doses for the involved employees could not be accurately determined. A preliminary White finding, Apparent Violation (AV) 05000255/2008011-01, was issued in inspection report 05000255/2008011. A final White finding, based on the results of radiological risk in accordance with the occupational radiation safety-significance determination process, was issued with a Notice of Violation (NOV) in a letter dated January 30, 2009. The licensee informed the NRC staff that they were ready for the supplemental inspection on August 12, 2009. The licensee performed a root cause evaluation (RCE),
* provide assurance that the licensee's corrective actions for risk-significant issues were or will be sufficient to address the root and contributing causes to preclude  
CR-PLP-2008-05200, Revision 01, to identify the direct and contributing causes and also causal factors, which allowed for the risk-significant finding and to determine the organizational attributes that resulted in the White finding. The licensee also addressed safety culture in the RCE. The inspectors reviewed the licensee's RCE, as well as other evaluations conducted in support and as a result of the RCE. The inspectors reviewed corrective actions that were taken or planned to address the identified causes. The inspectors also held discussions with licensee personnel to ensure that the root and contributing causes and the contribution of safety culture components were understood and corrective actions taken or planned were appropriate to address the causes and preclude repetition.
 
repetition.
 
The licensee entered the Regulatory Response Column of the NRC's Action Matrix in the fourth quarter of 2008 as a result of one inspection finding of low to moderate  
 
safety-significance (White). On October 04, 2007, during the demobilization of fuel  
 
reconstitution equipment, three supplemental employees received unanticipated dose rate  
 
alarms. The licensee's response to these alarms did not adequately recognize and  
 
assess the radiological hazards. As a result, the internal and extremity radiation doses for  
 
the involved employees could not be accurately determined. A preliminary White finding, Apparent Violation (AV) 05000255/2008011-01, was issued in inspection report  
 
05000255/2008011. A final White finding, based on the results of radiological risk in  
 
accordance with the occupational radiation safety-significance determination process, was  
 
issued with a Notice of Violation (NOV) in a letter dated January 30, 2009.
 
The licensee informed the NRC staff that they were ready for the supplemental inspection on August 12, 2009. The licensee performed a root cause evaluation (RCE),
CR-PLP-2008-05200, Revision 01, to identify the direct and contributing causes and also causal factors, which allowed for the risk-significant finding and to determine the  
 
organizational attributes that resulted in the White finding. The licensee also addressed  
 
safety culture in the RCE.
 
The inspectors reviewed the licensee's RCE, as well as other evaluations conducted in support and as a result of the RCE. The inspectors reviewed corrective actions that were  
 
taken or planned to address the identified causes. The inspectors also held discussions  
 
with licensee personnel to ensure that the root and contributing causes and the  
 
contribution of safety culture components were understood and corrective actions taken or  
 
planned were appropriate to address the causes and preclude repetition.


402. Evaluation of Inspection Requirements 02.01 Problem Identification a. Inspection Procedure 95001 requires that the inspection staff determine that the licensee's evaluation of the issue documents who identified the issue (i.e.,
402. Evaluation of Inspection Requirements 02.01 Problem Identification a. Inspection Procedure 95001 requires that the inspection staff determine that the licensee's evaluation of the issue documents who identified the issue (i.e.,
licensee-identified, self-revealing, or NRC-identified) and the conditions under which the issue was identified. This issue of inadequate response to electronic dosimeter alarms because the licensee's radiation safety staff did not adequately recognize and assess the radiological hazards associated with the three supplemental employees receiving unanticipated dose rate alarms was identified by regional NRC health physics staff as a part of the baseline inspection program. The issue is documented in several records within the licensee's corrective action program, including the licensee's RCE. b. Inspection Procedure 95001 requires that the inspection staff determine that the licensee's evaluation of the issue documents how long the issue existed and prior opportunities for identification. During the conduct of the root cause evaluation, the licensee reviewed the radiological circumstances associated with this event. Additionally, the licensee reviewed its corrective action and work control databases for similar type issues specific to inadequate radiological evaluations that led to the failure to identify radiological hazards of regulatory significance. However, there was a significant time lapse from the time the NRC identified the event to completion of the licensee's evaluation.
licensee-identified, self-revealing, or NRC-identified) and the conditions under which  
 
the issue was identified.
 
This issue of inadequate response to electronic dosimeter alarms because the licensee's radiation safety staff did not adequately recognize and assess the  
 
radiological hazards associated with the three supplemental employees receiving  
 
unanticipated dose rate alarms was identified by regional NRC health physics staff as  
 
a part of the baseline inspection program. The issue is documented in several records  
 
within the licensee's corrective action program, including the licensee's RCE.
 
b. Inspection Procedure 95001 requires that the inspection staff determine that the licensee's evaluation of the issue documents how long the issue existed and prior  
 
opportunities for identification.
 
During the conduct of the root cause evaluation, the licensee reviewed the radiological circumstances associated with this event. Additionally, the licensee reviewed its  
 
corrective action and work control databases for similar type issues specific to  
 
inadequate radiological evaluations that led to the failure to identify radiological  
 
hazards of regulatory significance. However, there was a significant time lapse from  
 
the time the NRC identified the event to completion of the licensee's evaluation.
 
Additionally, the licensee missed several opportunities to self-identify the issue. A
 
comprehensive review of the issue began after prompting by NRC inspectors. c. Inspection Procedure 95001 requires that the inspection staff determine that the licensee's evaluation documents the plant specific risk consequences, as applicable, and compliance concerns associated with the issue.
 
A plant specific probabilistic risk-assessment is not applicable to this issue. However, the licensee did evaluate the occupational external exposures and bounded the
 
shallow dose equivalent, with uncertainties, given the limited initial radiological data
 
that was available. The licensee indicated that a more thorough dose evaluation
 
including internal dose from alpha radiation would be performed. This action is tracked
 
as CR-PLP-2009-4555. 02.02 Root Cause, Extent of Condition, and Extent of Cause Evaluation a. Inspection Procedure 95001 requires that the inspection staff determine that the licensee evaluated the issue using a systematic methodology to identify the root and


Additionally, the licensee missed several opportunities to self-identify the issue. A comprehensive review of the issue began after prompting by NRC inspectors. c. Inspection Procedure 95001 requires that the inspection staff determine that the licensee's evaluation documents the plant specific risk consequences, as applicable, and compliance concerns associated with the issue. A plant specific probabilistic risk-assessment is not applicable to this issue. However, the licensee did evaluate the occupational external exposures and bounded the shallow dose equivalent, with uncertainties, given the limited initial radiological data that was available. The licensee indicated that a more thorough dose evaluation including internal dose from alpha radiation would be performed. This action is tracked as CR-PLP-2009-4555. 02.02 Root Cause, Extent of Condition, and Extent of Cause Evaluation a. Inspection Procedure 95001 requires that the inspection staff determine that the licensee evaluated the issue using a systematic methodology to identify the root and contributing causes. The licensee conducted a root cause analysis of the performance issue, which was later supplemented with an extent of cause review during the licensee's Focused Area Self-Assessment. The licensee used Procedure EN-LI-118, "Root Cause Analysis Process," Revision 11, and other implementing procedures to evaluate these issues.
contributing causes.


These procedures included such analysis tools as Event and Causal Factor Charting, 5Change Analysis, Barrier Analysis, Causal Factor Trending, and Human Performance Error Reviews. The inspectors evaluated the root cause evaluation report against the requirements of the licensee's procedures and determined that the evaluations performed followed the administrative procedure requirements.
The licensee conducted a root cause analysis of the performance issue, which was later supplemented with an extent of cause review during the licensee's Focused Area


The inspectors concluded that systematic methods were used to identify the root cause and contributing cause. b. Inspection Procedure 95001 requires that the inspection staff determine that the licensee's RCE was conducted to a level of detail commensurate with the significance of the issue. The inspectors concluded that the root cause evaluation had identified and assessed the potential contributors to the decrease in performance in sufficient detail to identify appropriate corrective actions. Although acceptable, the inspectors concluded that the RCE missed opportunities that would have been beneficial to identify the full extent of the issue, as described below. Root Cause The licensee identified one root cause in its evaluation, in that Palisades underestimated the extent of radiological hazards during the demobilization following fuel reconstitution due to the "lack of radiation protection management and supervisory oversight. This led to:  (a) low standards; (b) mindset; and (c) complacency associated with the reconstitution of severely damaged fuel."  Contributing Causes Additionally, two contributing causes were identified.
Self-Assessment. The licensee used Procedure EN-LI-118, "Root Cause Analysis Process," Revision 11, and other implementing procedures to evaluate these issues.


===1. Inadequate communications as evidenced by the following:
These procedures included such analysis tools as Event and Causal Factor Charting, 5 Change Analysis, Barrier Analysis, Causal Factor Trending, and Human Performance Error Reviews. The inspectors evaluated the root cause evaluation report against the
* Communications between the RP technician and the contract workers led the contract workers to believe that they could disassemble the temporary storage ===
 
requirements of the licensee's procedures and determined that the evaluations
 
performed followed the administrative procedure requirements.
 
The inspectors concluded that systematic methods were used to identify the root cause and contributing cause. b. Inspection Procedure 95001 requires that the inspection staff determine that the licensee's RCE was conducted to a level of detail commensurate with the significance
 
of the issue.
 
The inspectors concluded that the root cause evaluation had identified and assessed the potential contributors to the decrease in performance in sufficient detail to identify
 
appropriate corrective actions. Although acceptable, the inspectors concluded that the
 
RCE missed opportunities that would have been beneficial to identify the full extent of
 
the issue, as described below.
 
Root Cause The licensee identified one root cause in its evaluation, in that Palisades underestimated the extent of radiological hazards during the demobilization
 
following fuel reconstitution due to the "lack of radiation protection management
 
and supervisory oversight. This led to:  (a) low standards; (b) mindset; and (c) complacency associated with the reconstitution of severely damaged fuel."
 
Contributing Causes Additionally, two contributing causes were identified.
 
===1. Inadequate communications as evidenced by the following: ===
* Communications between the RP technician and the contract workers led the contract workers to believe that they could disassemble the temporary storage  


baskets without the RP technician being present.
baskets without the RP technician being present.
* Communications between reactor engineering, RP management, and other members of the Palisades staff did not adequately alert the organization, including the condition review group and corrective action review board personnel, of the potential contamination and exposure problems associated with damaged fuel. 2. Insufficient supervisory RP staff resources available to provide needed supervision and oversight. The inspectors identified that the RCE was acceptable but was narrow in scope, in that the terminal objective identified in the root cause evaluation drove the extent of condition review. Specifically, the root cause evaluation truncated at the point where the RP staff failed to recognize and assess the radiological hazards after responding to the unanticipated dose rate alarms. The inspection team observed that there was a missed opportunity to obtain pertinent information relevant to why the RP staff failed to 6recognize the radiological hazards. Through means independent of the RCE, the NRC discovered several additional facts which were not explored by the licensee's root cause team. First, at the time of the initial incident, the need to perform extremity dose assessments was brought to the attention of several members of the RP staff, including the RP Manager. However, the licensee's root cause team did not explore why no follow-up actions occurred despite the licensee's knowledge of this issue.
* Communications between reactor engineering, RP management, and other members of the Palisades staff did not adequately alert the organization, including the condition review group and corrective action review board  
 
personnel, of the potential contamination and exposure problems associated  
 
with damaged fuel. 2. Insufficient supervisory RP staff resources available to provide needed supervision and oversight.
 
The inspectors identified that the RCE was acceptable but was narrow in scope, in that the terminal objective identified in the root cause evaluation drove the extent of  


Second, the presence of high energy beta and alpha emitting isotopes on the refueling floor, as well as elevated alpha to beta/gamma ratios, were being identified to senior RP staff, including the RP Manager at the time the event occurred. The inspectors also identified that alpha ratios were anomalous to industry norms. Lastly, the NRC learned that there may have been additional data available to Palisades near the time of the event occurrence relative to the spacer pins. Specifically, the inspectors were informed that persons had opened the tool box while it was under quarantine on the refuel floor and this activity could have provided information to aid in worker dose reconstructions. c. Inspection Procedure 95001 requires that the inspection staff determine that the licensee's RCE included a consideration of prior occurrences of the issue and knowledge of operating experience (OE). The RCE included an historical review of the licensee's corrective action and work control databases and did not document any similar type issues associated with inadequate radiological evaluations that led to the failure to identify radiological hazards of regulatory significance. The RCE conducted a review of previous industry events. This review did not identify any directly related issues.
condition review. Specifically, the root cause evaluation truncated at the point where


The inspectors concluded that, in general, the licensee's root cause evaluation appropriately considered both internal and external operating experience. The evaluation assessed the licensee's previous lack of recognition, evaluation, and timely mitigation of radiological events. d. Inspection Procedure 95001 requires that the inspection staff determine that the licensee's RCE addresses the extent of condition and extent of cause of the issue(s). The licensee's evaluations considered the potential for common cause and extent of condition for each of the identified root causes. Additionally, the licensee evaluated radiation protection department and other department responses to unanticipated alarm conditions. The inspectors concluded that the extent of condition and extent of cause reviews performed by the licensee were adequate. e. Inspection Procedure 95001 requires that the inspection staff determine that the licensee's root cause, extent of condition, and extent of cause evaluations appropriately considered the safety culture components as described in IMC 0305. The inspectors concluded that the current safety culture aspect associated with this issue was appropriately considered in the licensee's RCE and included consideration of whether a weakness in any safety culture component was a root cause or a significant contributing cause of the issue.
the RP staff failed to recognize and assess the radiological hazards after responding to  


702.03 Corrective Actions a. Inspection Procedure 95001 requires that the inspection staff determines that:  (1) the licensee specified appropriate corrective actions for each root and/or contributing cause; or (2) an evaluation that states no actions are necessary is adequate. Corrective actions were developed to address the identified causes and the contributors so as to prevent recurrence of the performance issue. Corrective actions as documented in the root cause evaluation included:
the unanticipated dose rate alarms. The inspection team observed that there was a
* Enhancements to Radiation Work Permits for SFP and Reactor Cavity work to require the use of extremity dosimetry for the removal of equipment from the water, unless waived in writing by the Radiation Protection Manager.
 
missed opportunity to obtain pertinent information relevant to why the RP staff failed to 6 recognize the radiological hazards. Through means independent of the RCE, the NRC discovered several additional facts which were not explored by the licensee's root
 
cause team. First, at the time of the initial incident, the need to perform extremity dose
 
assessments was brought to the attention of several members of the RP staff, including the RP Manager. However, the licensee's root cause team did not explore
 
why no follow-up actions occurred despite the licensee's knowledge of this issue.
 
Second, the presence of high energy beta and alpha emitting isotopes on the refueling
 
floor, as well as elevated alpha to beta/gamma ratios, were being identified to senior
 
RP staff, including the RP Manager at the time the event occurred. The inspectors
 
also identified that alpha ratios were anomalous to industry norms. Lastly, the NRC
 
learned that there may have been additional data available to Palisades near the time
 
of the event occurrence relative to the spacer pins. Specifically, the inspectors were
 
informed that persons had opened the tool box while it was under quarantine on the
 
refuel floor and this activity could have provided information to aid in worker dose
 
reconstructions. c. Inspection Procedure 95001 requires that the inspection staff determine that the licensee's RCE included a consideration of prior occurrences of the issue and
 
knowledge of operating experience (OE).
 
The RCE included an historical review of the licensee's corrective action and work control databases and did not document any similar type issues associated with
 
inadequate radiological evaluations that led to the failure to identify radiological
 
hazards of regulatory significance. The RCE conducted a review of previous industry events. This review did not identify any directly related issues.
 
The inspectors concluded that, in general, the licensee's root cause evaluation appropriately considered both internal and external operating experience. The
 
evaluation assessed the licensee's previous lack of recognition, evaluation, and timely
 
mitigation of radiological events. d. Inspection Procedure 95001 requires that the inspection staff determine that the licensee's RCE addresses the extent of condition and extent of cause of the issue(s).
 
The licensee's evaluations considered the potential for common cause and extent of condition for each of the identified root causes. Additionally, the licensee evaluated
 
radiation protection department and other department responses to unanticipated
 
alarm conditions.
 
The inspectors concluded that the extent of condition and extent of cause reviews performed by the licensee were adequate. e. Inspection Procedure 95001 requires that the inspection staff determine that the licensee's root cause, extent of condition, and extent of cause evaluations
 
appropriately considered the safety culture components as described in IMC 0305.
 
The inspectors concluded that the current safety culture aspect associated with this issue was appropriately considered in the licensee's RCE and included consideration
 
of whether a weakness in any safety culture component was a root cause or a
 
significant contributing cause of the issue.
 
702.03 Corrective Actions a. Inspection Procedure 95001 requires that the inspection staff determines that:   
(1) the licensee specified appropriate corrective actions for each root and/or  
 
contributing cause; or (2) an evaluation that states no actions are necessary is  
 
adequate. Corrective actions were developed to address the identified causes and the contributors so as to prevent recurrence of the performance issue. Corrective  
 
actions as documented in the root cause evaluation included:
* Enhancements to Radiation Work Permits for SFP and Reactor Cavity work to require the use of extremity dosimetry for the removal of equipment from  
 
the water, unless waived in writing by the Radiation Protection Manager.
* Development of a Work Instruction (WI) RSD-H-019 for High Risk Assessment and Supervisory Oversight.
* Development of a Work Instruction (WI) RSD-H-019 for High Risk Assessment and Supervisory Oversight.
* Implementation of Entergy fleet procedure EN-OP-116 for Infrequently Performed Test and Evolutions.
* Implementation of Entergy fleet procedure EN-OP-116 for Infrequently Performed Test and Evolutions.
* Expanded RP staffing to meet the Entergy Standard level for qualified technicians and supervisors. The licensee also provided supplemental information to the NRC regarding additional actions that have been taken to ensure that there is an appropriate level of radiation protection management and supervisory oversight associated with radiologically significant work activities, including responses to unanticipated electronic dosimeter alarms and work associated with the reconstitution of severely damaged fuel. The inspectors determined that the corrective actions taken were appropriate for the associated causes. b. Inspection Procedure 95001 requires that the inspection staff determine that the licensee prioritized corrective actions with consideration of risk significance and regulatory compliance.
* Expanded RP staffing to meet the Entergy Standard level for qualified technicians and supervisors.
 
The licensee also provided supplemental information to the NRC regarding additional actions that have been taken to ensure that there is an appropriate level  
 
of radiation protection management and supervisory oversight associated with  
 
radiologically significant work activities, including responses to unanticipated  
 
electronic dosimeter alarms and work associated with the reconstitution of  
 
severely damaged fuel.
 
The inspectors determined that the corrective actions taken were appropriate for the associated causes. b. Inspection Procedure 95001 requires that the inspection staff determine that the licensee prioritized corrective actions with consideration of risk significance and  
 
regulatory compliance.
 
The workers involved exited the plant after receiving Dose Rate Alarms, reporting to RP Supervision at Access Control. The RP staff then restricted access for the
 
workers, in accordance with station procedures. Follow-up radiological surveys
 
were performed and administrative controls were put in place prior to resuming
 
work on the refueling floor. An RP standard for Continuous RP Coverage was
 
implemented for removal of items from the Spent Fuel Pool and a site-wide
 
communication was issued regarding this event and the requirement to have
 
continuous coverage for removal of items from the Spent Fuel Pool.


The workers involved exited the plant after receiving Dose Rate Alarms, reporting to RP Supervision at Access Control. The RP staff then restricted access for the workers, in accordance with station procedures. Follow-up radiological surveys were performed and administrative controls were put in place prior to resuming work on the refueling floor. An RP standard for Continuous RP Coverage was implemented for removal of items from the Spent Fuel Pool and a site-wide communication was issued regarding this event and the requirement to have continuous coverage for removal of items from the Spent Fuel Pool. Additionally, the station implemented long term corrective actions that included means to ensure there was an appropriate level of radiation protection management and supervisory oversight associated with radiologically significant work activities on the refuel floor, including the reconstitution of severely damaged fuel.
Additionally, the station implemented long term corrective actions that included means to ensure there was an appropriate level of radiation protection  


8The inspectors considered the prioritization of the established corrective actions to be appropriate. c. Inspection Procedure 95001 requires that the inspection staff determine that the licensee established a schedule for implementing and completing the corrective actions. The licensee established adequate schedules for the completion of the specified corrective actions. The majority of the corrective actions had been completed prior to this inspection, and the remaining corrective actions were on schedule for completion. The inspectors reviewed the completed corrective actions and concluded that they had been generally implemented in a timely and effective manner. The inspectors did not identify any concerns with the scheduling or completion of corrective actions. d. Inspection Procedure 95001 requires that the inspection staff determine that the licensee developed quantitative and/or qualitative measures of success for determining the effectiveness of the corrective actions to preclude repetition. The licensee developed a means to validate the effectiveness of its corrective actions for the performance deficiency. However, the inspectors questioned the adequacy of certain performance measures. The inspection team reviewed the licensee's proposed effectiveness reviews in detail and concluded that some of the proposed reviews were narrowly focused. Specifically, the licensee planned to review the effectiveness of radiological controls for EN-RP-123 "Radiological Controls for Highly Radioactive Objects" through Snap Shot Self-Assessments for Spent Fuel Pool and Reactor Cavity Work. The NRC concluded that although the root cause of the event was a lack of RP management and supervisory oversight, the effectiveness review did not include an assessment of RP management and supervisory oversight of all radiologically significant work at the station, only work that occurs on the refuel floor. Additionally, the NRC communicated to the licensee that its focus did not include station response to other unanticipated radiological alarms, including electronic dosimeters, area radiation monitors, liquid and air effluent monitors, continuous air monitors, etc. The licensee agreed to re-evaluate the comprehensiveness of the effectiveness review performance measures. Condition Report CR-PLP-2009-04543 was generated by the licensee to address this issue. e. Inspection Procedure 95001 requires that the inspection staff determine that the licensee's planned or taken corrective actions adequately address a Notice of Violation (NOV) that was the basis for the supplemental inspection, if applicable.
management and supervisory oversight associ ated with radiologically significant work activities on the refuel floor, including the reconstitution of severely damaged


The NRC issued its final significance determination and Notice of Violation (05000255/2008011-01), Failure to Assess Dose to Three Workers after a Known Change in Radiological Conditions Near the Spent Fuel Pool) to the licensee on January 30, 2009. The NRC concluded that information regarding the reason for the violation, the corrective actions taken and planned to correct the violation and prevent recurrence, and full compliance has been achieved. The NRC staff did not require a response to the NOV from the licensee; therefore, this inspection requirement was not applicable.
fuel.


903 OTHER ISSUES 03.01 (Open/Closed) Violations (VIO) 050000255/2009007-01
8 The inspectors considered the prioritization of the established corrective actions to be appropriate. c. Inspection Procedure 95001 requires that the inspection staff determine that the licensee established a schedule for implementing and completing the corrective
 
actions.
 
The licensee established adequate schedules for the completion of the specified corrective actions. The majority of the corrective actions had been completed
 
prior to this inspection, and the remaining corrective actions were on schedule for
 
completion. The inspectors reviewed the completed corrective actions and
 
concluded that they had been generally im plemented in a timely and effective manner. The inspectors did not identify any concerns with the scheduling or
 
completion of corrective actions. d. Inspection Procedure 95001 requires that the inspection staff determine that the licensee developed quantitative and/or qualitative measures of success for
 
determining the effectiveness of the corrective actions to preclude repetition.
 
The licensee developed a means to validate the effectiveness of its corrective actions for the performance deficiency. However, the inspectors questioned the
 
adequacy of certain performance measures. The inspection team reviewed the
 
licensee's proposed effectiveness reviews in detail and concluded that some of
 
the proposed reviews were narrowly focused. Specifically, the licensee planned
 
to review the effectiveness of radiological controls for EN-RP-123 "Radiological
 
Controls for Highly Radioactive Objects" through Snap Shot Self-Assessments for
 
Spent Fuel Pool and Reactor Cavity Work. The NRC concluded that although the
 
root cause of the event was a lack of RP management and supervisory oversight, the effectiveness review did not include an assessment of RP management and
 
supervisory oversight of all radiologically significant work at the station, only work
 
that occurs on the refuel floor. Additionally, the NRC communicated to the
 
licensee that its focus did not include station response to other unanticipated
 
radiological alarms, including electronic dosimeters, area radiation monitors, liquid
 
and air effluent monitors, continuous air monitors, etc.
 
The licensee agreed to re-evaluate the comprehensiveness of the effectiveness review performance measures. Condition Report CR-PLP-2009-04543 was
 
generated by the licensee to address this issue.
 
e. Inspection Procedure 95001 requires that the inspection staff determine that the licensee's planned or taken corrective actions adequately address a Notice of
 
Violation (NOV) that was the basis for the supplemental inspection, if applicable.
 
The NRC issued its final significance determination and Notice of Violation (05000255/2008011-01), Failure to Assess Dose to Three Workers after a Known
 
Change in Radiological Conditions Near the Spent Fuel Pool) to the licensee on
 
January 30, 2009. The NRC concluded that information regarding the reason for
 
the violation, the corrective actions taken and planned to correct the violation and
 
prevent recurrence, and full compliance has been achieved. The NRC staff did
 
not require a response to the NOV from the licensee; therefore, this inspection
 
requirement was not applicable.
 
9 03 OTHER ISSUES 03.01 (Open/Closed) Violations (VIO) 050000255/2009007-01


====a. Inspection Scope====
====a. Inspection Scope====
The inspectors assessed the radiological controls for work areas having a history of, or the potential for, airborne transuranics. Additionally, the inspectors assessed the adequacy of the licensee's extremity and internal dose assessment processes, and the regulatory required documentation associated with those assessments.
The inspectors assessed the radiological controls for work areas having a history of, or the potential for, airborne transuranics. Additionally, the inspectors assessed the  
 
adequacy of the licensee's extremity and internal dose assessment processes, and the  
 
regulatory required documentation associated with those assessments.


====b. Findings====
====b. Findings====
Introduction
:  The inspectors identified a violation of 10 CFR 50.9 "Completeness and Accuracy of Information," in that the licensee submitted to the NRC an NRC Form 5, "Occupational Dose Record for a Monitoring Period," that is required to comply with
10 CFR 20.2106, "Records of Individual Monitoring Results," for three individuals
that were involved in the demobilization of spent fuel reconstitution equipment in
October 2007. Specifically, the NRC Form 5s were not complete and accurate in all
material respects by omitting data relevant to the worker's radiation exposures.
Description
:  The NRC Form 5s completed for the workers involved in the October 2007 incident, involving demobilization of fuel reconstitution equipment did not
include pertinent information relative to the radiological implications to these
individuals regarding their personal involvement in these work activities under
circumstances when the licensee's ability to assess the worker's dose was
compromised. Specifically, the licensee failed to document the uncertainties in the
worker dose estimates as was necessary for these circumstances, consistent with
the instructions for the NRC Form 5. When the NRC questioned the licensee on the
accuracy of these NRC Form 5 submittals, the licensee submitted revised NRC
Form 5s on September 29, 2009. The revised NRC Form 5s included reference to


=====Introduction:=====
NRC inspection reports that are publicly available, such that the involved individuals
The inspectors identified a violation of 10 CFR 50.9 "Completeness and Accuracy of Information," in that the licensee submitted to the NRC an NRC Form 5,
"Occupational Dose Record for a Monitoring Period," that is required to comply with 10 CFR 20.2106, "Records of Individual Monitoring Results," for three individuals that were involved in the demobilization of spent fuel reconstitution equipment in October 2007. Specifically, the NRC Form 5s were not complete and accurate in all material respects by omitting data relevant to the worker's radiation exposures.


=====Description:=====
would be cognizant of the circumstances surrounding their personal radiation  
The NRC Form 5s completed for the workers involved in the October 2007 incident, involving demobilization of fuel reconstitution equipment did not include pertinent information relative to the radiological implications to these individuals regarding their personal involvement in these work activities under circumstances when the licensee's ability to assess the worker's dose was compromised. Specifically, the licensee failed to document the uncertainties in the worker dose estimates as was necessary for these circumstances, consistent with the instructions for the NRC Form 5. When the NRC questioned the licensee on the accuracy of these NRC Form 5 submittals, the licensee submitted revised NRC Form 5s on September 29, 2009. The revised NRC Form 5s included reference to NRC inspection reports that are publicly available, such that the involved individuals would be cognizant of the circumstances surrounding their personal radiation exposures.  
 
exposures.


=====Analysis:=====
=====Analysis:=====
The inspectors determined that the failure to include all pertinent information on NRC Form 5s was a performance deficiency because licensees are required to adhere to the regulations of 10 CFR Part 20. The inspectors concluded that the cause of the deficiency was reasonably within the licensee's ability to foresee and correct.
The inspectors determined that the failure to include all pertinent information on NRC Form 5s was a performance deficiency because licensees are required to  
 
adhere to the regulations of 10 CFR Part 20. The inspectors concluded that the cause  
 
of the deficiency was reasonably within the licensee's ability to foresee and correct.
 
The violation was subject to traditional enforcement because it potentially impacted the
 
NRC's ability to perform its regulatory function and was more than minor because the
 
missing information was material to the NRC. Specifically, this information is used by
 
the NRC in its evaluation of the risk of radiation exposure associated with the licensed
 
activity and in exercising its statutory authority to monitor and regulate the safety and
 
health practices of its licensees. This violation is a Severity Level IV violation of very
 
low safety-significance because if the information had been complete and accurate
 
when reviewed by the NRC, it likely would not have resulted in a reconsideration of a
 
regulatory position or substantial further inquiry, such as an additional inspection or a
 
formal request for information. No cross-cutting aspects were identified with this
 
violation.
 
10 Enforcement
:  During the NRC inspection, a violation of NRC requirements was identified. Title 10 CFR 50.9 "Completeness and Accuracy of Information," requires in
 
part, that information provided to the Commission by an applicant for a license, or by a
 
licensee or information required by statute or by the Commission's regulations, Orders, or license conditions to be maintained by the applicant or the licensee, is complete and
 
accurate in all material respects. Title 10 CFR 20.2106 "Records of Individual
 
Monitoring Results" requires in part, that the licensee shall maintain records of doses
 
received by all individuals for whom monitoring was required, pursuant to 10 CFR
 
20.1502. Additionally, the licensee shall maintain these records on NRC Form 5, in
 
accordance with the instructions for NRC Form 5, which require additional information
 
is included, which may be necessary to determine compliance with limits.
 
Contrary to the above, on April 17, 2008, the licensee provided information to the NRC that was not complete and accurate in all material respects. Specifically, the licensee
 
submitted to the NRC inadequate NRC Form 5s, "Occupational Dose Record for a
 
Monitoring Period" for three individuals that were involved in the demobilization of
 
spent fuel reconstitution equipment in October 2007. The NRC Form 5s were not
 
complete and accurate in all material respects in that, the NRC Form 5s did not
 
include pertinent information relative to the radiological implications to these
 
individuals regarding their personal involvement in the demobilization of spent fuel
 
reconstitution equipment under circumstances when the licensee's ability to assess


The violation was subject to traditional enforcement because it potentially impacted the NRC's ability to perform its regulatory function and was more than minor because the missing information was material to the NRC. Specifically, this information is used by the NRC in its evaluation of the risk of radiation exposure associated with the licensed activity and in exercising its statutory authority to monitor and regulate the safety and health practices of its licensees. This violation is a Severity Level IV violation of very low safety-significance because if the information had been complete and accurate when reviewed by the NRC, it likely would not have resulted in a reconsideration of a regulatory position or substantial further inquiry, such as an additional inspection or a formal request for information. No cross-cutting aspects were identified with this violation.
dose was compromised. Because this violation was of very low safety-significance, neither was it repetitive nor willful, and was entered into the licensee's corrective action


10Enforcement:  During the NRC inspection, a violation of NRC requirements was identified. Title 10 CFR 50.9 "Completeness and Accuracy of Information," requires in part, that information provided to the Commission by an applicant for a license, or by a licensee or information required by statute or by the Commission's regulations, Orders, or license conditions to be maintained by the applicant or the licensee, is complete and accurate in all material respects. Title 10 CFR 20.2106 "Records of Individual Monitoring Results" requires in part, that the licensee shall maintain records of doses received by all individuals for whom monitoring was required, pursuant to 10 CFR 20.1502. Additionally, the licensee shall maintain these records on NRC Form 5, in accordance with the instructions for NRC Form 5, which require additional information is included, which may be necessary to determine compliance with limits. Contrary to the above, on April 17, 2008, the licensee provided information to the NRC that was not complete and accurate in all material respects. Specifically, the licensee submitted to the NRC inadequate NRC Form 5s, "Occupational Dose Record for a Monitoring Period" for three individuals that were involved in the demobilization of spent fuel reconstitution equipment in October 2007. The NRC Form 5s were not complete and accurate in all material respects in that, the NRC Form 5s did not include pertinent information relative to the radiological implications to these individuals regarding their personal involvement in the demobilization of spent fuel reconstitution equipment under circumstances when the licensee's ability to assess dose was compromised. Because this violation was of very low safety-significance, neither was it repetitive nor willful, and was entered into the licensee's corrective action program (Condition Reports CR-PLP-2009-04213), this violation is being treated as an NCV, consistent with the NRC Enforcement Policy:  NCV 05000255/2009007-01; Violation or 10 CFR 20.50.9; "Completeness and Accuracy of Information" regarding support of 10 CFR 20.2106 "Records of Individual Monitoring Results."  Corrective actions included resubmitting updated NRC Form 5s for the involved individuals. 03.02 (Closed) Violation (VIO) 050000255/2008011-01:  Failure To Assess Dose To Three Workers After A Known Change In Radiological Conditions Near The Spent Fuel Pool. The inspectors reviewed the corrective actions to address the violation as documented in this report. This violation is closed. 04 MANAGEMENT MEETINGS Regulatory Performance Meeting Summary On September 25, 2009, the inspectors presented the inspection results to Mr. C. Schwarz, Site-Vice President, and other members of the staff who acknowledged the results of the inspection and the violation of applicable regulatory requirements. The inspectors confirmed that proprietary information was not provided or examined during this inspection. ATTACHMENT:   
program (Condition Reports CR-PLP-2009-04213), this violation is being treated as an  
 
NCV, consistent with the NRC Enforcement Policy:  NCV 05000255/2009007-01;  
 
Violation or 10 CFR 20.50.9; "Completeness and Accuracy of Information" regarding  
 
support of 10 CFR 20.2106 "Records of Individual Monitoring Results."  Corrective  
 
actions included resubmitting updated NRC Form 5s for the involved individuals. 03.02 (Closed) Violation (VIO) 050000255/2008011-01:  Failure To Assess Dose To Three Workers After A Known Change In Radiological Conditions Near The Spent Fuel Pool. The inspectors reviewed the corrective actions to address the violation as documented in this report. This violation is closed.
 
04 MANAGEMENT MEETINGS Regulatory Performance Meeting Summary On September 25, 2009, the inspectors presented the inspection results to Mr. C. Schwarz, Site-Vice President, and other members of the staff who  
 
acknowledged the results of the inspection and the violation of applicable regulatory  
 
requirements. The inspectors confirmed that proprietary information was not provided or examined during this inspection.
 
ATTACHMENT:   


=SUPPLEMENTAL INFORMATION=
=SUPPLEMENTAL INFORMATION=


==KEY POINTS OF CONTACT==
==KEY POINTS OF CONTACT==
Licensee  
Licensee  
: [[contact::M. Ginzel]], Palisades Radiation Protection  
: [[contact::M. Ginzel]], Palisades Radiation Protection  
Line 119: Line 621:
: [[contact::R. Prescott]], PLP CA&A  
: [[contact::R. Prescott]], PLP CA&A  
: [[contact::R. Scudder]], PLP Operations  
: [[contact::R. Scudder]], PLP Operations  
: [[contact::C. Sherman]], PLP RP Manager NRC  
: [[contact::C. Sherman]], PLP RP Manager
: [[contact::R. Lavera]], US NRC Headquarters Other  
NRC  
: [[contact::R. Lavera]], US NRC Headquarters
Other  
: [[contact::S. Bell]], DC Cook Radiation Protection  
: [[contact::S. Bell]], DC Cook Radiation Protection  
==LIST OF ITEMS OPENED, CLOSED, AND DISCUSSED==
==LIST OF ITEMS OPENED, CLOSED, AND DISCUSSED==
Opened and  
Opened and  
===Discussed===
===Discussed===
: 050000255/2009007-01 SL-IV Violation or Title 10 CFR 50.9 Completeness and Accuracy of Information regarding in Support of 10 CFR 20.2106  
: 050000255/2009007-01 SL-IV Violation or Title 10 CFR 50.9 Completeness and Accuracy
"Records of Individual Monitoring Results."
of Information regarding in Support of 10 CFR 20.2106  
 
"Records of Individual Monitoring Results."  
 
===Closed===
===Closed===
: 050000255/2009007-01 SL-IV Violation or Title10 CFR 50.9 Completeness and Accuracy of Information regarding in Support of 10 CFR 20.2106  
: 050000255/2009007-01 SL-IV  
: Violation or Title10 CFR 50.9 Completeness and Accuracy
of Information regarding in Support of 10 CFR 20.2106  
 
"Records of Individual Monitoring Results."   
"Records of Individual Monitoring Results."   
: 050000255/2008011-01; VIO Failure to assess dose to workers after a known change in radiological conditions near the spent fuel pool - White  
: 050000255/2008011-01; VIO  
: Failure to assess dose to workers after a known change in
radiological conditions near the spent fuel pool - White  
: Finding     
: Finding     
: 2
 
==LIST OF DOCUMENTS REVIEWED==
==LIST OF DOCUMENTS REVIEWED==
===Procedures===
===Procedures===
Line 167: Line 681:
: HP 8.2; Whole Body Count Evaluation; Revision 15  
: HP 8.2; Whole Body Count Evaluation; Revision 15  
: HP 8.6; Bioassay Sample Collection and Analyses; Revision 02   
: HP 8.6; Bioassay Sample Collection and Analyses; Revision 02   
: 3HP 8.9;
: HP 8.9;
: DAC-Hour Dose Assignment; Revision 12 HP 8.11; Whole Body Counting; Revision 15 Evaluations
: DAC-Hour Dose Assignment; Revision 12  
: HP 8.11; Whole Body Counting; Revision 15  
: Evaluations
: CR-PLP-2006-03826; INPO AFI Weakness in Radiation Permits; August 2006
: CR-PLP-2006-03826; INPO AFI Weakness in Radiation Permits; August 2006
: CR-PLP-2007-04002; Increased Noble Gas Concentration in Containment; September 2007
: CR-PLP-2007-04002; Increased Noble Gas Concentration in Containment; September 2007
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: CR-PLP-2007-04338; Personnel Contamination Upon Return to Station; September 2007
: CR-PLP-2007-04338; Personnel Contamination Upon Return to Station; September 2007
: CR-PLP-2007-04383; Evaluation of New Fuel Inspection Elevator; September 2007
: CR-PLP-2007-04383; Evaluation of New Fuel Inspection Elevator; September 2007
: CR-PLP-2007-04638; Non-Generation of CR's for Unanticipated Dose Rate Alarms; September 2007
: CR-PLP-2007-04638; Non-Generation of CR's for Unanticipated Dose Rate Alarms;  
: September 2007
: CR-PLP-2007-04869; Unposted High Radiation Area; October 2007
: CR-PLP-2007-04869; Unposted High Radiation Area; October 2007
: CR-PLP-2008-02671; INPO AFI Regarding Improper Radioactive Material Control; June 2008
: CR-PLP-2008-02671; INPO AFI Regarding Improper Radioactive Material Control; June 2008
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: CR-PLP-2009-03755;
: CR-PLP-2009-03755;
: NRC 95001 Readiness Self Assessment; July 2009
: NRC 95001 Readiness Self Assessment; July 2009
: CR-PLP-2009-04213; Proposed Severity Level IV Violation for Information on NRC Form 5s; September 2009 Miscellaneous EAD Dose and Dose Rate Alarms; Condition Reports Pertaining to EAD Dose and Dose Rate Alarms; various dates EAD Dose and Dose Rate Alarms;
: CR-PLP-2009-04213; Proposed Severity Level IV Violation for Information on NRC Form 5s;  
: September 2009
===Miscellaneous===
: EAD Dose and Dose Rate Alarms; Condition Reports Pertaining to EAD Dose and Dose Rate Alarms; various dates  
: EAD Dose and Dose Rate Alarms;
: EN-RP-203 Attachment 9.10's pertaining to EAD Dose and Dose Rate Alarms; various dates
: EN-RP-203 Attachment 9.10's pertaining to EAD Dose and Dose Rate Alarms; various dates
: EN-LI-118
: EN-LI-118
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: LO-PLPLO-2009-00031; Pre-NRC 95-001 Assessment; August 2009  
: LO-PLPLO-2009-00031; Pre-NRC 95-001 Assessment; August 2009  
: O2C-PAL-2007-0298; September 2007   
: O2C-PAL-2007-0298; September 2007   
: 4Operational Experience 28239; February 2009 Personnel Contamination Event Data;
: Operational Experience 28239; February 2009  
: Personnel Contamination Event Data;
: CR-PLP-2009-00127 To 0375 Regarding Dose And Dose Rate Alarms; Various Dates Personnel Contamination Event Data;
: CR-PLP-2009-00127 To 0375 Regarding Dose And Dose Rate Alarms; Various Dates Personnel Contamination Event Data;
: EN-RP-203 Attachment 9.10 Packages Regarding Dose And Dose Rate Alarms; Various Dates
: EN-RP-203 Attachment 9.10 Packages Regarding Dose And Dose Rate Alarms; Various Dates
: RWP 2009-0438 Fuel Inspection and Reconstitution;
: RWP 2009-0438 Fuel Inspection and Reconstitution
;
: WI-RSD-H-018; Containment and Auxiliary Building Posting
: WI-RSD-H-018; Containment and Auxiliary Building Posting
: WI-RSD-H-019; Radiological Risk Assessment and Oversight
: WI-RSD-H-019; Radiological Risk Assessment and Oversight
: WI-RSD-H-021; Radiological Controls for Highly Radioactive Objects Work Order (WO)
: WI-RSD-H-021; Radiological Controls for Highly Radioactive Objects  
: Work Order (WO)
: 00155853 01; Irradiated Fuel Assemblies   
: 00155853 01; Irradiated Fuel Assemblies   
: 5ACRONYMS AV
: ACRONYMS AV
: Apparent Violation CFR
: Apparent Violation CFR
: Code of Federal Regulations  
: Code of Federal Regulations  
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: NRC
: NRC
: Nuclear Regulatory Commission  
: Nuclear Regulatory Commission  
: OE
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: Operating Experience  
===Operating Experience===
: RCE
: RCE
: Root Cause Evaluation  
: Root Cause Evaluation  
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: WO
: WO
: Work Order  
: Work Order  
: C. Schwartz    -3- 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 System (PARS) component of NRC's Agencywide Documents Access and Management System (ADAMS), accessible from the NRC Web site at http://www.nrc.gov/reading-rm/adams.html (the Public Electronic Reading Room).
: C. Schwartz    -3-  
: 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 av ailable electronically for public inspection in the NRC Public Document Room or from the Publicly Available Records System (PARS)
component of NRC's Agencywide Documents Access and Management System (ADAMS), accessible from the NRC Web site at http://www.nrc.gov/reading-rm/adams.html (the Public Electronic Reading Room).
: Sincerely,   
: Sincerely,   
       /RA/  
       /RA/  
: Anne T. Boland, Director Division of Reactor Safety  
: Anne T. Boland, Director Division of Reactor Safety  
: Docket Nos. 50-255  
: Docket Nos. 50-255  
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: Enclosure: Inspection Report 05000255/2009007
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: DOCUMENT NAME:
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: NAME WSlawinski for MPhalen WSlawinski JGiessner ABoland DATE 11/3/09 11/3/09 11/3/09 11/5/09
: NAME WSlawinski for MPhalen WSlawinski JGiessner ABoland DATE 11/3/09 11/3/09 11/3/09 11/5/09  
: OFFICIAL RECORD COPY
: OFFICIAL RECORD COPY
: Letter to Mr. Christopher Schwartz from Ms. Anne T. Boland dated November 5, 2009. SUBJECT: PALISADES NUCLEAR PLANT NRC SUPPLEMENTAL (95001) INSPECTION REPORT 05000255/2009007
: Letter to Mr. Christopher Schwartz from Ms. Anne T. Boland dated November 5, 2009. SUBJECT: PALISADES NUCLEAR PLANT NRC SUPPLEMENTAL (95001) INSPECTION  
: REPORT 05000255/2009007  
: DISTRIBUTION
: Susan Bagley
: RidsNrrPMPalisades
: RidsNrrDorlLpl3-1 Resource
: RidsNrrDirsIrib Resource
: Cynthia Pederson
: Steven Orth
: Jared Heck
: Allan Barker
: Carole Ariano
: Linda Linn
: DRPIII
: DRSIII
: Patricia Buckley
: Tammy Tomczak
: ROPreports@nrc.gov
}}
}}

Revision as of 23:57, 24 August 2018

IR 05000255-09-007, on 08/31/09 - 09/25/09; Palisades Nuclear Plant. Inspection Procedure 95001 Supplemental Inspection
ML093100139
Person / Time
Site: Palisades Entergy icon.png
Issue date: 11/05/2009
From: Boland A T
Division of Reactor Safety III
To: Schwarz C J
Entergy Nuclear Operations
References
EA-09-349 IR-09-007
Download: ML093100139 (21)
v • d • e


Text

UNITED STATES NUCLEAR REGULATORY COMMISSION REGION III 2443 WARRENVILLE ROAD, SUITE 210 LISLE, IL 60532-4352

November 5, 2009

EA-09-349 Mr. Christopher Vice President Operations

Entergy Nuclear Operations, Inc.

Palisades Nuclear Plant

27780 Blue Star Memorial Highway

Covert, MI 49043-9530

SUBJECT: PALISADES NUCLEAR PLANT NRC SUPPLEMENTAL (95001) INSPECTION REPORT 05000255/2009007

Dear Mr. Schwarz:

On September 25, 2009, the U.S. Nuclear Regulatory Commission (NRC) completed a supplemental inspection at your Palisades Nuclear Plant. The enclosed report documents the

inspection results which were discussed on September 25, 2009, with you and members of your

staff. The NRC performed this supplemental inspection c onsistent with the NRC Action Matrix due to a White performance issue in the Occupational Radi ation Safety Cornerstone. Specifically, on January 30, 2009, the NRC issued its Final Significance Determination and a Notice of Violation (NRC Inspection Report 05000255/2008011(DRS)) for a White finding that involved failures by

your staff to perform adequate radiological eval uations necessary to properly identify the radiological hazards to assess the dose for workers performing demobilization of fuel

reconstitution equipment. The NRC staff was informed on August 12, 2009, of your staff's

readiness for this inspection.

This supplemental inspection utilized NRC Inspection Procedure 95001, "Inspection for One or Two White Inputs in a Strategic Performance Area," and was conducted to provide assurance

that: (1) the root and contributing causes of the White performance issue were understood;

(2) the extent of condition and extent of cause were identified; and (3) your corrective actions

were sufficient to address the root causes and contributing causes and to prevent recurrence.

The inspection was an examination of activities conducted under your license as they relate to safety and to compliance with the Commission's Rules and Regulations and with the conditions

of your license. Within these areas, the inspection focused on your staff's evaluation of the

White performance issue and consisted of a selective review of procedures, documents and

representative records, observation of activities, and interviews of personnel.

C. Schwartz -2-

Your staff's evaluation identified that the root cause of the issue was a lack of radiation protection management and supervisory oversight of the work activity that led to low standards

and complacency. As a result, the radiological hazards were underestimated. Based on the

results of this inspection, no findings associated with your staff's evaluation of this performance

issue were identified. The inspectors determined that your root cause evaluation and

associated self-assessment for the White finding were conducted using systematic techniques

and adequately identified the root and contributory causes for the specific performance issue.

Corrective actions were developed to address the identified cause and contributors, which included improvements to the radiation work permi ts that govern reactor cavity and spent fuel pool work, development of a work instruction for high risk activities, and expanded staffing for

the radiation protection organization. We concluded that your corrective actions were adequate

to address the causes that were identified in your evaluation so as to prevent recurrence.

Therefore, consistent with NRC Manual Chapter 0305, "Operating Reactor Assessment

Program," this issue has been removed from c onsideration of future agency actions because four quarters has elapsed following our input of the original finding in the assessment program (i.e., the end of the third quarter 2009). Based on our assessment of your performance, as of

the end of the third quarter 2009, Palisades is in the licensee response band (Column 1) of the

Action Matrix.

However, during the course of our inspection ac tivities the inspectors identified one Severity Level IV Non-Cited Violation (NCV) for the failure to include information pertinent to worker

radiation exposures as documented on NRC Form 5s, as required by 10 CFR 50.9,

"Completeness and Accuracy of Information." No cross-cutting aspects were identified with this

violation. Because the violation was of very low safety-significance, neither was it repetitive nor

willful, and was entered into the Palisades' corrective action program, this violation is being

treated as an NCV, in accordance with the NRC's Enforcement Policy. If you contest the NCV

in this report, you should provide a response within 30 days of the date of this inspection report, with the basis for your denial, to the Nuclear Regulatory Commission, ATTN.:

Document Control Desk, Washington DC 20555-0001; with copies to the Regional

Administrator, Region III; the Director, Office of Enforcement, United States Nuclear Regulatory

Commission, Washington, DC 20555-0001; and the NRC Resident Inspector at the Palisades Nuclear Plant.

C. Schwartz -3-

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 av ailable electronically for public inspection in the NRC Public Document Room or from the Publicly Available Records System (PARS)

component of NRC's Agencywide Documents Access and Management System (ADAMS), accessible from the NRC Web site at http://www.nrc.gov/reading-rm/adams.html (the Public Electronic Reading Room).

Sincerely,/RA/

Anne T. Boland, Director Division of Reactor Safety

Docket Nos. 50-255

License Nos. DPR-20

Enclosure:

Inspection Report 05000255/2009007

w/Attachments:

Supplemental Information cc w/encl: Distribution via ListServ Enclosure U.S. NUCLEAR REGULATORY COMMISSION REGION III Dockets: 50-255 Licenses Nos.: DPR-20 Reports Nos.: 05000255/2009007 Licensee: Entergy Nuclear Operations Company, Inc.

Facility: Palisades Nuclear Plant Location: Covert, MI Dates: August 31 through September 25, 2009 Inspectors: J. Cassidy, Senior Health Physicist M. Phalen, Health Physicist J. Ellegood, Senior Resident Inspector Technical P. Lee, PhD, Health Physics Specialists: R. Pedersen, Senior Technical Advisor for NRR Health Physics Program Office Approved By: Wayne Slawinski, Branch Chief (Acting) Plant Support Team Division of Reactor Safety, RIII Enclosure 1

SUMMARY OF FINDINGS

IR 05000255/2009007; 08/31/09 - 09/25/09; Palisades Nuclear Plant. Inspection Procedure 95001 Supplemental Inspection.

The report covers a supplemental inspection performed by regional health physics inspectors, the Palisades Nuclear Plant senior resident inspector, and assistance from NRC regional and headquarters personnel. One Severity Level IV NCV of 10 CFR 50.9 was identified. The significance of most findings is indicated by their color (Green, White, Yellow, Red) using

Inspection Manual Chapter 0609, "Significance Determination Process" (SDP). Cross-cutting aspects are determined using Inspection Manual Chapter 0305 "Operating Reactor Assessment

Program." Findings for which the SDP does not apply may be Green or assigned a severity level after NRC management review. 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.

Cornerstone: Occupational Radiation Safety

The NRC performed this supplemental inspection in accordance with inspection procedure (IP) 95001, "Inspection for One or Two White Inputs in a Strategic Performance Area," to assess the licensee's evaluation associated with the failure to perform adequate radiological evaluations necessary to properly identify the radiological hazards and to assess the dose for workers that received unanticipated dose rate alarms on their electronic dosimeters while performing demobilization of fuel reconstitution equipment in October 2007. The NRC staff previously characterized this issue as having low to moderate safety-significance (White) as documented in NRC Inspection Report 05000225/2008011(DRS). During this supplemental inspection, the inspectors determined that the licensee performed an adequate evaluation of the specific performance issue and that comprehensive corrective actions addressed each of the root and contributing causes. The licensee identified one root cause in that Palisades under-

estimated the extent of radiological hazards that were present during the demobilization of the equipment due to the "lack of radiation protec tion management and supervisory oversight. This led to: (a) low standards; (b) mindset; and (c) complacency associated with the work activity."

Additionally, two contributing causes were identified. Specifically, inadequate communications and insufficient supervisory radiation protection (RP) staff resource was devoted to the work.

Corrective actions as documented in the root cause evaluation included:

  • Enhancement to Radiation Work Permits (RWPs) for Spent Fuel Pool (SFP) and reactor cavity work to require the use of extremity dosimetry for the removal of equipment from the water, unless waived in writing by the Radiation Protection Manager.
  • Development of a Work instruction (WI) RSD-H-019 for High Risk Assessment and Supervisory Oversight.

2* Implementation of Entergy fleet procedure EN-OP-116 for Infrequently Performed Test and Evolution.

  • Expanded RP staffing to meet the Entergy Standard level for qualified technicians and supervisors.

The station also provided supplemental information to the NRC regarding additional actions that have been taken to ensure that there is an appropriate level of radiation protection management and supervisory oversight associated with radiologically significant work activities, including the reconstitution of damaged fuel.

Based on the licensee's progress in evaluating and correcting the issues associated with the failures to perform adequate radiological evaluations necessary to properly identify the radiological hazards to assess the dose for workers performing demobilization of fuel reconstitution equipment that resulted in the White finding, this occupational radiation safety cornerstone performance issue will not be held open beyond the normal four quarters provided in NRC Manual Chapter 0305, "Operating Reactor Assessment Program."

Findings Severity Level IV. The inspectors identified a Severity Level IV NCV of 10 CFR 50.9, "Completeness and Accuracy of Information." The inspectors identified that the licensee, on April 17, 2008, submitted to the NRC inadequate NRC Form 5s, "Occupational Dose Record for a Monitoring Period" for three individuals that were involved in the demobilization of spent fuel reconstitution equipment in October 2007. The NRC Form 5s were not complete and accurate in all material respects. Specifically, the NRC Form 5s did not include pertinent information relative to the radiological implications to these individuals regarding their personal involvement in the demobilization of spent fuel reconstitution equipment under circumstances when the licensee's ability to assess the worker's dose was compromised. In particular, the NRC

Form 5s failed to document the uncertainties associated with the workers' radiation doses, as was necessary in this instance consistent with the instructions on the Form 5. When the NRC questioned the licensee on the accuracy of these NRC Form 5 submittals, the licensee submitted revised NRC Form 5s.

The violation was more than minor because the missing information was material to the NRC.

Specifically, this information is used by the NRC in its evaluation of the risk of radiation exposure associated with the licensed activity and in exercising its statutory authority to monitor and regulate the safety and health practices of its licensees. This Severity Level IV violation is of very low safety-significance because if the information had been complete and accurate when reviewed by the NRC, it likely would not have resulted in a reconsideration of a regulatory position or substantial further inquiry, such as an additional inspection or a formal request for information. Because this violation was of very low safety-significance, neither was it repetitive nor willful, and was entered into the licensee's corrective action program [Condition Report (CR)-PLP-2009-04213], the violation is being treated as an NCV, consistent with the NRC

Enforcement Policy. No cross-cutting aspects were identified with this violation. (Section 03.01)

3

REPORT DETAILS

01. Inspection Scope The NRC staff performed this supplemental inspection in accordance with IP 95001 to assess the licensee's evaluation of a (White) finding, which affected the occupational

radiation safety cornerstone in the radiation safety strategic performance area. The

inspection objectives were to:

  • provide assurance that the root and contributing causes of risk-significant issues were understood;
  • provide assurance that the extent of condition and extent of cause of risk-significant issues were identified; and
  • provide assurance that the licensee's corrective actions for risk-significant issues were or will be sufficient to address the root and contributing causes to preclude

repetition.

The licensee entered the Regulatory Response Column of the NRC's Action Matrix in the fourth quarter of 2008 as a result of one inspection finding of low to moderate

safety-significance (White). On October 04, 2007, during the demobilization of fuel

reconstitution equipment, three supplemental employees received unanticipated dose rate

alarms. The licensee's response to these alarms did not adequately recognize and

assess the radiological hazards. As a result, the internal and extremity radiation doses for

the involved employees could not be accurately determined. A preliminary White finding, Apparent Violation (AV)05000255/2008011-01, was issued in inspection report

05000255/2008011. A final White finding, based on the results of radiological risk in

accordance with the occupational radiation safety-significance determination process, was

issued with a Notice of Violation (NOV) in a letter dated January 30, 2009.

The licensee informed the NRC staff that they were ready for the supplemental inspection on August 12, 2009. The licensee performed a root cause evaluation (RCE),

CR-PLP-2008-05200, Revision 01, to identify the direct and contributing causes and also causal factors, which allowed for the risk-significant finding and to determine the

organizational attributes that resulted in the White finding. The licensee also addressed

safety culture in the RCE.

The inspectors reviewed the licensee's RCE, as well as other evaluations conducted in support and as a result of the RCE. The inspectors reviewed corrective actions that were

taken or planned to address the identified causes. The inspectors also held discussions

with licensee personnel to ensure that the root and contributing causes and the

contribution of safety culture components were understood and corrective actions taken or

planned were appropriate to address the causes and preclude repetition.

402. Evaluation of Inspection Requirements 02.01 Problem Identification a. Inspection Procedure 95001 requires that the inspection staff determine that the licensee's evaluation of the issue documents who identified the issue (i.e.,

licensee-identified, self-revealing, or NRC-identified) and the conditions under which

the issue was identified.

This issue of inadequate response to electronic dosimeter alarms because the licensee's radiation safety staff did not adequately recognize and assess the

radiological hazards associated with the three supplemental employees receiving

unanticipated dose rate alarms was identified by regional NRC health physics staff as

a part of the baseline inspection program. The issue is documented in several records

within the licensee's corrective action program, including the licensee's RCE.

b. Inspection Procedure 95001 requires that the inspection staff determine that the licensee's evaluation of the issue documents how long the issue existed and prior

opportunities for identification.

During the conduct of the root cause evaluation, the licensee reviewed the radiological circumstances associated with this event. Additionally, the licensee reviewed its

corrective action and work control databases for similar type issues specific to

inadequate radiological evaluations that led to the failure to identify radiological

hazards of regulatory significance. However, there was a significant time lapse from

the time the NRC identified the event to completion of the licensee's evaluation.

Additionally, the licensee missed several opportunities to self-identify the issue. A

comprehensive review of the issue began after prompting by NRC inspectors. c. Inspection Procedure 95001 requires that the inspection staff determine that the licensee's evaluation documents the plant specific risk consequences, as applicable, and compliance concerns associated with the issue.

A plant specific probabilistic risk-assessment is not applicable to this issue. However, the licensee did evaluate the occupational external exposures and bounded the

shallow dose equivalent, with uncertainties, given the limited initial radiological data

that was available. The licensee indicated that a more thorough dose evaluation

including internal dose from alpha radiation would be performed. This action is tracked

as CR-PLP-2009-4555. 02.02 Root Cause, Extent of Condition, and Extent of Cause Evaluation a. Inspection Procedure 95001 requires that the inspection staff determine that the licensee evaluated the issue using a systematic methodology to identify the root and

contributing causes.

The licensee conducted a root cause analysis of the performance issue, which was later supplemented with an extent of cause review during the licensee's Focused Area

Self-Assessment. The licensee used Procedure EN-LI-118, "Root Cause Analysis Process," Revision 11, and other implementing procedures to evaluate these issues.

These procedures included such analysis tools as Event and Causal Factor Charting, 5 Change Analysis, Barrier Analysis, Causal Factor Trending, and Human Performance Error Reviews. The inspectors evaluated the root cause evaluation report against the

requirements of the licensee's procedures and determined that the evaluations

performed followed the administrative procedure requirements.

The inspectors concluded that systematic methods were used to identify the root cause and contributing cause. b. Inspection Procedure 95001 requires that the inspection staff determine that the licensee's RCE was conducted to a level of detail commensurate with the significance

of the issue.

The inspectors concluded that the root cause evaluation had identified and assessed the potential contributors to the decrease in performance in sufficient detail to identify

appropriate corrective actions. Although acceptable, the inspectors concluded that the

RCE missed opportunities that would have been beneficial to identify the full extent of

the issue, as described below.

Root Cause The licensee identified one root cause in its evaluation, in that Palisades underestimated the extent of radiological hazards during the demobilization

following fuel reconstitution due to the "lack of radiation protection management

and supervisory oversight. This led to: (a) low standards; (b) mindset; and (c) complacency associated with the reconstitution of severely damaged fuel."

Contributing Causes Additionally, two contributing causes were identified.

1. Inadequate communications as evidenced by the following:

  • Communications between the RP technician and the contract workers led the contract workers to believe that they could disassemble the temporary storage

baskets without the RP technician being present.

  • Communications between reactor engineering, RP management, and other members of the Palisades staff did not adequately alert the organization, including the condition review group and corrective action review board

personnel, of the potential contamination and exposure problems associated

with damaged fuel. 2. Insufficient supervisory RP staff resources available to provide needed supervision and oversight.

The inspectors identified that the RCE was acceptable but was narrow in scope, in that the terminal objective identified in the root cause evaluation drove the extent of

condition review. Specifically, the root cause evaluation truncated at the point where

the RP staff failed to recognize and assess the radiological hazards after responding to

the unanticipated dose rate alarms. The inspection team observed that there was a

missed opportunity to obtain pertinent information relevant to why the RP staff failed to 6 recognize the radiological hazards. Through means independent of the RCE, the NRC discovered several additional facts which were not explored by the licensee's root

cause team. First, at the time of the initial incident, the need to perform extremity dose

assessments was brought to the attention of several members of the RP staff, including the RP Manager. However, the licensee's root cause team did not explore

why no follow-up actions occurred despite the licensee's knowledge of this issue.

Second, the presence of high energy beta and alpha emitting isotopes on the refueling

floor, as well as elevated alpha to beta/gamma ratios, were being identified to senior

RP staff, including the RP Manager at the time the event occurred. The inspectors

also identified that alpha ratios were anomalous to industry norms. Lastly, the NRC

learned that there may have been additional data available to Palisades near the time

of the event occurrence relative to the spacer pins. Specifically, the inspectors were

informed that persons had opened the tool box while it was under quarantine on the

refuel floor and this activity could have provided information to aid in worker dose

reconstructions. c. Inspection Procedure 95001 requires that the inspection staff determine that the licensee's RCE included a consideration of prior occurrences of the issue and

knowledge of operating experience (OE).

The RCE included an historical review of the licensee's corrective action and work control databases and did not document any similar type issues associated with

inadequate radiological evaluations that led to the failure to identify radiological

hazards of regulatory significance. The RCE conducted a review of previous industry events. This review did not identify any directly related issues.

The inspectors concluded that, in general, the licensee's root cause evaluation appropriately considered both internal and external operating experience. The

evaluation assessed the licensee's previous lack of recognition, evaluation, and timely

mitigation of radiological events. d. Inspection Procedure 95001 requires that the inspection staff determine that the licensee's RCE addresses the extent of condition and extent of cause of the issue(s).

The licensee's evaluations considered the potential for common cause and extent of condition for each of the identified root causes. Additionally, the licensee evaluated

radiation protection department and other department responses to unanticipated

alarm conditions.

The inspectors concluded that the extent of condition and extent of cause reviews performed by the licensee were adequate. e. Inspection Procedure 95001 requires that the inspection staff determine that the licensee's root cause, extent of condition, and extent of cause evaluations

appropriately considered the safety culture components as described in IMC 0305.

The inspectors concluded that the current safety culture aspect associated with this issue was appropriately considered in the licensee's RCE and included consideration

of whether a weakness in any safety culture component was a root cause or a

significant contributing cause of the issue.

702.03 Corrective Actions a. Inspection Procedure 95001 requires that the inspection staff determines that:

(1) the licensee specified appropriate corrective actions for each root and/or

contributing cause; or (2) an evaluation that states no actions are necessary is

adequate. Corrective actions were developed to address the identified causes and the contributors so as to prevent recurrence of the performance issue. Corrective

actions as documented in the root cause evaluation included:

  • Enhancements to Radiation Work Permits for SFP and Reactor Cavity work to require the use of extremity dosimetry for the removal of equipment from

the water, unless waived in writing by the Radiation Protection Manager.

  • Development of a Work Instruction (WI) RSD-H-019 for High Risk Assessment and Supervisory Oversight.
  • Implementation of Entergy fleet procedure EN-OP-116 for Infrequently Performed Test and Evolutions.
  • Expanded RP staffing to meet the Entergy Standard level for qualified technicians and supervisors.

The licensee also provided supplemental information to the NRC regarding additional actions that have been taken to ensure that there is an appropriate level

of radiation protection management and supervisory oversight associated with

radiologically significant work activities, including responses to unanticipated

electronic dosimeter alarms and work associated with the reconstitution of

severely damaged fuel.

The inspectors determined that the corrective actions taken were appropriate for the associated causes. b. Inspection Procedure 95001 requires that the inspection staff determine that the licensee prioritized corrective actions with consideration of risk significance and

regulatory compliance.

The workers involved exited the plant after receiving Dose Rate Alarms, reporting to RP Supervision at Access Control. The RP staff then restricted access for the

workers, in accordance with station procedures. Follow-up radiological surveys

were performed and administrative controls were put in place prior to resuming

work on the refueling floor. An RP standard for Continuous RP Coverage was

implemented for removal of items from the Spent Fuel Pool and a site-wide

communication was issued regarding this event and the requirement to have

continuous coverage for removal of items from the Spent Fuel Pool.

Additionally, the station implemented long term corrective actions that included means to ensure there was an appropriate level of radiation protection

management and supervisory oversight associ ated with radiologically significant work activities on the refuel floor, including the reconstitution of severely damaged

fuel.

8 The inspectors considered the prioritization of the established corrective actions to be appropriate. c. Inspection Procedure 95001 requires that the inspection staff determine that the licensee established a schedule for implementing and completing the corrective

actions.

The licensee established adequate schedules for the completion of the specified corrective actions. The majority of the corrective actions had been completed

prior to this inspection, and the remaining corrective actions were on schedule for

completion. The inspectors reviewed the completed corrective actions and

concluded that they had been generally im plemented in a timely and effective manner. The inspectors did not identify any concerns with the scheduling or

completion of corrective actions. d. Inspection Procedure 95001 requires that the inspection staff determine that the licensee developed quantitative and/or qualitative measures of success for

determining the effectiveness of the corrective actions to preclude repetition.

The licensee developed a means to validate the effectiveness of its corrective actions for the performance deficiency. However, the inspectors questioned the

adequacy of certain performance measures. The inspection team reviewed the

licensee's proposed effectiveness reviews in detail and concluded that some of

the proposed reviews were narrowly focused. Specifically, the licensee planned

to review the effectiveness of radiological controls for EN-RP-123 "Radiological

Controls for Highly Radioactive Objects" through Snap Shot Self-Assessments for

Spent Fuel Pool and Reactor Cavity Work. The NRC concluded that although the

root cause of the event was a lack of RP management and supervisory oversight, the effectiveness review did not include an assessment of RP management and

supervisory oversight of all radiologically significant work at the station, only work

that occurs on the refuel floor. Additionally, the NRC communicated to the

licensee that its focus did not include station response to other unanticipated

radiological alarms, including electronic dosimeters, area radiation monitors, liquid

and air effluent monitors, continuous air monitors, etc.

The licensee agreed to re-evaluate the comprehensiveness of the effectiveness review performance measures. Condition Report CR-PLP-2009-04543 was

generated by the licensee to address this issue.

e. Inspection Procedure 95001 requires that the inspection staff determine that the licensee's planned or taken corrective actions adequately address a Notice of

Violation (NOV) that was the basis for the supplemental inspection, if applicable.

The NRC issued its final significance determination and Notice of Violation (05000255/2008011-01), Failure to Assess Dose to Three Workers after a Known

Change in Radiological Conditions Near the Spent Fuel Pool) to the licensee on

January 30, 2009. The NRC concluded that information regarding the reason for

the violation, the corrective actions taken and planned to correct the violation and

prevent recurrence, and full compliance has been achieved. The NRC staff did

not require a response to the NOV from the licensee; therefore, this inspection

requirement was not applicable.

9 03 OTHER ISSUES 03.01 (Open/Closed) Violations (VIO) 050000255/2009007-01

a. Inspection Scope

The inspectors assessed the radiological controls for work areas having a history of, or the potential for, airborne transuranics. Additionally, the inspectors assessed the

adequacy of the licensee's extremity and internal dose assessment processes, and the

regulatory required documentation associated with those assessments.

b. Findings

Introduction

The inspectors identified a violation of 10 CFR 50.9 "Completeness and Accuracy of Information," in that the licensee submitted to the NRC an NRC Form 5, "Occupational Dose Record for a Monitoring Period," that is required to comply with

10 CFR 20.2106, "Records of Individual Monitoring Results," for three individuals

that were involved in the demobilization of spent fuel reconstitution equipment in

October 2007. Specifically, the NRC Form 5s were not complete and accurate in all

material respects by omitting data relevant to the worker's radiation exposures.

Description

The NRC Form 5s completed for the workers involved in the October 2007 incident, involving demobilization of fuel reconstitution equipment did not

include pertinent information relative to the radiological implications to these

individuals regarding their personal involvement in these work activities under

circumstances when the licensee's ability to assess the worker's dose was

compromised. Specifically, the licensee failed to document the uncertainties in the

worker dose estimates as was necessary for these circumstances, consistent with

the instructions for the NRC Form 5. When the NRC questioned the licensee on the

accuracy of these NRC Form 5 submittals, the licensee submitted revised NRC

Form 5s on September 29, 2009. The revised NRC Form 5s included reference to

NRC inspection reports that are publicly available, such that the involved individuals

would be cognizant of the circumstances surrounding their personal radiation

exposures.

Analysis:

The inspectors determined that the failure to include all pertinent information on NRC Form 5s was a performance deficiency because licensees are required to

adhere to the regulations of 10 CFR Part 20. The inspectors concluded that the cause

of the deficiency was reasonably within the licensee's ability to foresee and correct.

The violation was subject to traditional enforcement because it potentially impacted the

NRC's ability to perform its regulatory function and was more than minor because the

missing information was material to the NRC. Specifically, this information is used by

the NRC in its evaluation of the risk of radiation exposure associated with the licensed

activity and in exercising its statutory authority to monitor and regulate the safety and

health practices of its licensees. This violation is a Severity Level IV violation of very

low safety-significance because if the information had been complete and accurate

when reviewed by the NRC, it likely would not have resulted in a reconsideration of a

regulatory position or substantial further inquiry, such as an additional inspection or a

formal request for information. No cross-cutting aspects were identified with this

violation.

10 Enforcement

During the NRC inspection, a violation of NRC requirements was identified. Title 10 CFR 50.9 "Completeness and Accuracy of Information," requires in

part, that information provided to the Commission by an applicant for a license, or by a

licensee or information required by statute or by the Commission's regulations, Orders, or license conditions to be maintained by the applicant or the licensee, is complete and

accurate in all material respects. Title 10 CFR 20.2106 "Records of Individual

Monitoring Results" requires in part, that the licensee shall maintain records of doses

received by all individuals for whom monitoring was required, pursuant to 10 CFR

20.1502. Additionally, the licensee shall maintain these records on NRC Form 5, in

accordance with the instructions for NRC Form 5, which require additional information

is included, which may be necessary to determine compliance with limits.

Contrary to the above, on April 17, 2008, the licensee provided information to the NRC that was not complete and accurate in all material respects. Specifically, the licensee

submitted to the NRC inadequate NRC Form 5s, "Occupational Dose Record for a

Monitoring Period" for three individuals that were involved in the demobilization of

spent fuel reconstitution equipment in October 2007. The NRC Form 5s were not

complete and accurate in all material respects in that, the NRC Form 5s did not

include pertinent information relative to the radiological implications to these

individuals regarding their personal involvement in the demobilization of spent fuel

reconstitution equipment under circumstances when the licensee's ability to assess

dose was compromised. Because this violation was of very low safety-significance, neither was it repetitive nor willful, and was entered into the licensee's corrective action

program (Condition Reports CR-PLP-2009-04213), this violation is being treated as an

NCV, consistent with the NRC Enforcement Policy: NCV 05000255/2009007-01;

Violation or 10 CFR 20.50.9; "Completeness and Accuracy of Information" regarding

support of 10 CFR 20.2106 "Records of Individual Monitoring Results." Corrective

actions included resubmitting updated NRC Form 5s for the involved individuals. 03.02 (Closed) Violation (VIO) 050000255/2008011-01: Failure To Assess Dose To Three Workers After A Known Change In Radiological Conditions Near The Spent Fuel Pool. The inspectors reviewed the corrective actions to address the violation as documented in this report. This violation is closed.

04 MANAGEMENT MEETINGS Regulatory Performance Meeting Summary On September 25, 2009, the inspectors presented the inspection results to Mr. C. Schwarz, Site-Vice President, and other members of the staff who

acknowledged the results of the inspection and the violation of applicable regulatory

requirements. The inspectors confirmed that proprietary information was not provided or examined during this inspection.

ATTACHMENT:

SUPPLEMENTAL INFORMATION

KEY POINTS OF CONTACT

Licensee

M. Ginzel, Palisades Radiation Protection
D. Nestle, Palisades Operations
R. Prescott, PLP CA&A
R. Scudder, PLP Operations
C. Sherman, PLP RP Manager

NRC

R. Lavera, US NRC Headquarters

Other

S. Bell, DC Cook Radiation Protection

LIST OF ITEMS OPENED, CLOSED, AND DISCUSSED

Opened and

Discussed

050000255/2009007-01 SL-IV Violation or Title 10 CFR 50.9 Completeness and Accuracy

of Information regarding in Support of 10 CFR 20.2106

"Records of Individual Monitoring Results."

Closed

050000255/2009007-01 SL-IV
Violation or Title10 CFR 50.9 Completeness and Accuracy

of Information regarding in Support of 10 CFR 20.2106

"Records of Individual Monitoring Results."

050000255/2008011-01; VIO
Failure to assess dose to workers after a known change in

radiological conditions near the spent fuel pool - White

Finding

LIST OF DOCUMENTS REVIEWED

Procedures

EN-LI-118; Root Cause Analysis Process; Revision 11
EN-OP-116; Infrequently Performed Tests or Evolutions; Revision 02
EN-RP-100; Radworker Expectations; Revision 03
EN-RP-101; Access Control for Radiologically Controlled Areas; Revision 04
EN-RP-104; Personnel Contamination Events; Revision 04
EN-RP-105; Radiological Work Permits; Revision 06
EN-RP-106; Radiological Survey Documentation; Revision 02
EN-RP-110; ALARA Program; Revision 06
EN-RP-122; Alpha Monitoring; Revision 03
EN-RP-123; Radiological Controls for Highly Radioactive Objects; Revision 00
EN-RP-131; Air Sampling; Revision 07
EN-RP-141; Job Coverage; Revision 04
EN-RP-142; Failed Fuel Response; Revision 02
EN-RP-201; Dosimetry Administration; Revision 03
EN-RP-202; Personnel Monitoring; Revision 07
EN-RP-203; Dose Assessment; Revision 03
EN-RP-204; Special Monitoring Requirements; Revision 03
EN-RP-208; Whole Body Counting and In-Vitro Bioassay; Revision 03
HP 2.14; Radiological Surveys; Revision 25
HP 2.18; Personnel Contamination; Revision 19
HP 2.19; Airborne Radioactivity Sampling; Revision 24
HP 2.20; Radiation Safety Area Posting; Revision 20
HP 2028; Miscellaneous Dosimetry Areas; Revision 30
HP 2.33; Dose Investigations and Assessment; Revision 13
HP 2.44; (Hot) Particle Contamination; Revision 08
HP 2.5; High Radiation Area Entry and Control; Revision 26
HP 2.8; Response to Unusual Radiological Occurrences; Revision 18
HP 2.8; Response to Unusual Radiological Occurrences; Revision 19
HP 2.8; Response to Unusual Radiological Occurrences; Revision 20
HP 2.8; Response to Unusual Radiological Occurrences; Revision 21
HP 8.2; Whole Body Count Evaluation; Revision 15
HP 8.6; Bioassay Sample Collection and Analyses; Revision 02
HP 8.9;
DAC-Hour Dose Assignment; Revision 12
HP 8.11; Whole Body Counting; Revision 15
Evaluations
CR-PLP-2006-03826; INPO AFI Weakness in Radiation Permits; August 2006
CR-PLP-2007-04002; Increased Noble Gas Concentration in Containment; September 2007
CR-PLP-2007-04003; Passport to Sentinel Issues; September 2007
CR-PLP-2007-04304; Locked High Radiation Area Found Unlocked; September 2007
CR-PLP-2007-04361; Override Key for New Fuel Elevator Incident; September 2007
CR-PLP-2007-04338; Personnel Contamination Upon Return to Station; September 2007
CR-PLP-2007-04383; Evaluation of New Fuel Inspection Elevator; September 2007
CR-PLP-2007-04638; Non-Generation of CR's for Unanticipated Dose Rate Alarms;
September 2007
CR-PLP-2007-04869; Unposted High Radiation Area; October 2007
CR-PLP-2008-02671; INPO AFI Regarding Improper Radioactive Material Control; June 2008
CR-PLP-2008-05200; NRC White Finding Regarding Un-Assessed Dose; December 2008 (and subsequent daughter documents)
CR-PLP-2009-03755;
NRC 95001 Readiness Self Assessment; July 2009
CR-PLP-2009-04213; Proposed Severity Level IV Violation for Information on NRC Form 5s;
September 2009

Miscellaneous

EAD Dose and Dose Rate Alarms; Condition Reports Pertaining to EAD Dose and Dose Rate Alarms; various dates
EAD Dose and Dose Rate Alarms;
EN-RP-203 Attachment 9.10's pertaining to EAD Dose and Dose Rate Alarms; various dates
EN-LI-118
CR-PLP-2008-05200 Effectiveness Review Criteria; Revision 11
Focused Self-Assessment Report - Draft; July 2009
Focused Self Assessment Concerns Response - Final; August 2009
Formal Evaluation Dose Consequence Associated with Areva Spacer Pins; July 2009
LO-PLPLO-2007-00160; Entergy Pre-outage Readiness Assessment; July 2007
LO-PLPLO-2009-00002; Effectiveness Review of
CR-05200; June 2009
LO-PLPLO-2009-00031; Pre-NRC 95-001 Assessment; August 2009
O2C-PAL-2007-0298; September 2007
Operational Experience 28239; February 2009
Personnel Contamination Event Data;
CR-PLP-2009-00127 To 0375 Regarding Dose And Dose Rate Alarms; Various Dates Personnel Contamination Event Data;
EN-RP-203 Attachment 9.10 Packages Regarding Dose And Dose Rate Alarms; Various Dates
RWP 2009-0438 Fuel Inspection and Reconstitution
WI-RSD-H-018; Containment and Auxiliary Building Posting
WI-RSD-H-019; Radiological Risk Assessment and Oversight
WI-RSD-H-021; Radiological Controls for Highly Radioactive Objects
Work Order (WO)
00155853 01; Irradiated Fuel Assemblies
ACRONYMS AV
Apparent Violation CFR
Code of Federal Regulations
CR

Condition Report

DRS
Division of Reactor Safety
IMC
Inspection Manual Chapter
IP
Inspection Procedure
NCV
Non-Cited Violation
NOV
Notice of Violation
NRC
Nuclear Regulatory Commission
OE

Operating Experience

RCE
Root Cause Evaluation
RP
Radiation Protection
RWP
Radiation Work Permit
SDP
Significance Determination Process
SFP
Spent Fuel Pool
SL
Severity Level
VIO
Violation
WI
Work Instruction
WO
Work Order
C. Schwartz -3-
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 av ailable electronically for public inspection in the NRC Public Document Room or from the Publicly Available Records System (PARS)

component of NRC's Agencywide Documents Access and Management System (ADAMS), accessible from the NRC Web site at http://www.nrc.gov/reading-rm/adams.html (the Public Electronic Reading Room).

Sincerely,

/RA/

Anne T. Boland, Director Division of Reactor Safety
Docket Nos. 50-255
License Nos.
DPR-20
Enclosure: Inspection Report 05000255/2009007

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Letter to Mr. Christopher Schwartz from Ms. Anne T. Boland dated November 5, 2009. SUBJECT: PALISADES NUCLEAR PLANT NRC SUPPLEMENTAL (95001) INSPECTION
REPORT 05000255/2009007
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