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{{Adams | |||
| number = ML100130231 | |||
| issue date = 01/12/2010 | |||
| title = IR 05000282-09-015 & 05000306-09-015 on 11/30/09 - 12/04/09 for Prairie Island, Units 1 & 2, Supplemental Inspection | |||
| author name = Boland A | |||
| author affiliation = NRC/RGN-III/DRS | |||
| addressee name = Schimmel M | |||
| addressee affiliation = Northern States Power Co | |||
| docket = 05000282, 05000306, 07200010 | |||
| license number = DPR-042, DPR-060 | |||
| contact person = | |||
| case reference number = EA-08-349 | |||
| document report number = IR-09-015 | |||
| document type = Inspection Report, Letter | |||
| page count = 17 | |||
}} | |||
See also: [[see also::IR 05000282/2009015]] | |||
=Text= | |||
{{#Wiki_filter:UNITED STATES | |||
NUCLEAR REGULATORY COMMISSION | |||
REGION III | |||
2443 WARRENVILLE ROAD, SUITE 210 | |||
LISLE, IL 60532-4352 | |||
January 12, 2010 | |||
EA-08-349 | |||
Mr. Mark Schimmel | |||
Site Vice President | |||
Prairie Island Nuclear Generating Plant | |||
Northern States Power Company, Minnesota | |||
1717 Wakonade Drive East | |||
Welch, MN 55089 | |||
SUBJECT: PRAIRIE ISLAND NUCLEAR GENERATING PLANT, UNITS 1 AND 2, NRC | |||
SUPPLEMENTAL INSPECTION REPORT 05000282/2009015; | |||
05000306/2009015 | |||
Dear Mr. Schimmel: | |||
On December 4, 2009, the U. S. Nuclear Regulatory Commission (NRC) completed a | |||
supplemental inspection pursuant to Inspection Procedure 95001, Inspection for One or | |||
Two White Inputs in a Strategic Performance Area, at your Prairie Island Nuclear Generating | |||
Plant. The enclosed report documents the inspection results, which were discussed at the | |||
combined exit and regulatory performance meeting conducted on December 4, 2009, with | |||
Messrs. Bradley Sawatzke, Kevin Ryan and other members of your staff. | |||
As required by the NRC Reactor Oversight Process Action Matrix, this supplemental | |||
inspection was performed due to a White performance issue in the Public Radiation Safety | |||
Cornerstone. Specifically, on May 6, 2009, the NRC issued its Final Significance Determination | |||
and Notice of Violation (NRC Inspection Report 05000282/2009008 and 05000306/2009008) for | |||
a White finding that involved the failure to properly prepare and ship a package containing | |||
radioactive material in a manner that assured conformance with Department of Transportation | |||
(DOT) radiation level limits specified in 49 CFR 173.441. The NRC staff was informed on | |||
October 30, 2009, of your staffs readiness for this inspection. | |||
The objectives of this supplemental inspection were to provide assurance that: (1) the root | |||
causes and the contributing causes for the White performance issue were understood; (2) the | |||
extent of condition and extent of cause were identified; and (3) corrective actions were or will be | |||
sufficient to address and preclude repetition of the root and contributing causes. The inspection | |||
consisted of examination of activities conducted under your license as they related to safety, | |||
compliance with the Commission=s rules and regulations, and the conditions of your operating | |||
license. | |||
The inspectors determined that your staff performed a comprehensive evaluation of the White | |||
finding using systematic techniques to determine the root and contributory causes of the | |||
performance issue. Your staff=s evaluation identified that the root causes centered on poor | |||
processes and procedure quality, and insufficient oversight including the lack of a risk | |||
management process associated with the shipment program. In particular, your staff correctly | |||
concluded that | |||
M. Schimmel -2- | |||
the root causes involved programmatic issues and that the singular failure of a human | |||
performance barrier was not a major contributor to the overall problems that led to the incident. | |||
Corrective actions were implemented to address the identified causes and contributors, which | |||
included significant modification to existing procedures along with the development of new | |||
procedures. Also, the training and qualification program for staff involved in shipment activities | |||
was enhanced. Additionally, an integrated risk management process was developed that | |||
incorporates risk insights and thresholds to ensure the proper level of management engagement | |||
in shipment related activities. | |||
Although issues with aspects of your staff's extent of cause review for the White performance | |||
issue were identified by our inspectors and documentation deficiencies associated with your | |||
staff's root cause evaluation report were noted, based on the results of this inspection, no | |||
findings of significance were identified. | |||
Given your acceptable performance in addressing this performance issue, the White finding was | |||
considered in assessing plant performance for a total of four quarters in accordance with the | |||
guidance in IMC 0305, AOperating Reactor Assessment Program.@ Consequently, 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 | |||
fourth quarter 2009). Although this finding is removed from consideration in the Action Matrix, | |||
Unit 2 remains in the regulatory response band (column 2) of the matrix based on a White | |||
finding in the mitigating systems cornerstone assessed during the third quarter of 2009. We | |||
have assessed Unit 1 as returning to the licensee response band (column 1) based on | |||
successful completion of this supplemental inspection. | |||
In accordance with 10 CFR 2.390 of the NRC's "Rules of Practice," a copy of this letter and | |||
its enclosure will be available electronically for public inspection in the NRC Public Document | |||
Room or from the Publicly Available Records (PARS) component of NRC's document 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. 50-282; 50-306; 72-010 | |||
License Nos. DPR-42; DPR-60 | |||
Enclosure: IR 05000282/2009015; 05000306/2009015 | |||
w/Attachment: Supplemental Information | |||
cc w/encl: Distribution via ListServ | |||
U.S. NUCLEAR REGULATORY COMMISSION | |||
REGION III | |||
Docket Nos: 50-282; 50-306 | |||
License Nos: DPR-42; DPR-60 | |||
Report No: 05000282/2009015; 05000306/2009015 | |||
Licensee: Northern States Power Company, Minnesota | |||
Facility: Prairie Island Nuclear Generating Plant, Units 1 & 2 | |||
Location: Welch, MN | |||
Dates: November 30 through December 4, 2009 | |||
Inspectors: W. Slawinski, Senior Health Physicist | |||
M. Phalen, Health Physicist | |||
Approved by: A. Boland, Director | |||
Division of Reactor Safety | |||
SUMMARY OF FINDINGS | |||
IR 05000282/2009015; 05000306/2009015; 11/30/2009 - 12/04/2009; Prairie Island Nuclear | |||
Generating Plant, Units 1 & 2; Supplemental Inspection 95001. | |||
This report covers an announced supplemental inspection by two regional health physics | |||
inspectors. No findings were 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, as applicable, were determined using | |||
Inspection Manual Chapter 0305, "Operating Reactor Assessment Program." Findings for | |||
which the SDP does not apply may be Green or be assigned a severity level after NRC | |||
management review. The NRCs program for overseeing the safe operation of commercial | |||
nuclear power reactors is described in NUREG-1649, Reactor Oversight Process, Revision 4, | |||
dated December 2006. | |||
Cornerstone: Public Radiation Safety | |||
The NRC staff 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 properly prepare and ship a package | |||
containing radioactive material in October 2008, in a manner that assured conformance with the | |||
Department of Transportation (DOT) radiation level limits specified in 49 CFR 173.441. The | |||
NRC staff previously characterized this issue as having low to moderate safety significance | |||
(White), as documented in NRC IR 05000282/2009008; 05000306/2009008. During this | |||
supplemental inspection, the inspectors determined that the licensee performed a | |||
comprehensive evaluation of the specific performance issue and that appropriate corrective | |||
actions were taken to address each of the root and contributing causes. The licensee | |||
determined that the performance issue had two root causes identified as: (1) inadequate | |||
procedures and methods to successfully evaluate, package and ship radioactive materials in | |||
accordance with NRC and DOT regulations; and (2) lack of a risk management process leading | |||
to inadequate management oversight of the radioactive material shipment program. | |||
Contributing causes were identified as: (1) ineffective incorporation of industry operating | |||
experiences into the radioactive material shipment program; and (2) deficient training and | |||
certification programs for radiation protection personnel that perform shipment related activities. | |||
Corrective actions focused on development of new procedures and enhancement of existing | |||
ones, improvements to the training and qualification program for staff involved in shipment | |||
activities, and the development of an integrated risk management program to drive | |||
management engagement and ensure proper oversight of potentially risk significant shipments. | |||
Given the licensee=s acceptable performance in addressing the failure to evaluate, package and | |||
transport a radioactive material shipment to satisfy DOT/NRC radiological limits that resulted in | |||
the White finding, this public radiation safety cornerstone performance issue will not be held | |||
open beyond the normal four quarters provided in accordance with the guidance in IMC 0305, | |||
AOperating Reactor Assessment Program.@ The four quarters elapsed at the end of the fourth | |||
quarter of 2009. | |||
No findings of significance were identified. | |||
1 Enclosure | |||
REPORT DETAILS | |||
4. OTHER ACTIVITIES | |||
4OA4 Supplemental Inspection (95001) | |||
.01 Inspection Scope | |||
The NRC staff performed this supplemental inspection in accordance with IP 95001 to | |||
assess the licensees evaluation of a White finding, which affected the public 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 licensees 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 NRCs Action Matrix in | |||
the first quarter of 2009 as a result of one inspection finding of low to moderate safety | |||
significance (White). Specifically, on October 29, 2008, the Prairie Island Nuclear | |||
Generating Plant shipped contaminated fuel sipping equipment to a vendor in | |||
Pennsylvania following decontamination of the equipment after its removal from the | |||
spent fuel pool. The equipment was surveyed, radiologically characterized, and | |||
packaged by both licensee and contractor staff and shipped as a surface contaminated | |||
object (SCO) in an open transport vehicle. Upon receipt by the vendor two-days later, | |||
package surface dose rates were found to exceed applicable DOT limits primarily due to | |||
a discrete radioactive particle that was embedded in the fuel sipping equipment. The | |||
fuel sipping equipment was found not to be properly braced or secured and shifted within | |||
the package during transport. A preliminary Yellow finding and an associated apparent | |||
violation were issued in NRC Inspection Report 05000282/2008009; 05000306/2008009. | |||
Based on the results of a radiological risk assessment employing both the public | |||
radiation safety and qualitative criteria significance determination processes, a final | |||
significance determination for a White finding and an associated Notice of Violation was | |||
issued by letter dated May 6, 2009. | |||
The licensee staff informed the NRC staff that they were ready for the supplemental | |||
inspection on October 30, 2009. The licensee performed a root cause evaluation (RCE), | |||
No. 01157726, Revision 2, to identify the root and contributing causes and other causal | |||
factors which allowed the risk-significant finding to occur, and to determine the | |||
organizational attributes that resulted in the White finding. The licensee also addressed | |||
safety culture in the RCE. | |||
2 Enclosure | |||
The inspectors reviewed the licensees 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 each of the identified causes and contributors. The | |||
inspectors also held discussions with licensee personnel to ensure that the root and | |||
contributing causes and the safety culture components were understood, and that | |||
corrective actions taken or planned were appropriate to address the causes and | |||
preclude repetition. | |||
.02 Evaluation of Inspection Requirements | |||
02.01 Problem Identification | |||
a. Inspection Procedure 95001 requires that the inspection staff determine that the | |||
licensees 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. | |||
The excessive radiation levels on the package were revealed to the licensee by a vendor | |||
that identified the conditions upon package receipt at its facility in Pennsylvania. The | |||
elevated radiation levels were determined by the vendor through its routine package | |||
receipt survey practices. The inspectors verified that this information was documented | |||
in records maintained within the licensee's corrective action program including the | |||
licensees RCE. | |||
b. Inspection Procedure 95001 requires that the inspection staff determine that the | |||
licensees evaluation of the issue documents how long the issue existed and prior | |||
opportunities for identification. | |||
The DOT compliance issue existed for two-days while the shipment was en route from | |||
the Prairie Island facility to the vendors site in Pennsylvania. | |||
As part of its root cause evaluation, the licensee reviewed the specific circumstances | |||
associated with this incident to determine if opportunities existed for the problem to have | |||
been identified during the shipment preparation process before the shipment was | |||
released from the Prairie Island site. The licensee recognized that it missed | |||
opportunities to self-identify the issue because its radioactive material shipment program | |||
was not robust. Additionally, the licensee reviewed its corrective action program and | |||
internal/external operating experience databases and determined that prior opportunities | |||
to identify flaws in its radioactive material transportation program existed along with | |||
precursor incidents which the licensee failed to effectively address. | |||
c. Inspection Procedure 95001 requires that the inspection staff determine that the | |||
licensees evaluation documents the plant specific risk consequences, as applicable, | |||
and compliance concerns associated with the issue. | |||
A plant specific probabilistic risk-assessment was not applicable to this issue. However, | |||
the licensee evaluated the radiological risk to the public based on the actual | |||
circumstances of the incident including the potential for unnecessary dose to members | |||
of the public that could have come into contact with the shipment. Using risk insights | |||
provided in the significance determination process (SDP) for public radiation safety | |||
(Appendix D of Manual Chapter 0609) and the SDP that provides qualitative criteria | |||
3 Enclosure | |||
(Appendix M of Manual Chapter 0609), the NRC concluded the performance issue | |||
represented a White finding primarily due to the limited actual radiological risk to the | |||
public. The NRCs final risk determination and finding were issued on May 6, 2009. The | |||
licensees RCE also documented that the finding associated with this issue was a | |||
violation of DOT and NRC requirements which limit package radiation levels to | |||
prescribed values. | |||
d. Findings | |||
No findings of significance were identified. | |||
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 using fleet | |||
guidance document FG-PA-RCE-01, "Root Cause Evaluation Manual," Revision 14, and | |||
other implementing procedures. The licensee used the following systematic methods to | |||
complete the RCE: | |||
* data gathering through interviews and document review; | |||
* events and causal factor charting; | |||
* task, barrier and change analyses; and | |||
* why staircase analysis. | |||
The inspectors assessed the RCE report against the criteria in the licensee's guidance | |||
document and procedures, and determined that the evaluation followed the procedural | |||
requirements. Overall, the inspectors determined that the licensee evaluated the issue | |||
using systematic methodologies to adequately identify the root and contributing causes. | |||
b. Inspection Procedure 95001 requires that the inspection staff determine that the | |||
licensees RCE was conducted to a level of detail commensurate with the | |||
significance of the issue. | |||
The licensee's RCE employed various systematic methods to identify the causes of the | |||
performance issue as delineated above. Different methodologies were used to ensure | |||
the root and contributory causes were identified and aligned with those determined | |||
through alternate means. The licensees RCE determined the root causes of the | |||
performance issue were: (1) inadequate procedures and methods to successfully | |||
evaluate, package and ship radioactive materials in accordance with NRC and DOT | |||
regulations; and (2) the lack of a risk management process leading to inadequate | |||
management oversight of the radioactive material shipment program. In particular, the | |||
licensee's RCE correctly concluded that the root causes involved systemic issues with | |||
the radioactive material transportation program and that the failure of a human | |||
4 Enclosure | |||
performance barrier or other singular barrier was not a major contributor to the overall | |||
problems that led to the incident. | |||
Two contributing causes were identified as: (1) ineffective incorporation of industry | |||
operating experiences into the radioactive material transportation program; and (2) | |||
deficient training and certification programs for personnel that perform shipment related | |||
activities. | |||
The inspectors determined that the licensees evaluation was comprehensive and of | |||
sufficient scope and depth to reach the proper conclusions. As a result, the inspectors | |||
concluded that the root cause evaluation was conducted to a level of detail | |||
commensurate with the significance of the problem. | |||
c. Inspection Procedure 95001 requires that the inspection staff determine that the | |||
licensees RCE included a consideration of prior occurrences of the issue and | |||
knowledge of operating experience (OE). | |||
As part of the RCE, the licensee reviewed its corrective action program and | |||
internal/external operating experience databases and determined that prior opportunities | |||
to identify flaws in its radioactive material transportation program existed along with | |||
precursor incidents which the licensee failed to effectively address. Previous corrective | |||
actions were limited in scope and focused on singular barriers such as worker | |||
performance rather than addressing broader programmatic flaws. Consequently, | |||
previous actions were not broadly effective. Moreover, the licensee determined there | |||
were numerous opportunities following the issuance of NRC Information Notice 88-101 | |||
for Prairie Island to respond to industry trends associated with radioactive material | |||
shipments containing discrete radioactive particles. The licensee determined that | |||
industry operating experiences related to radioactive material shipments were not | |||
formally evaluated. Consequently, the licensee concluded that industry operating | |||
experiences had not been effectively incorporated into its shipment program and this | |||
failure was a contributing cause of the White performance issue. | |||
Based on the licensees detailed evaluation and conclusions, the inspectors determined | |||
that the licensees RCE included consideration of prior occurrences of the problem and | |||
knowledge of OE. | |||
d. Inspection Procedure 95001 requires that the inspection staff determine that the | |||
licensees RCE addresses the extent of condition and extent of cause of the issue(s). | |||
The licensee=s evaluation considered the extent to which the actual condition (failure to | |||
meet shipment regulations) exists within other plant processes, equipment or human | |||
performance. The licensee's evaluation considered the potential for extent of condition | |||
within any of its hazardous material shipment programs including chemical and other | |||
non-radiological hazardous shipments. The licensee's extent of condition evaluation | |||
determined that no significant issues existed with other shipments of hazardous material | |||
based on a review of its corrective action program dating back to 2006. | |||
The licensees evaluation considered the extent to which the root causes of the | |||
radioactive material shipment problem impacted other plant processes, equipment or | |||
human performance. Five distinct areas of the licensee's hazardous material shipment | |||
program were evaluated in an effort to answer the following questions: | |||
5 Enclosure | |||
* Environment - Do the causes impact other work environments/locations ? | |||
* Equipment - Do the causes impact other equipment, systems or components? | |||
* People - Do the causes impact other personnel or other human performance | |||
issues? | |||
* Organization - Do the causes impact other crews, departments or organizations? | |||
* Process - Are there similar processes or procedures that were impacted by the | |||
causes? | |||
To conduct its review, the licensee evaluated each of its hazardous material shipment | |||
programs in the five areas listed above to determine the actual or potential impact of the | |||
root causes. The review was performed for the licensee's warehouse and security | |||
organizations and the environmental, chemistry, and construction departments, all of | |||
which were involved in hazardous material shipment activities to varying degrees. | |||
These shipment programs were reviewed to assess procedure adequacy, to determine if | |||
the activities were adequately covered under a work management risk process and to | |||
assess the quality of the associated training and certification programs. Overall, the | |||
licensee identified no significant conditions adverse to quality associated with its other | |||
(non-radiological) hazardous material shipment programs; however, the licensee | |||
identified procedural deficiencies and process flaws which were being addressed | |||
through the corrective action program. | |||
The inspectors concluded that the licensees RCE addressed the extent of condition and | |||
the extent of cause for the White performance issue. However, the inspectors identified | |||
a deficiency with the validation method for one of the licensee's extent of cause | |||
conclusions. Specifically, the RCE validated that staff involved in non-radiological | |||
hazardous material shipments were trained and qualified based solely on interviews, but | |||
failed to validate that requirements were met through more effective means such as | |||
record reviews. A corrective action document was generated by the licensee to address | |||
the validation issue identified by the inspectors. | |||
Additionally, some of the conclusions in the extent of cause review were not supported in | |||
the RCE report. Specifically, the root cause report failed to document the basis for | |||
concluding that certain non-radiological hazardous material shipment procedures were | |||
adequate and that those procedures did not impact the root cause. Similarly, the report | |||
failed to document the basis for concluding that the "work environment" and "equipment" | |||
associated with the extent of cause review did not impact the root cause. The inspectors | |||
determined through interviews that the licensee reached its conclusions using sound | |||
methodologies, but failed to document how those conclusions were derived. Corrective | |||
action document was generated by the licensee to address RCE report deficiencies | |||
identified by the inspectors. | |||
e. Inspection Procedure 95001 requires that the inspection staff determine that the | |||
licensees root cause, extent of condition, and extent of cause evaluations appropriately | |||
considered the safety culture components as described in IMC 0305. | |||
6 Enclosure | |||
The inspectors concluded that the safety culture aspects associated with the | |||
performance issue were appropriately considered in the licensee's RCE and included | |||
consideration whether a weakness in any safety culture component was a root cause or | |||
a significant contributing cause of the issue. | |||
The RCE determined that several safety culture components had impact on the | |||
performance issue and contributed to the White finding. Specifically, decision making | |||
(H.1), resources (H.2), work control and work practices (H.3 & H.4), and operating | |||
experience (P.2) all impacted the radioactive material shipment program and collectively | |||
led to the shipment incident. Each of these safety culture components had corrective | |||
actions to address the issues. | |||
The inspectors determined that the root cause report erroneously documented that the | |||
corrective action program (P.1) did not impact the performance issue. Nevertheless, | |||
actions had been taken by the licensee to address this safety culture component. The | |||
error was attributed to a documentation flaw in the final revision (Revision 2) of the RCE | |||
report. | |||
f. Findings | |||
No findings of significance were identified. | |||
02.03 Corrective Actions | |||
a. Inspection Procedure 95001 requires that the inspection staff determine 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. | |||
The licensee's corrective actions focused on the programmatic problems associated with | |||
the identified root and contributing causes, and centered on the most risk significant | |||
activities to drive staff and management involvement. Those activities related to the | |||
radiological characterization of material to be shipped including the identification of | |||
discrete radioactive particles, the packaging of the material and its loading into shipping | |||
containers, the evaluation of radiological survey differences and resolution of anomalous | |||
radiological data, and delineating thresholds and levels of management engagement | |||
consistent with shipment risk. | |||
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 report included but were not limited to: | |||
* Revisions to the suite of radioactive material shipment procedures to define, | |||
improve and enhance a variety of procedural attributes that impact shipment | |||
compliance. | |||
* Revisions to radiation protection procedures to address methods to assist in the | |||
identification of discrete radioactive particles, package labeling and notification | |||
requirements should particles exist. | |||
* Development of procedures for packaging of radioactive material. | |||
7 Enclosure | |||
* Development of a training and qualification program for shipping specialists and | |||
improvements in training for those involved in radioactive material shipment | |||
activities. | |||
* Development of an integrated risk management assessment process that | |||
includes radioactive material shipment activities. | |||
* Enhancements to the licensee's self-assessment program and audit activities for | |||
the radioactive material shipment program. | |||
To address the safety culture components related to human performance, the licensee | |||
had initiated a Human Performance Improvement Plan as part of a larger Performance | |||
Recovery Project. These plans address multiple aspects of human performance and are | |||
tracked in the corrective action program. | |||
The inspectors determined that the corrective actions were appropriate for the | |||
associated causes. However, the inspectors found that the RCE report failed to | |||
document all of the corrective actions which the licensee implemented to prevent | |||
recurrence. Specifically, several additional corrective actions were taken to address the | |||
causes developed but were not documented in the RCE report. These included actions | |||
to notify the shipment coordinator under certain circumstances, to identify | |||
inconsistencies in package versus equipment radiological conditions, and the measures | |||
to ensure staff are trained before involvement in certain shipping activities. A corrective | |||
action document was generated by the licensee to address inspector identified RCE | |||
report deficiencies. | |||
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 licensee=s ceased all further radioactive material shipments following the vendor's | |||
notification to the licensee of the problem. The licensee dispatched members of the | |||
Prairie Island and corporate health physics staff to the vendor's site to facilitate its | |||
investigation. Various interim actions were taken before shipment activities | |||
recommenced which focused on radiological characterization and surveys, proper | |||
packaging to prevent migration of contaminants, and additional shipping specialist and | |||
management involvement in high risk shipments. Effectiveness reviews were performed | |||
following the development of corrective actions to ensure their adequacy. | |||
The inspectors determined that the corrective actions were prioritized with consideration | |||
of the risk significance and regulatory compliance. | |||
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 its corrective actions | |||
associated with the RCE. All actions associated specifically with shipment evaluation, | |||
packaging and preparation were completed in 2009, including effectiveness reviews to | |||
determine risk significant shipment readiness. The remaining actions were on schedule | |||
for completion in early 2010. The inspectors reviewed the completed corrective actions | |||
8 Enclosure | |||
and concluded that they had been implemented timely and effectively. No concerns | |||
were identified 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 means to validate the effectiveness of its corrective actions for | |||
the White performance issue. These were documented in the RCE and consisted of | |||
direct observations of risk significant shipment activities by industry peers, site | |||
management and the nuclear oversight organization, an external assessment of the | |||
radioactive material shipment program and a pending evaluation of recent operating | |||
experience reviews. Action items were entered into the corrective action program to | |||
ensure the effectiveness reviews were performed. The inspectors determined that | |||
quantitative and qualitative measures of success had been developed for determining | |||
the effectiveness of the corrective actions to preclude repetition. | |||
e. Inspection Procedure 95001 requires that the inspection staff determine that the | |||
licensees 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 NOV ((05000282/2009008; | |||
05000306/2009008), Radioactive Material Shipment Package Radiation Levels | |||
Exceeded) to the licensee on May 6, 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 the date when full compliance was achieved, | |||
was already adequately addressed on the docket in Inspection Report No. | |||
05000282/2008009; 05000306/2008009. The NRC staff did not require a response from | |||
the licensee; therefore, this inspection requirement was not applicable. | |||
f. Findings | |||
No findings of significance were identified. | |||
4OA6 Exit Meeting - Regulatory Performance Meeting Summary | |||
On December 4, 2009, the inspectors presented the inspection results to Messrs. B. | |||
Sawatzke, Site Director, and K. Ryan, Plant Manager, and other members of the Prairie | |||
Island and Excel Energy staffs, who acknowledged the conclusions. As part of this | |||
meeting, in accordance with IMC 0305, Section 10.01(a), Mr. K. O'Brien and other NRC | |||
staff discussed the issues related to the White finding that resulted in Prairie Island being | |||
placed in the Regulatory Response Column of the Action matrix. The discussions | |||
included the causes, corrective actions, extent of condition, and extent of cause | |||
associated with the White performance issue in the public radiation safety cornerstone. | |||
The inspectors asked the licensee if any of the material examined during the inspection | |||
should be considered proprietary. The licensee did not identify any information | |||
considered proprietary. | |||
ATTACHMENT: SUPPLEMENTAL INFORMATION | |||
9 Enclosure | |||
SUPPLEMENTAL INFORMATION | |||
KEY POINTS OF CONTACT | |||
Licensee | |||
B. Sawatzke, Director, Site Operations | |||
K. Ryan, Plant Manager | |||
J. Anderson, Regulatory Affairs Manager | |||
R. Hite, Radiation Protection and Chemistry Manager | |||
J. LeClair, CAP Project Engineering Supervisor/RCE Team Leader | |||
C. England, General Supervisor, Radiation Protection | |||
S. Nelson, Fleet Radiation Protection and Chemistry Manager | |||
S. Derleth, Radioactive Material Shipping Coordinator | |||
C. Sweet, Radioactive Material Shipping Coordinator | |||
K. Mews, Regulatory Affairs Engineer | |||
Nuclear Regulatory Commission | |||
K. O'Brien, Deputy Director, Division of Reactor Safety | |||
J. Giessner, Chief, Reactor Projects Branch 4 | |||
K. Stoedter, Senior Resident Inspector | |||
P. Zurawski, Resident Inspector | |||
LIST OF ITEMS OPENED, CLOSED AND DISCUSSED | |||
Opened | |||
None | |||
Closed | |||
05000282 and VIO Radioactive Material Shipment Package Radiation Levels | |||
05000306/2009008-01 Exceeded | |||
1 Attachment | |||
LIST OF DOCUMENTS REVIEWED | |||
The following is a list of documents reviewed during the inspection. Inclusion on this list does | |||
not imply that the NRC inspectors reviewed the documents in their entirety, but rather, that | |||
selected sections or portions of the documents were evaluated as part of the overall inspection | |||
effort. Inclusion of a document on this list does not imply NRC acceptance of the document or | |||
any part of it, unless this is stated in the body of the inspection report. | |||
4OA4 Supplemental Inspection | |||
Procedures | |||
FP-RP-JPP-01; RP Job Planning; Revision 4 & 5 | |||
FG-PA-RCE-01; Root Cause Evaluation Manual; Revision 14 | |||
RPP-D11; Radioactive Material Shipment; Revision 17 | |||
RPP-D11.7; Radioactive Material Shipment - LSA/SCO/LTD to a Licensed Facility; Revision 21 | |||
RPIP 1303; Packaging of Radioactive Material for Shipment; Revision 5 | |||
RPIP 1319; Loading of LSA Boxes and Containers; Revision 17 | |||
FP-WM-IRM-01; Integrated Risk Management; Revision 3 | |||
FP-WM-PLA-01; Work Order Planning Process; Revision 5 | |||
QF-2010; Work Order Risk Screening Worksheet; Revision 4 | |||
FP-PA-OE-01; Operating Experience Program; Revision 12 | |||
RPIP 1122; Discrete Radioactive Particle Program; Revision 16 | |||
Evaluations | |||
Root Cause Evaluation Report No. 01157726; Radioactive Material Shipment Exceeded DOT | |||
Limits; Revision 2 | |||
Nuclear Oversight Observation Report No. 2009-02-006 & 2009-04-005; Radwaste Shipping & | |||
Radioactive Material Shipment; May 29, 2009 & October 12, 2009, respectively | |||
Focused Self-Assessment No. 011832521; Transportation 95001 Inspection Preparation; | |||
August 17, 2009 | |||
Prairie Island High Risk Shipment Assessment; October 29, 2009 | |||
Miscellaneous | |||
AR-01209032; Extent of Cause Improvement Opportunity; December 2, 2009 | |||
2 Attachment | |||
AR-01209175; RCE Report Corrective Action Documentation; December 3, 2009 | |||
Lesson Plan No. P9030L-001; Radioactive Material Shipment; Revision 8 | |||
Lesson Plan No. P9030L-002; Radioactive Material and Fuel Receipt; Revision 6 | |||
Lesson Plan No. P9070L-004; Radioactive Material Shipment/Receipt; Revision 2 | |||
Lesson Plan No. P9070L-052; Human Performance Case Studies; Revision 0 | |||
LIST OF ACRONYMS USED | |||
CAP Corrective Action Program | |||
CFR Code of Federal Regulations | |||
DOT Department of Transportation | |||
IP Inspection Procedure | |||
NCV Non-Cited Violation | |||
NRC Nuclear Regulatory Commission | |||
OE Operating Experience | |||
RCE Root Cause Evaluation | |||
SDP Significance Determination Process | |||
3 Attachment | |||
M. Schimmel -2- | |||
the root causes involved programmatic issues and that the singular failure of a human performance | |||
barrier was not a major contributor to the overall problems that led to the incident. Corrective actions were | |||
implemented to address the identified causes and contributors, which included significant modification to | |||
existing procedures along with the development of new procedures. Also, the training and qualification | |||
program for staff involved in shipment activities was enhanced. Additionally, an integrated risk | |||
management process was developed that incorporates risk insights and thresholds to ensure the proper | |||
level of management engagement in shipment related activities. | |||
Although issues with aspects of your staff's extent of cause review for the White performance issue were | |||
identified by our inspectors and documentation deficiencies associated with your staff's root cause | |||
evaluation report were noted, based on the results of this inspection, no findings of significance were | |||
identified. | |||
Given your acceptable performance in addressing this performance issue, the White finding was only | |||
considered in assessing plant performance for a total of four quarters in accordance with the guidance in | |||
IMC 0305, AOperating Reactor Assessment Program.@ Consequently, 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 fourth quarter 2009). Although this finding | |||
is removed from consideration in the Action Matrix, Unit-2 remains in the regulatory response band | |||
(column 2) of the matrix based on a White finding in the mitigating systems cornerstone assessed during | |||
the third quarter of 2009. | |||
In accordance with 10 CFR 2.390 of the NRC's "Rules of Practice," a copy of this letter and its enclosure | |||
will be available electronically for public inspection in the NRC Public Document Room or from the | |||
Publicly Available Records (PARS) component of NRC's document 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. 50-282; 50-306 | |||
License Nos. DPR-42; DPR-60 | |||
Enclosure: IR 05000282/2009015; 05000306/2009015 | |||
w/Attachment: Supplemental Information | |||
cc w/encl: Distribution via ListServ | |||
DOCUMENT NAME: G:\DRS\Work in Progress\PRA 2009-015 Supp for Transp .doc | |||
9 Publicly Available 9 Non-Publicly Available 9 Sensitive 9 Non-Sensitive | |||
To receive a copy of this document, indicate in the concurrence box C = Copy without attach/encl; E = Copy with attach/encl N = No copy | |||
OFFICE RIII RIII | |||
NAME WSlawinski DBetancourt- ABoland | |||
Roldan for | |||
JGiessner | |||
DATE 01/12/10 01/12/10 01/12/10 | |||
OFFICIAL RECORD COPY | |||
Letter to Mark Schimmel from Anne T. Boland dated January 12, 2010 | |||
SUBJECT: PRAIRIE ISLAND NUCLEAR GENERATING PLANT, NRC SUPPLEMENTAL | |||
INSPECTION REPORT 05000282/2009015; 05000306/2009015 | |||
DISTRIBUTION: | |||
Susan Bagley | |||
RidsNrrPMPrairieIsland | |||
RidsNrrDorlLpl3-1 Resource | |||
RidsNrrDirsIrib Resource | |||
Cynthia Pederson | |||
Steven Orth | |||
Jared Heck | |||
Allan Barker | |||
Carole Ariano | |||
Linda Linn | |||
DRPIII | |||
DRSIII | |||
Patricia Buckley | |||
Tammy Tomczak | |||
ROPreports Resource | |||
}} |
Latest revision as of 22:55, 13 November 2019
ML100130231 | |
Person / Time | |
---|---|
Site: | Prairie Island |
Issue date: | 01/12/2010 |
From: | Boland A Division of Reactor Safety III |
To: | Schimmel M Northern States Power Co |
References | |
EA-08-349 IR-09-015 | |
Download: ML100130231 (17) | |
See also: IR 05000282/2009015
Text
UNITED STATES
NUCLEAR REGULATORY COMMISSION
REGION III
2443 WARRENVILLE ROAD, SUITE 210
LISLE, IL 60532-4352
January 12, 2010
Mr. Mark Schimmel
Site Vice President
Prairie Island Nuclear Generating Plant
Northern States Power Company, Minnesota
1717 Wakonade Drive East
Welch, MN 55089
SUBJECT: PRAIRIE ISLAND NUCLEAR GENERATING PLANT, UNITS 1 AND 2, NRC
SUPPLEMENTAL INSPECTION REPORT 05000282/2009015;
Dear Mr. Schimmel:
On December 4, 2009, the U. S. Nuclear Regulatory Commission (NRC) completed a
supplemental inspection pursuant to Inspection Procedure 95001, Inspection for One or
Two White Inputs in a Strategic Performance Area, at your Prairie Island Nuclear Generating
Plant. The enclosed report documents the inspection results, which were discussed at the
combined exit and regulatory performance meeting conducted on December 4, 2009, with
Messrs. Bradley Sawatzke, Kevin Ryan and other members of your staff.
As required by the NRC Reactor Oversight Process Action Matrix, this supplemental
inspection was performed due to a White performance issue in the Public Radiation Safety
Cornerstone. Specifically, on May 6, 2009, the NRC issued its Final Significance Determination
and Notice of Violation (NRC Inspection Report 05000282/2009008 and 05000306/2009008) for
a White finding that involved the failure to properly prepare and ship a package containing
radioactive material in a manner that assured conformance with Department of Transportation
(DOT) radiation level limits specified in 49 CFR 173.441. The NRC staff was informed on
October 30, 2009, of your staffs readiness for this inspection.
The objectives of this supplemental inspection were to provide assurance that: (1) the root
causes and the contributing causes for the White performance issue were understood; (2) the
extent of condition and extent of cause were identified; and (3) corrective actions were or will be
sufficient to address and preclude repetition of the root and contributing causes. The inspection
consisted of examination of activities conducted under your license as they related to safety,
compliance with the Commission=s rules and regulations, and the conditions of your operating
license.
The inspectors determined that your staff performed a comprehensive evaluation of the White
finding using systematic techniques to determine the root and contributory causes of the
performance issue. Your staff=s evaluation identified that the root causes centered on poor
processes and procedure quality, and insufficient oversight including the lack of a risk
management process associated with the shipment program. In particular, your staff correctly
concluded that
M. Schimmel -2-
the root causes involved programmatic issues and that the singular failure of a human
performance barrier was not a major contributor to the overall problems that led to the incident.
Corrective actions were implemented to address the identified causes and contributors, which
included significant modification to existing procedures along with the development of new
procedures. Also, the training and qualification program for staff involved in shipment activities
was enhanced. Additionally, an integrated risk management process was developed that
incorporates risk insights and thresholds to ensure the proper level of management engagement
in shipment related activities.
Although issues with aspects of your staff's extent of cause review for the White performance
issue were identified by our inspectors and documentation deficiencies associated with your
staff's root cause evaluation report were noted, based on the results of this inspection, no
findings of significance were identified.
Given your acceptable performance in addressing this performance issue, the White finding was
considered in assessing plant performance for a total of four quarters in accordance with the
guidance in IMC 0305, AOperating Reactor Assessment Program.@ Consequently, 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
fourth quarter 2009). Although this finding is removed from consideration in the Action Matrix,
Unit 2 remains in the regulatory response band (column 2) of the matrix based on a White
finding in the mitigating systems cornerstone assessed during the third quarter of 2009. We
have assessed Unit 1 as returning to the licensee response band (column 1) based on
successful completion of this supplemental inspection.
In accordance with 10 CFR 2.390 of the NRC's "Rules of Practice," a copy of this letter and
its enclosure will be available electronically for public inspection in the NRC Public Document
Room or from the Publicly Available Records (PARS) component of NRC's document 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. 50-282; 50-306;72-010
Enclosure: IR 05000282/2009015; 05000306/2009015
w/Attachment: Supplemental Information
cc w/encl: Distribution via ListServ
U.S. NUCLEAR REGULATORY COMMISSION
REGION III
Docket Nos: 50-282; 50-306
Report No: 05000282/2009015; 05000306/2009015
Licensee: Northern States Power Company, Minnesota
Facility: Prairie Island Nuclear Generating Plant, Units 1 & 2
Location: Welch, MN
Dates: November 30 through December 4, 2009
Inspectors: W. Slawinski, Senior Health Physicist
M. Phalen, Health Physicist
Approved by: A. Boland, Director
Division of Reactor Safety
SUMMARY OF FINDINGS
IR 05000282/2009015; 05000306/2009015; 11/30/2009 - 12/04/2009; Prairie Island Nuclear
Generating Plant, Units 1 & 2; Supplemental Inspection 95001.
This report covers an announced supplemental inspection by two regional health physics
inspectors. No findings were 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, as applicable, were determined using
Inspection Manual Chapter 0305, "Operating Reactor Assessment Program." Findings for
which the SDP does not apply may be Green or be assigned a severity level after NRC
management review. The NRCs program for overseeing the safe operation of commercial
nuclear power reactors is described in NUREG-1649, Reactor Oversight Process, Revision 4,
dated December 2006.
Cornerstone: Public Radiation Safety
The NRC staff 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 properly prepare and ship a package
containing radioactive material in October 2008, in a manner that assured conformance with the
Department of Transportation (DOT) radiation level limits specified in 49 CFR 173.441. The
NRC staff previously characterized this issue as having low to moderate safety significance
(White), as documented in NRC IR 05000282/2009008; 05000306/2009008. During this
supplemental inspection, the inspectors determined that the licensee performed a
comprehensive evaluation of the specific performance issue and that appropriate corrective
actions were taken to address each of the root and contributing causes. The licensee
determined that the performance issue had two root causes identified as: (1) inadequate
procedures and methods to successfully evaluate, package and ship radioactive materials in
accordance with NRC and DOT regulations; and (2) lack of a risk management process leading
to inadequate management oversight of the radioactive material shipment program.
Contributing causes were identified as: (1) ineffective incorporation of industry operating
experiences into the radioactive material shipment program; and (2) deficient training and
certification programs for radiation protection personnel that perform shipment related activities.
Corrective actions focused on development of new procedures and enhancement of existing
ones, improvements to the training and qualification program for staff involved in shipment
activities, and the development of an integrated risk management program to drive
management engagement and ensure proper oversight of potentially risk significant shipments.
Given the licensee=s acceptable performance in addressing the failure to evaluate, package and
transport a radioactive material shipment to satisfy DOT/NRC radiological limits that resulted in
the White finding, this public radiation safety cornerstone performance issue will not be held
open beyond the normal four quarters provided in accordance with the guidance in IMC 0305,
AOperating Reactor Assessment Program.@ The four quarters elapsed at the end of the fourth
quarter of 2009.
No findings of significance were identified.
1 Enclosure
REPORT DETAILS
4. OTHER ACTIVITIES
4OA4 Supplemental Inspection (95001)
.01 Inspection Scope
The NRC staff performed this supplemental inspection in accordance with IP 95001 to
assess the licensees evaluation of a White finding, which affected the public 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 licensees 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 NRCs Action Matrix in
the first quarter of 2009 as a result of one inspection finding of low to moderate safety
significance (White). Specifically, on October 29, 2008, the Prairie Island Nuclear
Generating Plant shipped contaminated fuel sipping equipment to a vendor in
Pennsylvania following decontamination of the equipment after its removal from the
spent fuel pool. The equipment was surveyed, radiologically characterized, and
packaged by both licensee and contractor staff and shipped as a surface contaminated
object (SCO) in an open transport vehicle. Upon receipt by the vendor two-days later,
package surface dose rates were found to exceed applicable DOT limits primarily due to
a discrete radioactive particle that was embedded in the fuel sipping equipment. The
fuel sipping equipment was found not to be properly braced or secured and shifted within
the package during transport. A preliminary Yellow finding and an associated apparent
violation were issued in NRC Inspection Report 05000282/2008009; 05000306/2008009.
Based on the results of a radiological risk assessment employing both the public
radiation safety and qualitative criteria significance determination processes, a final
significance determination for a White finding and an associated Notice of Violation was
issued by letter dated May 6, 2009.
The licensee staff informed the NRC staff that they were ready for the supplemental
inspection on October 30, 2009. The licensee performed a root cause evaluation (RCE),
No. 01157726, Revision 2, to identify the root and contributing causes and other causal
factors which allowed the risk-significant finding to occur, and to determine the
organizational attributes that resulted in the White finding. The licensee also addressed
safety culture in the RCE.
2 Enclosure
The inspectors reviewed the licensees 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 each of the identified causes and contributors. The
inspectors also held discussions with licensee personnel to ensure that the root and
contributing causes and the safety culture components were understood, and that
corrective actions taken or planned were appropriate to address the causes and
preclude repetition.
.02 Evaluation of Inspection Requirements
02.01 Problem Identification
a. Inspection Procedure 95001 requires that the inspection staff determine that the
licensees 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.
The excessive radiation levels on the package were revealed to the licensee by a vendor
that identified the conditions upon package receipt at its facility in Pennsylvania. The
elevated radiation levels were determined by the vendor through its routine package
receipt survey practices. The inspectors verified that this information was documented
in records maintained within the licensee's corrective action program including the
licensees RCE.
b. Inspection Procedure 95001 requires that the inspection staff determine that the
licensees evaluation of the issue documents how long the issue existed and prior
opportunities for identification.
The DOT compliance issue existed for two-days while the shipment was en route from
the Prairie Island facility to the vendors site in Pennsylvania.
As part of its root cause evaluation, the licensee reviewed the specific circumstances
associated with this incident to determine if opportunities existed for the problem to have
been identified during the shipment preparation process before the shipment was
released from the Prairie Island site. The licensee recognized that it missed
opportunities to self-identify the issue because its radioactive material shipment program
was not robust. Additionally, the licensee reviewed its corrective action program and
internal/external operating experience databases and determined that prior opportunities
to identify flaws in its radioactive material transportation program existed along with
precursor incidents which the licensee failed to effectively address.
c. Inspection Procedure 95001 requires that the inspection staff determine that the
licensees evaluation documents the plant specific risk consequences, as applicable,
and compliance concerns associated with the issue.
A plant specific probabilistic risk-assessment was not applicable to this issue. However,
the licensee evaluated the radiological risk to the public based on the actual
circumstances of the incident including the potential for unnecessary dose to members
of the public that could have come into contact with the shipment. Using risk insights
provided in the significance determination process (SDP) for public radiation safety
(Appendix D of Manual Chapter 0609) and the SDP that provides qualitative criteria
3 Enclosure
(Appendix M of Manual Chapter 0609), the NRC concluded the performance issue
represented a White finding primarily due to the limited actual radiological risk to the
public. The NRCs final risk determination and finding were issued on May 6, 2009. The
licensees RCE also documented that the finding associated with this issue was a
violation of DOT and NRC requirements which limit package radiation levels to
prescribed values.
d. Findings
No findings of significance were identified.
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 using fleet
guidance document FG-PA-RCE-01, "Root Cause Evaluation Manual," Revision 14, and
other implementing procedures. The licensee used the following systematic methods to
complete the RCE:
- data gathering through interviews and document review;
- events and causal factor charting;
- task, barrier and change analyses; and
- why staircase analysis.
The inspectors assessed the RCE report against the criteria in the licensee's guidance
document and procedures, and determined that the evaluation followed the procedural
requirements. Overall, the inspectors determined that the licensee evaluated the issue
using systematic methodologies to adequately identify the root and contributing causes.
b. Inspection Procedure 95001 requires that the inspection staff determine that the
licensees RCE was conducted to a level of detail commensurate with the
significance of the issue.
The licensee's RCE employed various systematic methods to identify the causes of the
performance issue as delineated above. Different methodologies were used to ensure
the root and contributory causes were identified and aligned with those determined
through alternate means. The licensees RCE determined the root causes of the
performance issue were: (1) inadequate procedures and methods to successfully
evaluate, package and ship radioactive materials in accordance with NRC and DOT
regulations; and (2) the lack of a risk management process leading to inadequate
management oversight of the radioactive material shipment program. In particular, the
licensee's RCE correctly concluded that the root causes involved systemic issues with
the radioactive material transportation program and that the failure of a human
4 Enclosure
performance barrier or other singular barrier was not a major contributor to the overall
problems that led to the incident.
Two contributing causes were identified as: (1) ineffective incorporation of industry
operating experiences into the radioactive material transportation program; and (2)
deficient training and certification programs for personnel that perform shipment related
activities.
The inspectors determined that the licensees evaluation was comprehensive and of
sufficient scope and depth to reach the proper conclusions. As a result, the inspectors
concluded that the root cause evaluation was conducted to a level of detail
commensurate with the significance of the problem.
c. Inspection Procedure 95001 requires that the inspection staff determine that the
licensees RCE included a consideration of prior occurrences of the issue and
knowledge of operating experience (OE).
As part of the RCE, the licensee reviewed its corrective action program and
internal/external operating experience databases and determined that prior opportunities
to identify flaws in its radioactive material transportation program existed along with
precursor incidents which the licensee failed to effectively address. Previous corrective
actions were limited in scope and focused on singular barriers such as worker
performance rather than addressing broader programmatic flaws. Consequently,
previous actions were not broadly effective. Moreover, the licensee determined there
were numerous opportunities following the issuance of NRC Information Notice 88-101
for Prairie Island to respond to industry trends associated with radioactive material
shipments containing discrete radioactive particles. The licensee determined that
industry operating experiences related to radioactive material shipments were not
formally evaluated. Consequently, the licensee concluded that industry operating
experiences had not been effectively incorporated into its shipment program and this
failure was a contributing cause of the White performance issue.
Based on the licensees detailed evaluation and conclusions, the inspectors determined
that the licensees RCE included consideration of prior occurrences of the problem and
knowledge of OE.
d. Inspection Procedure 95001 requires that the inspection staff determine that the
licensees RCE addresses the extent of condition and extent of cause of the issue(s).
The licensee=s evaluation considered the extent to which the actual condition (failure to
meet shipment regulations) exists within other plant processes, equipment or human
performance. The licensee's evaluation considered the potential for extent of condition
within any of its hazardous material shipment programs including chemical and other
non-radiological hazardous shipments. The licensee's extent of condition evaluation
determined that no significant issues existed with other shipments of hazardous material
based on a review of its corrective action program dating back to 2006.
The licensees evaluation considered the extent to which the root causes of the
radioactive material shipment problem impacted other plant processes, equipment or
human performance. Five distinct areas of the licensee's hazardous material shipment
program were evaluated in an effort to answer the following questions:
5 Enclosure
- Environment - Do the causes impact other work environments/locations ?
- Equipment - Do the causes impact other equipment, systems or components?
- People - Do the causes impact other personnel or other human performance
issues?
- Organization - Do the causes impact other crews, departments or organizations?
- Process - Are there similar processes or procedures that were impacted by the
causes?
To conduct its review, the licensee evaluated each of its hazardous material shipment
programs in the five areas listed above to determine the actual or potential impact of the
root causes. The review was performed for the licensee's warehouse and security
organizations and the environmental, chemistry, and construction departments, all of
which were involved in hazardous material shipment activities to varying degrees.
These shipment programs were reviewed to assess procedure adequacy, to determine if
the activities were adequately covered under a work management risk process and to
assess the quality of the associated training and certification programs. Overall, the
licensee identified no significant conditions adverse to quality associated with its other
(non-radiological) hazardous material shipment programs; however, the licensee
identified procedural deficiencies and process flaws which were being addressed
through the corrective action program.
The inspectors concluded that the licensees RCE addressed the extent of condition and
the extent of cause for the White performance issue. However, the inspectors identified
a deficiency with the validation method for one of the licensee's extent of cause
conclusions. Specifically, the RCE validated that staff involved in non-radiological
hazardous material shipments were trained and qualified based solely on interviews, but
failed to validate that requirements were met through more effective means such as
record reviews. A corrective action document was generated by the licensee to address
the validation issue identified by the inspectors.
Additionally, some of the conclusions in the extent of cause review were not supported in
the RCE report. Specifically, the root cause report failed to document the basis for
concluding that certain non-radiological hazardous material shipment procedures were
adequate and that those procedures did not impact the root cause. Similarly, the report
failed to document the basis for concluding that the "work environment" and "equipment"
associated with the extent of cause review did not impact the root cause. The inspectors
determined through interviews that the licensee reached its conclusions using sound
methodologies, but failed to document how those conclusions were derived. Corrective
action document was generated by the licensee to address RCE report deficiencies
identified by the inspectors.
e. Inspection Procedure 95001 requires that the inspection staff determine that the
licensees root cause, extent of condition, and extent of cause evaluations appropriately
considered the safety culture components as described in IMC 0305.
6 Enclosure
The inspectors concluded that the safety culture aspects associated with the
performance issue were appropriately considered in the licensee's RCE and included
consideration whether a weakness in any safety culture component was a root cause or
a significant contributing cause of the issue.
The RCE determined that several safety culture components had impact on the
performance issue and contributed to the White finding. Specifically, decision making
(H.1), resources (H.2), work control and work practices (H.3 & H.4), and operating
experience (P.2) all impacted the radioactive material shipment program and collectively
led to the shipment incident. Each of these safety culture components had corrective
actions to address the issues.
The inspectors determined that the root cause report erroneously documented that the
corrective action program (P.1) did not impact the performance issue. Nevertheless,
actions had been taken by the licensee to address this safety culture component. The
error was attributed to a documentation flaw in the final revision (Revision 2) of the RCE
report.
f. Findings
No findings of significance were identified.
02.03 Corrective Actions
a. Inspection Procedure 95001 requires that the inspection staff determine 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.
The licensee's corrective actions focused on the programmatic problems associated with
the identified root and contributing causes, and centered on the most risk significant
activities to drive staff and management involvement. Those activities related to the
radiological characterization of material to be shipped including the identification of
discrete radioactive particles, the packaging of the material and its loading into shipping
containers, the evaluation of radiological survey differences and resolution of anomalous
radiological data, and delineating thresholds and levels of management engagement
consistent with shipment risk.
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 report included but were not limited to:
- Revisions to the suite of radioactive material shipment procedures to define,
improve and enhance a variety of procedural attributes that impact shipment
compliance.
- Revisions to radiation protection procedures to address methods to assist in the
identification of discrete radioactive particles, package labeling and notification
requirements should particles exist.
- Development of procedures for packaging of radioactive material.
7 Enclosure
- Development of a training and qualification program for shipping specialists and
improvements in training for those involved in radioactive material shipment
activities.
- Development of an integrated risk management assessment process that
includes radioactive material shipment activities.
- Enhancements to the licensee's self-assessment program and audit activities for
the radioactive material shipment program.
To address the safety culture components related to human performance, the licensee
had initiated a Human Performance Improvement Plan as part of a larger Performance
Recovery Project. These plans address multiple aspects of human performance and are
tracked in the corrective action program.
The inspectors determined that the corrective actions were appropriate for the
associated causes. However, the inspectors found that the RCE report failed to
document all of the corrective actions which the licensee implemented to prevent
recurrence. Specifically, several additional corrective actions were taken to address the
causes developed but were not documented in the RCE report. These included actions
to notify the shipment coordinator under certain circumstances, to identify
inconsistencies in package versus equipment radiological conditions, and the measures
to ensure staff are trained before involvement in certain shipping activities. A corrective
action document was generated by the licensee to address inspector identified RCE
report deficiencies.
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 licensee=s ceased all further radioactive material shipments following the vendor's
notification to the licensee of the problem. The licensee dispatched members of the
Prairie Island and corporate health physics staff to the vendor's site to facilitate its
investigation. Various interim actions were taken before shipment activities
recommenced which focused on radiological characterization and surveys, proper
packaging to prevent migration of contaminants, and additional shipping specialist and
management involvement in high risk shipments. Effectiveness reviews were performed
following the development of corrective actions to ensure their adequacy.
The inspectors determined that the corrective actions were prioritized with consideration
of the risk significance and regulatory compliance.
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 its corrective actions
associated with the RCE. All actions associated specifically with shipment evaluation,
packaging and preparation were completed in 2009, including effectiveness reviews to
determine risk significant shipment readiness. The remaining actions were on schedule
for completion in early 2010. The inspectors reviewed the completed corrective actions
8 Enclosure
and concluded that they had been implemented timely and effectively. No concerns
were identified 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 means to validate the effectiveness of its corrective actions for
the White performance issue. These were documented in the RCE and consisted of
direct observations of risk significant shipment activities by industry peers, site
management and the nuclear oversight organization, an external assessment of the
radioactive material shipment program and a pending evaluation of recent operating
experience reviews. Action items were entered into the corrective action program to
ensure the effectiveness reviews were performed. The inspectors determined that
quantitative and qualitative measures of success had been developed for determining
the effectiveness of the corrective actions to preclude repetition.
e. Inspection Procedure 95001 requires that the inspection staff determine that the
licensees 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 NOV ((05000282/2009008;
05000306/2009008), Radioactive Material Shipment Package Radiation Levels
Exceeded) to the licensee on May 6, 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 the date when full compliance was achieved,
was already adequately addressed on the docket in Inspection Report No.
05000282/2008009; 05000306/2008009. The NRC staff did not require a response from
the licensee; therefore, this inspection requirement was not applicable.
f. Findings
No findings of significance were identified.
4OA6 Exit Meeting - Regulatory Performance Meeting Summary
On December 4, 2009, the inspectors presented the inspection results to Messrs. B.
Sawatzke, Site Director, and K. Ryan, Plant Manager, and other members of the Prairie
Island and Excel Energy staffs, who acknowledged the conclusions. As part of this
meeting, in accordance with IMC 0305, Section 10.01(a), Mr. K. O'Brien and other NRC
staff discussed the issues related to the White finding that resulted in Prairie Island being
placed in the Regulatory Response Column of the Action matrix. The discussions
included the causes, corrective actions, extent of condition, and extent of cause
associated with the White performance issue in the public radiation safety cornerstone.
The inspectors asked the licensee if any of the material examined during the inspection
should be considered proprietary. The licensee did not identify any information
considered proprietary.
ATTACHMENT: SUPPLEMENTAL INFORMATION
9 Enclosure
SUPPLEMENTAL INFORMATION
KEY POINTS OF CONTACT
Licensee
B. Sawatzke, Director, Site Operations
K. Ryan, Plant Manager
J. Anderson, Regulatory Affairs Manager
R. Hite, Radiation Protection and Chemistry Manager
J. LeClair, CAP Project Engineering Supervisor/RCE Team Leader
C. England, General Supervisor, Radiation Protection
S. Nelson, Fleet Radiation Protection and Chemistry Manager
S. Derleth, Radioactive Material Shipping Coordinator
C. Sweet, Radioactive Material Shipping Coordinator
K. Mews, Regulatory Affairs Engineer
Nuclear Regulatory Commission
K. O'Brien, Deputy Director, Division of Reactor Safety
J. Giessner, Chief, Reactor Projects Branch 4
K. Stoedter, Senior Resident Inspector
P. Zurawski, Resident Inspector
LIST OF ITEMS OPENED, CLOSED AND DISCUSSED
Opened
None
Closed
05000282 and VIO Radioactive Material Shipment Package Radiation Levels05000306/2009008-01 Exceeded
1 Attachment
LIST OF DOCUMENTS REVIEWED
The following is a list of documents reviewed during the inspection. Inclusion on this list does
not imply that the NRC inspectors reviewed the documents in their entirety, but rather, that
selected sections or portions of the documents were evaluated as part of the overall inspection
effort. Inclusion of a document on this list does not imply NRC acceptance of the document or
any part of it, unless this is stated in the body of the inspection report.
4OA4 Supplemental Inspection
Procedures
FP-RP-JPP-01; RP Job Planning; Revision 4 & 5
FG-PA-RCE-01; Root Cause Evaluation Manual; Revision 14
RPP-D11; Radioactive Material Shipment; Revision 17
RPP-D11.7; Radioactive Material Shipment - LSA/SCO/LTD to a Licensed Facility; Revision 21
RPIP 1303; Packaging of Radioactive Material for Shipment; Revision 5
RPIP 1319; Loading of LSA Boxes and Containers; Revision 17
FP-WM-IRM-01; Integrated Risk Management; Revision 3
FP-WM-PLA-01; Work Order Planning Process; Revision 5
QF-2010; Work Order Risk Screening Worksheet; Revision 4
FP-PA-OE-01; Operating Experience Program; Revision 12
RPIP 1122; Discrete Radioactive Particle Program; Revision 16
Evaluations
Root Cause Evaluation Report No. 01157726; Radioactive Material Shipment Exceeded DOT
Limits; Revision 2
Nuclear Oversight Observation Report No. 2009-02-006 & 2009-04-005; Radwaste Shipping &
Radioactive Material Shipment; May 29, 2009 & October 12, 2009, respectively
Focused Self-Assessment No. 011832521; Transportation 95001 Inspection Preparation;
August 17, 2009
Prairie Island High Risk Shipment Assessment; October 29, 2009
Miscellaneous
AR-01209032; Extent of Cause Improvement Opportunity; December 2, 2009
2 Attachment
AR-01209175; RCE Report Corrective Action Documentation; December 3, 2009
Lesson Plan No. P9030L-001; Radioactive Material Shipment; Revision 8
Lesson Plan No. P9030L-002; Radioactive Material and Fuel Receipt; Revision 6
Lesson Plan No. P9070L-004; Radioactive Material Shipment/Receipt; Revision 2
Lesson Plan No. P9070L-052; Human Performance Case Studies; Revision 0
LIST OF ACRONYMS USED
CAP Corrective Action Program
CFR Code of Federal Regulations
DOT Department of Transportation
IP Inspection Procedure
NCV Non-Cited Violation
NRC Nuclear Regulatory Commission
OE Operating Experience
RCE Root Cause Evaluation
SDP Significance Determination Process
3 Attachment
M. Schimmel -2-
the root causes involved programmatic issues and that the singular failure of a human performance
barrier was not a major contributor to the overall problems that led to the incident. Corrective actions were
implemented to address the identified causes and contributors, which included significant modification to
existing procedures along with the development of new procedures. Also, the training and qualification
program for staff involved in shipment activities was enhanced. Additionally, an integrated risk
management process was developed that incorporates risk insights and thresholds to ensure the proper
level of management engagement in shipment related activities.
Although issues with aspects of your staff's extent of cause review for the White performance issue were
identified by our inspectors and documentation deficiencies associated with your staff's root cause
evaluation report were noted, based on the results of this inspection, no findings of significance were
identified.
Given your acceptable performance in addressing this performance issue, the White finding was only
considered in assessing plant performance for a total of four quarters in accordance with the guidance in
IMC 0305, AOperating Reactor Assessment Program.@ Consequently, 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 fourth quarter 2009). Although this finding
is removed from consideration in the Action Matrix, Unit-2 remains in the regulatory response band
(column 2) of the matrix based on a White finding in the mitigating systems cornerstone assessed during
the third quarter of 2009.
In accordance with 10 CFR 2.390 of the NRC's "Rules of Practice," a copy of this letter and its enclosure
will be available electronically for public inspection in the NRC Public Document Room or from the
Publicly Available Records (PARS) component of NRC's document 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. 50-282; 50-306
Enclosure: IR 05000282/2009015; 05000306/2009015
w/Attachment: Supplemental Information
cc w/encl: Distribution via ListServ
DOCUMENT NAME: G:\DRS\Work in Progress\PRA 2009-015 Supp for Transp .doc
9 Publicly Available 9 Non-Publicly Available 9 Sensitive 9 Non-Sensitive
To receive a copy of this document, indicate in the concurrence box C = Copy without attach/encl; E = Copy with attach/encl N = No copy
OFFICE RIII RIII
NAME WSlawinski DBetancourt- ABoland
Roldan for
JGiessner
DATE 01/12/10 01/12/10 01/12/10
OFFICIAL RECORD COPY
Letter to Mark Schimmel from Anne T. Boland dated January 12, 2010
SUBJECT: PRAIRIE ISLAND NUCLEAR GENERATING PLANT, NRC SUPPLEMENTAL
INSPECTION REPORT 05000282/2009015; 05000306/2009015
DISTRIBUTION:
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