ML23145A227

95001 Supplemental Inspection Report 05000382/2023040, and Exercise of Enforcement Discretion

ML23145A227
Person / Time
Site:	Waterford
Issue date:	06/02/2023
From:	Geoffrey Miller NRC/RGN-IV/DRSS
To:	Ferrick J Entergy Operations
References
EA-22-033, EA-22-119, EA-23-036 IR 2023040
Download: ML23145A227 (27)

See also: IR 05000382/2023040

Text

June 2, 2023

EA-22-033

EA-22-119

EA-23-036

John Ferrick, Site Vice President

Entergy Operations, Inc.

17265 River Road

Killona, LA 70057

SUBJECT: WATERFORD STEAM ELECTRIC STATION, UNIT 3 - 95001 SUPPLEMENTAL

INSPECTION REPORT 05000382/2023040 AND EXERCISE OF

ENFORCEMENT DISCRETION

Dear John Ferrick:

On May 16, 2023, the U.S. Nuclear Regulatory Commission (NRC) completed a supplemental

inspection using Inspection Procedure 95001, Supplemental Inspection Response to Action

Matrix Column 2 (Regulatory Response) Inputs at the Waterford Steam Electric Station, Unit 3

(Waterford). The enclosed inspection report documents the inspection results which were

discussed with Mandy Halter, General Manager of Plant Operations, and other members of your

staff during an on-site meeting on March 3, 2023. In addition, the results were discussed during

an exit meeting on May 16, 2023, with you and other members of your staff.

The NRC performed this inspection to review your stations actions in response to two White

violations in the emergency preparedness cornerstone area. On February 15, 2023, you

informed the NRC that your station was ready for the supplemental inspection.

The NRC determined that your staffs evaluation identified the cause of the two White violations.

Specifically, the root cause evaluations for the two White violations, as well as a common-cause

root cause evaluation, identified the root causes. These included ineffective technical reviews of

radiation monitor calibration procedures and practices, resulting in deficiencies in calibration

practices over many years. Also included was a radiation monitor database configuration control

process that lacked measures to ensure that the associated system data and documentation

was complete, accurate, and up-to-date. Corrective actions to preclude repetition are discussed

in detail in the enclosed inspection report.

Overall, the NRC determined that Waterfords problem identification, causal analyses, and

corrective actions sufficiently addressed the performance issues that led to the two White

violations. All inspection objectives, as described in Inspection Procedure 95001, were met, and

this inspection is, therefore, closed. With the closure of the two White violations, and as a result

of our continuous review of plant performance, the NRC has updated its assessment of

Waterford. This assessment supplements, but does not supersede, the end-of-cycle letter

issued on March 1, 2023. Based on successful completion of the supplemental inspection, and

J. Ferrick 2

issuance of this inspection report, Waterford has transitioned to the licensee response column

of the NRC Action Matrix (Column 1) as of the date of the exit meeting. However, consistent

with IMC 0305, the violations will still be considered for agency actions in accordance with the

Reactor Oversight Process Action Matrix until December 31, 2023.

The NRC inspectors also reviewed five additional violations occurring between November 11,

1987, to May 16, 2023, identified by your staff. The NRC has evaluated these examples and

determined that four violations are not greater than White significance, and one violation is not

greater than Green significance. However, because these violations were identified by

Waterford personnel through an extent of condition review, their causes are similar to the

causes for the original violations, and the corrective actions for the original violations will also

correct these violations, the NRC has determined that enforcement discretion is warranted for

all five violations as described in the NRC Enforcement Policy, Section 3.3.

In accordance with 10 CFR 2.390 of the NRCs Agency Rules of Practice and Procedure, a

copy of this letter, its enclosure, and your response, if you choose to provide one, will be made

available electronically for public inspection in the NRC Public Document Room and from the

NRCs Agencywide Documents Access and Management System (ADAMS), accessible from

the NRC website at http://www.nrc.gov/reading-rm/adams.html.

Sincerely,

Rivera-Varona, Aida signing on behalf

of Miller, Geoffrey

on 06/02/23

Geoffrey B. Miller, Director (Acting)

Division of Radiological Safety & Security

Docket No. 05000382

License No. NPF-38

Enclosure:

Supplemental Inspection Report 2023040

cc w/ encl: Distribution via LISTSERV

ML23145A227

SUNSI Review: ADAMS: Non-Publicly Available Non-Sensitive Keyword:

By: JGK Yes No Publicly Available Sensitive NRC-002

OFFICE SES:ACES HP:RCB SEP:RCB C:RCB C:PBD ATL:ACES

NAME JKramer DAntonangeli SHedger BAlferink JDixon RKumana

SIGNATURE /RA/ E /RA/ E /RA/ E /RA/ E /RA/ E /RA/ E

DATE 05/30/23 05/26/23 05/25/23 05/30/23 05/25/23 05/26/23

OFFICE RC OE DD:DORS D:DRSS

NAME DCylkowski DJones MHay GMiller

SIGNATURE /RA/ E /RA/ E /RA/ E /RA/ ARivera-Varona for

DATE 05/31/23 05/31/23 06/01/23 6/2/2023

U.S. NUCLEAR REGULATORY COMMISSION

Inspection Report

Docket Number: 05000382

License Number: NPF-38

Report Number: 05000382/2023040

Licensee: Entergy Operations, Inc.

Facility: Waterford Steam Electric Station, Unit 3

Location: Killona, LA

Inspection Dates: February 27, 2023 to May 16, 2023

Inspectors: S. Hedger, Senior Emergency Preparedness Inspector

D. Antonangeli, Health Physics Inspector

Approved By: Beth S. Alferink, Chief (Acting)

Response Coordination Branch

Division of Radiological Safety & Security

Enclosure

SUMMARY

The U.S. Nuclear Regulatory Commission (NRC) continued monitoring the licensees

performance by conducting an inspection procedure 95001 supplemental inspection at the

Waterford Steam Electric Station, Unit 3, in accordance with the Reactor Oversight Process.

The Reactor Oversight Process is the NRCs program for overseeing the safe operation of

commercial nuclear power reactors. Refer to

https://www.nrc.gov/reactors/operating/oversight.html for more information.

List of Findings and Violations

No findings or violations of more than minor significance were identified.

Additional Tracking Items

Type Issue Number Title Report Section Status

NOV 05000382/2022091-01 Failure to Maintain Accurate 95001 Closed

Dose Assessment Methods

EA-22-119

NOV 05000382/2022501-01 Failure to Maintain Accurate 95001 Closed

EAL Thresholds and Dose

Assessment Methods

EA-22-033

EDG EA-23-036 Main Steam Line B 95001 Closed

Radiation Monitor

(ARMIRE5500B) - Dose

Assessment (Example 1)

EDG EA-23-036 Boron Waste Management 95001 Closed

and Liquid Waste

Management Radiation

Monitors (PRMIRE0627,

PRMIRE0547) - Emergency

Action Level Classification

(Example 2)

EDG EA-23-036 Fuel Handling Building 95001 Closed

WRGM Mid-Range Detector

(PRMIRE3032) -

Emergency Action Level

Classification and Dose

Assessment (Example 3)

EDG EA-23-036 Containment High Range 95001 Closed

Radiation Monitors A and B

(ARMIRE5400AS,

ARMIRE5400BS) -

Emergency Action Level

Classification (Example 4)

EDG EA-23-036 Main Steam Line A 95001 Closed

Radiation Monitor

(PRMIRE5500A) - Dose

Assessment (Example 5)

2

INSPECTION SCOPES

Inspections were conducted using the appropriate portions of the inspection procedures (IPs) in

effect at the beginning of the inspection unless otherwise noted. Currently approved IPs with

their attached revision histories are located on the public website at http://www.nrc.gov/reading-

rm/doc-collections/insp-manual/inspection-procedure/index.html. Samples were declared

complete when the IP requirements most appropriate to the inspection activity were met

consistent with Inspection Manual Chapter (IMC) 2515, Light-Water Reactor Inspection

Program - Operations Phase. The inspectors reviewed selected procedures and records,

observed activities, and interviewed personnel to assess licensee performance and compliance

with Commission rules and regulations, license conditions, site procedures, and standards.

OTHER ACTIVITIES - TEMPORARY INSTRUCTIONS, INFREQUENT AND ABNORMAL

95001 - Supplemental Inspection Response to Action Matrix Column 2 (Regulatory Response)

Inputs

The inspectors reviewed and selectively challenged aspects of the licensees problem

identification, causal analysis, and corrective actions in response to two White findings in the

Emergency Preparedness cornerstone. The NRC communicated the licensees entry into

Reactor Oversight Process Action Matrix Column 2, Regulatory Response Column, in the

cover letter of NRC Inspection Report 05000382/2022090, dated September 12, 2022

(Agencywide Document and Management System (ADAMS) Accession Number

ML22241A143). Further, the NRC indicated with the second White finding that licensee

performance continued to be assessed in Action Matrix Column 2 in the cover letter of NRC

Inspection Report 05000382/2023090, dated February 1, 2023 (ML23035A384). The findings

are summarized below:

The licensee failed to follow and maintain the effectiveness of an emergency plan in

accordance with 10 CFR 50.54(q)(2). Specifically, the licensee failed to maintain a

standard emergency classification scheme as required by 10 CFR 50.47(b)(4) because

PRM-IRE-0002 (condenser exhaust wide range gas monitor, mid and high range

detectors) had errors in its output that could result in an over-classification up to a

General Emergency, resulting in unnecessary public protective actions. Also, the

licensee failed to use adequate methods, systems, and equipment for assessing and

monitoring actual and potential offsite consequences of a radiological emergency as

required by 10 CFR 50.47(b)(9), because those same errors would result in inaccurate

dose assessments for a radiological release through the main condenser exhaust.

The licensee failed to follow and maintain the effectiveness of an emergency plan in

accordance with 10 CFR 50.54(q)(2). Specifically, the licensee failed to use adequate

methods, systems, and equipment for assessing and monitoring actual and potential

offsite consequences of a radiological emergency as required by 10 CFR 50.47(b)(9),

because the licensee had conversion factor errors that would result in inaccurate dose

assessments for a radiological release through the plant vent stack exhaust path.

The correspondence communicating the changes in action matrix status documented the

issuance of two White Notices of Violation (NOVs). For the first White NOV, the licensee

responded in correspondence submitted on October 12, 2022 (ML22285A214). The licensees

response to the second White NOV was documented on February 20, 2023 (ML23051A002).

The inspectors reviewed these responses as part of the inspection.

3

The licensee staff informed the NRC staff by letter, dated February 15, 2023, of their readiness

for this supplemental inspection (ML23046A375). The licensee performed three root cause

evaluations (RCEs) in preparation for the inspection to identify the process and organizational

weaknesses that resulted in the two White findings. The key RCEs reviewed were:

RCE CR-WF3-2022-3999, Condenser Wide Range Gas Monitor RD72 Incorrect

Calibration Methodology, Revisions 1 through 3

RCE CR-WF3-2022-6367, Incorrect Calibration of Wide Range Gas Monitors Used in

Emergency Response Procedures, Revisions 1 through 3

RCE CR-WF3-2022-7836, Waterford 3 Steam Electric Station Collective Review of

Radiation Monitors Issues, Revisions 1 through 3

As part of the evaluations, the licensee also assessed their safety culture to identify any

contribution to the root or contributing causes. In addition, due to their having two White Action

Matrix inputs, the licensee conducted a common-cause analysis to assess potential

programmatic weaknesses in performance (RCE CR-WF3-2022-7836). The licensee provided

the NRC inspectors a copy of their RCEs on February 16, 2023, along with other supporting

evaluations and documentation by February 21, 2023. Subsequently, the NRC performed the

onsite portion of this supplemental inspection during the week of February 27-March 3, 2023.

The objectives of this supplemental inspection included the following:

Provide assurance that the root causes and contributing causes of risk-significant

performance issues were understood.

Provide assurance that the extent of condition and extent of cause of risk-significant

performance issues were identified.

Provide assurance that the licensees corrective actions for risk-significant performance

issues were sufficient to address the root and contributing causes and prevent

recurrence.

Evaluate additional examples of failures to maintain the effectiveness of the Waterford

Steam Electric Station, Unit 3 emergency plan occurring between 1987 and February 27,

2023, as identified by the licensee through their review of legacy radiation monitor

calibration practices, supporting technical documentation maintenance, and equipment

maintenance issues, as part of their overall corrective action review for the two White

findings.

The inspectors reviewed the licensees RCEs and other corrective action program evaluations

the licensee conducted in support of, or as a result of, the RCEs. The inspectors reviewed

corrective actions that the licensee had taken to address the identified causes. The inspectors

also held discussions, conducted field walkdowns reviewing subject radiation monitoring

equipment, and conducted interviews with licensee personnel to determine if the root and

contributing causes, and the contribution of safety culture components, were understood, as

well as whether completed or planned corrective actions were adequate to address the causes

and prevent recurrence.

4

Supplemental Inspection Response to Action Matrix Column 2 (Regulatory Response) Inputs

(1 Sample)

(1) This supplemental inspection is being conducted in response to the licensee being

placed in the Regulatory Response column due to two White findings in the

Emergency Preparedness Cornerstone.

INSPECTION RESULTS

Assessment 95001

1) Problem Identification

a) Identification

The issues resulting in the two White findings were identified by the licensee. The

situations leading to their identification are described in detail within the Event

Narrative of RCE CR-WF3-2022-3999 and CR-WF3-2022-6367.

RCE CR-WF3-2022-3999 - Reviews of questions involving the licensees

maintenance of calibration source information led to a review of calibration

documentation and performance starting in late 2021. On January 18, 2022,

the licensee identified that the main condenser wide range gas monitor

(WRGM) mid- and high-range detectors post replacement calibrations did not

correctly account for source decay correction.

RCE CR-WF3-2022-6367 - Engineering reviews of post-corrective maintenance

documentation on September 8, 2022, revealed engineering conversion factors

for the plant stack WRGM had been updated with incorrect values on

June 6, 2022.

b) Exposure Time

The issues had the following exposure times:

RCE CR-WF3-2022-3999 - The main condenser WRGM detectors had been in

this condition since January 18, 2011, until February 4, 2022 (approximately

11 years).

RCE CR-WF3-2022-6367 - The plant stack WRGM high-range detectors had

incorrect factors in use from June 6, 2022, until September 11, 2022

(approximately 97 days).

c) Identification Opportunities

The licensee had multiple prior opportunities to identify the conditions leading to the two

White findings, including operating experience, previous detector failures, response to

previous regulatory issues with calibration and maintenance practices, and system

reviews. The licensees RCEs sufficiently addressed these prior opportunities to identify

these conditions, as discussed below.

5

d) Risk and Compliance

With emergency preparedness issues being evaluated from a deterministic

perspective, no formal risk analysis was performed for the two White findings.

However, using the existing criteria, the two issues had violations of White significance

issued in their respective inspection reports. The licensee did evaluate the risk and

consequences as part of the Analysis of Risk and Safety Consequences sub-section

of Section 3.0, Analysis of the Event, in each RCE. The described consequences and

risk insights were consistent with the NRC assessments.

NRC Assessment:

The inspectors determined that the licensee had multiple opportunities to identify and address

the conditions that led to the White findings, prior to their recent licensee identification.

However, the root and common cause evaluations adequately addressed prior opportunities to

identify. The licensee appropriately understands the risk and compliance aspects of the White

findings.

2) Causal Analysis

a) Methodology

The RCE for the first White finding (CR-WF3-2022-3999) employed multiple causal

analysis methods to identify root and contributing causes. Methods included a

comparative timeline, event, and causal factor charting; barrier analysis, organization

and programmatic screening; and performance gap analyses.

For the second White finding RCE (CR-WF3-2022-6367), the licensee used similar

causal analysis methods to the first, with additional ones added in the effort to identify

root and contributing causes. Methods included event and causal factor charting;

barrier analysis, task analysis, performance gap analyses, organizational and

programmatic screening; and human performance evaluation.

To identify additional broader root or contributing causes related to both White findings,

the common-cause analysis RCE (CR-WF3-2022-7836) utilized similar analysis tools.

Common methods included event and causal factor charting (including Why Trees);

barrier analysis, and organization and programmatic screening. In addition, the

licensee employed a common cause analysis. The scope for using these tools included

not only the events associated with the two White findings, but also other radiation

monitoring system (RMS) events captured in the corrective action program over the

previous two years.

The inspectors determined that the different methods provided a reliable and scrutable

evaluation. Also, the inspectors determined these analyses were performed with

sufficient rigor to identify root and contributing causes.

b) Level of Detail

The inspectors determined that each of the three RCEs was of sufficient detail

commensurate with the significance and complexity of the issues and regulatory

requirements.

6

c) Operating Experience

For each of the three evaluations, the licensee conducted reviews of internal and

external operating experience. The reviews looked for occurrences of same or similar

performance issues where knowledge gained could be used to improve the evaluation.

RCE CR-WF3-2022-3999: Review of internal operating experience found one issue

previously identified that had applicability to this evaluation: a 2009 issue where

questions regarding the appropriate actions and calibration procedure accuracy with

respect to a RD-72 detector replacement in the plant stack WRGM mid-range detector

(CR-WF3-2009-1101). Additional text addressing calibration practice review after

detector replacement was added to an existing RMS desk guide (MI-005-906), but no

requirements to review and revise calibration procedures were implemented. This was

a missed opportunity to identify the lack of direction to correctly replace and calibrate

WRGM RD-72 detectors. Regarding external operating experience the licensee found

that there were missed opportunities to detect the White finding based on review of

NRC Information Notice 2013-13 and RMS users group feedback on engineering

conversion factor replacement requirements with detector replacements (CR-WF3-

2022-0284). The inspectors concluded the operating experience review was

appropriate.

RCE CR-WF3-2022-6367: Internal operating experience review considered whether

reviews of the RMS database update process were appropriate while evaluating and

correcting the first White finding (CR-WF3-2022-0284, -3999). However, since the first

White finding involved historical technical errors in WRGM calibration methods, and

dealt with RMS factor database configuration control processes, the issues appeared to

be separate. Regarding external operating experience, the licensee concluded there

were no specific opportunities where instrument database configuration control events

could have resulted in this issue being avoided. The inspectors concluded that the

operating experience review was appropriate.

RCE CR-WF3-2022-7836: Internal operating experience review included events with all

types of RMS equipment over the last two years. These provided input in the common

cause analysis conducted within the evaluation. Regarding external operating

experience the licensee found that there were missed opportunities to detect the White

findings based on review of NRC Information Notice 2013-13 and other industry

information. The inspectors concluded that the operating experience review was

appropriate.

d) Extent of Condition and Cause

RCE CR-WF3-2022-3999: The extent of condition started with the review of

methodology used to calibrate WRGM detectors needing calibration after replacement.

The same condition was confirmed to exist in other WRGM detectors. Based on this,

the licensee extended the review to include all other radiation detectors that need

calibration after replacement. There was the potential that inadequate calibration

practices mentioned as part of the root cause statement affected other radiation

monitors at the plant. Therefore, an additional expansion in review scope took place,

including site radiation monitors with questions about their calibrations with same or

similar conditions to those originally being evaluated. In some cases, the licensee

7

identified radiation monitor issues that constituted failures to maintain the effectiveness

of the emergency plan. This resulted in identification of the following:

Conflicts between directions in Procedure MI-005-906, Radiation Monitor

System Desk Guide, and specific radiation monitor calibration procedures, led

to incorrect calibration practices.

Additional radiation monitors were found to be out of calibration with similar

conditions. This included WRGMs and area radiation monitors which support

emergency preparedness, Technical Specifications, and other licensing basis

assumptions. Some examples are detailed in the enforcement discretion

descriptions (examples 2, 3, and 4).

Detectors calibrated without calibration certificates being maintained.

Detectors with incorrect supporting equipment installed. An example is detailed

in the enforcement discretion descriptions (example 4).

Detectors not calibrated on required intervals.

Area radiation monitor calibrations that did not account for needed calibration

practice changes based on changes in equipment configuration and design

basis changes. An example is detailed in the enforcement discretion

descriptions (example 5).

The extent of cause scope included a review of all radiation detector calibration

procedures and instrument calibrations to see if changes made over the years had

resulted in calibration methodologies that were invalid in some respect. This was

because the licensee recognized the practice of making procedural changes without

adequate technical reviews, a key part of the root cause, most likely caused issues

elsewhere. For the procedure change review process, it was identified that past efforts

to ensure cross discipline reviews of technical procedure changes with supporting

documentation, using document W2.109, Procedure Development, Review &

Approval, were incomplete. Therefore, changes were needed in the process

(CR-WF3-2022-3999, CA-04) (associated with enforcement discretion example 1). This

lack of adequate procedure change reviews contributed to an example in the

enforcement discretion descriptions (example 2). This resulted in identification of the

following:

Calibration procedures lacked transfer calibration datasheets, as well as steps

for correct detector replacement.

Area radiation detectors did not have their specific reference values and dates

of calibration.

Area radiation detectors did not have their own isotope half-life calculation

worksheets.

The inspectors concluded that the licensees root cause evaluation adequately

addressed the extent of condition and extent of cause.

RCE CR-WF3-2022-6367: The extent of condition review included an assessment of

computer database constant values for the WRGMs in the plant, as well as other

radiation monitors that have computer database constant values maintained. The

values were compared with the controlled printed copy of the database values located

in the control room. Further, the controlled database values were verified versus vendor

information to ensure that the controlled copy had the correct values. This resulted in

identifying needed corrections in another electronic reference set of the controlled

8

values, separate from those used for controlling the radiation instrumentation, as well

as actions to check engineering changes and work orders over the last two years to

see if they had any effects on the computer database constant values being

maintained.

The extent of cause included review of equipment important to emergency response

with digital parameters that could be negatively affected if configuration control is not

completed correctly for parameter changes. Control mechanisms of other

documentation that can affect RMS equipment function, both licensee-developed and

vendor supplied, were part of this review as well. The inspectors concluded that the

licensees root cause evaluation adequately addressed the extent of condition and

extent of cause.

RCE CR-WF3-2022-7836: The extent of condition review was largely an assessment

to see if extent of condition items identified in the other two RCE addressed the

appropriate scope. The licensee added an additional review to CR-WF3-2022-6367 to

perform a comprehensive evaluation for other potential conditions affecting radiation

monitors that could create vulnerabilities for operability or functionality. The extent of

cause reviewed the root and contributing causes from the other two RCEs to identify

any gaps in scope for corrective action that may have existed. Of note, this review

identified that earlier efforts with RCE CR-WF3-2022-3999 ensuring technically

defensible reviews of procedure changes using Procedure W2.109 were not fully

effective (CR-WF3-2022-7836, CA-08). Therefore, actions addressing the procedure

change review process were re-opened and addressed as a root cause in this

evaluation (focus of enforcement example 1). The inspectors concluded that the

licensees root cause evaluation adequately addressed the extent of condition and

extent of cause.

e) Safety Culture

The licensee addressed the safety culture aspects of the events within each of the

three evaluations. In each, there was a provided matrix discussing each of the

performance issues resulting in the subject White finding(s) with respect to each of the

safety culture traits noted in NUREG-2165, Safety Culture Common Language. The

licensee provided appropriate corrective actions for any of the performance deficiencies

that aligned with safety culture aspects. The inspectors concluded that the licensees

root cause evaluation appropriately considered safety culture traits.

NRC Assessment:

The licensee identified the following root causes and contributing causes for each of the

problem identification statements associated with the three RCEs:

RCE CR-WF3-2022-3999

Root Cause: Technical reviews of procedure revisions to MI-003-387, Condenser

Vacuum Pump Discharge Wide Range Noble Gas Radiation Monitor Channel

Calibration PRMIR0002, were inadequate to account for validation methodology

changes to ensure proper setup and calibration to within requirements for dose

assessment for the RD-72 detectors (detector type in WRGMs).

9

Contributing Cause 1: The instrumentation and control (I&C) maintenance group had

not established requirements for calibrating the RD-72 detector to account for

infrequent performance and unique requirements for calibration when the detector is

replaced.

Contributing Cause 2: The I&C maintenance group had not obtained equipment to

validate specific count rates for replaced equipment or utilized vendor support with

available equipment (for example, a Multi-level Channel Analyzer) to verify detector

replacement setup is adequate.

Contributing Cause 3: Standards had not been reinforced for the I&C maintenance

group to incorporate lessons learned from post maintenance activities when additional

information was required to complete task.

Contributing Cause 4: Condition Reports related to calibration and replacement of the

RD-72 detectors had not been screened appropriately to require thorough evaluation

(level of evaluation and extent of condition) and effective corrective actions assigned.

This would have identified proper calibration actions after detector replacement and

would have provided assessments of equipment post-calibration ensuring the tasks

were completed correctly.

RCE CR-WF3-2022-6367

Root Cause: The configuration control process for radiation monitoring system (RMS)

monitors (Procedure UNT-007-029, Control of the Radiation Monitoring System

Database) had not been consistently implemented for the affected equipment.

Verification that the RMS data and documentation was complete, accurate, and

up-to-date was not consistently occurring when returning equipment to service.

Contributing Cause 1: Engineering and I&C Maintenance supervision had not

reinforced standards with their personnel requiring documentation to be maintained

complete, accurate, and up-to-date for radiation monitoring equipment.

Contributing Cause 2: WRGM calibration and functional test instructions were not

explicit as to what actions were needed to verify accuracy of RMS databases, what

information should be maintained for documentation, and what documentation is

required to be up-to-date and accurate prior to return to service.

Contributing Cause 3: Previous corrective actions had focused specifically on correctly

updating the equipment data points and the technical procedure for replacing RD-72

detectors. Corrective actions did not fully evaluate the administrative process for

updating the RMS database, leading to unforeseen issues after return to service.

RCE CR-WF3-2022-7836

Root Cause 1: Historic technical issues with RMS maintenance instructions were not

identified and addressed during the procedure revision process.

Root Cause 2: Maintenance instructions and change processes did not have clear

guidance that would ensure documentation for radiation monitoring systems was

maintained up-to-date and accurate.

10

Contributing Cause 1: I&C maintenance and engineering management had not been

enforcing corporate standards for procedural use and adherence. This includes

processes for updating procedures and performance of maintenance activities on RMS

equipment.

Contributing Cause 2: I&C maintenance and engineering management had not ensured

internal and external operating experiences, including industry best practices, had been

integrated into the RMS program and processes.

Contributing Cause 3: Plant management had not ensured that risks were identified,

evaluated, and mitigated for radiation monitoring maintenance activities through

systematic methods to ensure acceptable outcomes.

Contributing Cause 4: Historic corrective action process reviews associated with prior

RMS deficiencies have not resulted in aggregate reviews to identify larger issues.

Contributing Cause 5: Program governance had not been adequately established,

ensuring that periodic assessments and benchmarking activities resulted in system

improvements.

The inspectors determined that each of the three RCEs appropriately identified and

documented the root and contributing causes for the associated problem statements and

identified the appropriate extent of cause and condition.

3) Corrective Actions

RCE CR-WF3-2022-3999

a) Corrective Actions to Preclude Repetition

(1) Completed

(a) Revised the Fuel Handling Building WRGM calibration

procedure (MI-003-371) to include calibration instructions when

replacement of a RD-72 detector replacement is required. Revisions

address use of a multi-channel analyzer for replacement activities.

(b) Revised the Plant Stack WRGM calibration procedure (MI-003-383) to

include calibration instructions when replacement of a RD-72 detector

replacement is required. Revisions address use of a multi-channel analyzer

for replacement activities.

(c) Revised the Main Condenser WRGM calibration procedure (MI-003-387) to

include calibration instructions when replacement of a RD-72 detector

replacement is required. Revisions address use of a multi-channel analyzer

for replacement activities.

The effectiveness reviews for the Corrective Action to Preclude Repetition (CAPR)

involved an independent technical review of actions taken and produced

documentation following the next calibration following a RD-72 detector

replacement in one of the three subject WRGMs. The inspectors concluded

that the licensee has identified an appropriate effectiveness review for

RCE CR-WF3-2022-3999.

11

b) Other Corrective Actions

(1) Completed

(a) Completed calibration verifications of multiple site radiation monitors due to

questions raised about past calibration practices, calibration equipment

usage, and maintenance or correct supporting documentation. Initiated and

completed corrective maintenance as identified (extent of condition and

cause).

(b) Revised WRGM calibration procedures to include transfer calibration

datasheets.

(c) Revised Procedure W2.109, Procedure Development and Approval, to

include independent technical review (engineering cross-discipline reviews

at minimum) for proposed revisions changing the methodology for

completing tasks, as well as changing the equipment used to address a

task.

(d) Updated radiation monitor engineering basis documentation to ensure it is

based on the most accurate source information.

(e) Revised other radiation detector calibration procedures (non WRGM) to

ensure that correct calibration methodology following detector replacement

was documented. In addition, revised these procedures to ensure that

correct calculations and reference documentation will be maintained with

subsequent calibrations.

(f) Updated I&C maintenance group training to better address infrequent

activities such as detector replacement practices.

(g) Revised arrangements and plans for RD-72 detector replacements to

ensure that appropriate equipment and expertise are involved replacement

activities.

(h) Documented risk mitigation expectations for site management, providing

training on site-wide expectations.

(i) Revised both corrective action and performance improvement process

documentation to better address the level of rigor desired in condition report

reviews.

RCE CR-WF3-2022-6367

a) Corrective Actions to Preclude Repetition

(1) Completed

(a) Revised RMS calibration procedures with instruction ensuring database

values are maintained complete, accurate, and up to date prior to returning

affected equipment to service.

(b) Define reviewer and supervisor roles ensuring database values are

addressed during maintenance correctly. Individuals in these roles ensure

any database value change is implemented correctly as required.

(c) Define engineering reviews for database value changes to ensure impacts

are reviewed and addressed prior to returning affected equipment to

service.

The effectiveness reviews for the CAPR involve a sample review of work activity

documentation associated with replacement and calibration of radiation monitors.

This review activity will verify that correct vendor information is being documented,

12

actions to ensure accurate database values are in place and are being completed

appropriately, supervisory reviews are correctly being performed, and that

engineering reviews of proposed changes are taking place correctly. The

inspectors concluded that the licensee has identified an appropriate effectiveness

review for RCE CR-WF3-2022-6367.

b) Other Corrective Actions

(1) Completed

(a) Performed a review of RMS database values in place to ensure that correct

ones are being used for all associated radiation monitors.

(b) Reviewed work orders over the last two years affecting radiation monitors to

see if anything affecting database values was being documented correctly

and updated in the respective database.

(c) Reviewed radiation monitor database values and supporting basis

documentation to ensure that traceability of correct values can be

established to support their design functions.

(d) Established and communicated standards for RMS database value

maintenance to engineering and I&C maintenance supervision. Standards

were documented in observation tools used by supervision to ensure that

activities affecting the RMS database values are addressed appropriately.

(e) Revised radiation monitor calibration and functional test procedures (not just

those affecting WRGMs) to include database value verification activities

before and after doing work affecting the associated monitor. This included

line-by-line independent verification of actions steps, and revisions to

technician training on completing these tasks.

(f) Provided training on the RMS database change process to ensure staff

understand standards to improve audit quality and issue identification. Also

included was an action to audit the database change process semiannually.

RCE CR-WF3-2022-7836

a) Corrective Actions to Preclude Repetition

(1) Completed

(a) Root Cause 1: Revised Procedure W2.109, Procedure Development and

Approval, with direction in the editorial review process ensuring that

proposed changes get categorized as editorial or non-editorial changes

properly. This procedure revision ensures that technical issues are reviewed

by the appropriate licensee personnel. This was an additional action beyond

what was taken as part of corrective actions associated with RCE CR-WF3-

2022-3999 addressing a gap in previous efforts ensuring calibration

procedure changes get appropriate cross discipline reviews and have

technical background documentation supporting the changes adequacy.

(b) Root Cause 2: No additional corrective actions were identified following

review of RCE CR-WF3-2022-7836. CAPR RCE CR-WF3-2022-6367 (a)(1)

remains sufficient to address maintenance instructions and change

processes.

The effectiveness review for the CAPR involves sampling calibration procedure changes to

see if the changes to Procedure W2.109 are being implemented as designed. This will

involve reviewing the procedure change documentation, as well as radiation monitor work

orders and condition reports to see if the RMS database values are being maintained up to

13

date, and if there are any other needed corrections to see if any issues with radiation

monitor procedures and equipment are being identified that were previously missed. The

inspectors concluded that the licensee has identified an appropriate effectiveness review

for RCE CR-WF3-2022-7836.

b) Other Corrective Actions

(1) Completed - None

(2) Planned

(a) Perform an independent technical review of site maintenance instructions

for radiation monitors using vendor technical guidance. Identify any

discrepancies and address them using the corrective action program.

(b) Complete a health assessment of the RMS in the next year. Document any

identified common deficiencies, repetitive issues, and outstanding

maintenance activities which could negatively affect the systems health.

(c) Perform a review of procedure revisions categorized as editorial changes

over the last 24 months to see if the process described in

Procedure W2.109 was followed correctly. This involves radiation protection

procedures, as well as other types of procedures onsite (extent of cause).

(d) Complete training on lessons-learned and desired behaviors in procedural

adherence for leadership, managers, and supervisors. Leaderships

observation tools for work will be reviewed and documentation from required

observations will be evaluated to verify training effectiveness.

(e) Incorporate lessons learned from response to the two White findings into the

model work orders used for radiation monitor work activities.

(f) Perform a radiation monitor program self-assessment on a 12-month

periodicity. This is to ensure RMS equipment parameters are being

maintained accurately, and calibrations are being performed error-free.

NRC Assessment:

The inspectors determined that the licensee implemented or planned appropriate and timely

corrective actions to preclude repetition. The licensee also identified appropriate effectiveness

reviews for these actions. With respect to evaluating the licensees response to the two White

NOVs, the licensee demonstrated actions addressing the reasons for the violations, have

taken or planned for corrective actions with achievable results, and have addressed restoration

of full compliance. The inspectors identified the following weaknesses/performance

deficiencies (no significant weaknesses identified) in this inspection:

Weaknesses:

The inspectors identified that one of the actions for the first White findings root cause

(RCE CR-WF3-2022-3999, RC-CA4) was appropriately identified, but was not

appropriately implemented. Corrective action to revise document W2.109, Procedure

Development, Review & Approval, included revising parts of the process to include

independent technical reviews (cross-discipline, at a minimum including engineering)

for revisions changing methodology or equipment requirements to carry out tasks.

While procedure changes were implemented to address this as part of the normal

procedure revision process, no changes were made in the Editorial Correction (EC)

Review Process to ensure that proposed changes, which were not editorial by nature,

were identified, and assigned the necessary independent technical reviews. As a result,

this contributed to the issue with Main Steam Line B Radiation Monitor ARMIRE5500B

14

not reading correctly in October-November 2022 (CR-WF3-2022-6367) (see

enforcement discretion example 1). However, the inspectors noted the licensee

reevaluated this process issue in RCE CR-WF3-2022-7836; elevating actions from a

contributing cause to a CAPR; and completing the new actions in a prompt manner,

which fully addressed process vulnerabilities.

The inspectors identified that appropriate measures of success for the CAPR with RCE

CR-WF3-2022-3999 had not been developed such that the corrective actions

effectiveness would be evaluated. This involved an effectiveness review assessing

calibration effectiveness of RD-72 detectors after replacement. As was stated in

Section 8.0 of the RCE, the time standard for conducting this effectiveness review

would be completed at the next detector calibration after CAPR completion. Since the

next RD-72 detector calibration may occur for various situations, one of which is if there

is a detector replacement, the scope of when the effectiveness review could be

completed may be implemented for a calibration activity that does not include the

appropriate circumstances to measure corrective action effectiveness. In addition, the

reviews success criteria did not include qualitative measures for evaluation. The

licensee initiated actions to revise the effectiveness reviews scope addressing this

issue in CR-WF3-2023-01052.

4) Conclusion

Overall, the inspectors determined that the licensees problem identification, causal analyses,

and corrective actions sufficiently addressed the performance issues that led to the two White

findings. All inspection objectives, as described in the Inspection Procedure 95001, were met.

Scheduled corrective action items will be inspected as part of the ongoing NRC baseline

inspection program. Therefore, this inspection is closed.

Enforcement Discretion Enforcement Action EA-23-036: Main Steam Line B 95001

Radiation Monitor (ARMIRE5500B) - Dose

Assessment (Example 1)

Description: During the licensees extent of cause reviews associated with RCEs

CR-WF3-2022-3999 and CR-WF3-2022-6367, they broadened the scope of their corrective

actions to look at all radiation monitor detector replacements and the associated procedures.

The licensee added steps into their procedure change process to include independent

technical reviews of procedure changes associated with calibration methodology. However, a

subject matter expert evaluation of the detector replacement of Main Steam Line B Radiation

Monitor on October 20, 2022, resulted in the monitor being declared inoperable since it was

replaced (CR-WF3-2022-07376). Based on a causal analysis review, a calibration after the

monitor was replaced did not take place and was required to restore operability. In 2022, the

procedure MI-003-389 was revised to include steps for detector replacement. However, no

independent technical review of this procedure change occurred, which could have recognized

the error of no calibration required after install being in the revised procedure. As a result,

there was no radiation monitor calibration after detector replacement in October 2022. For

ARMIRE5500B, during the affected time, the monitor would read 40 percent lower than it was

supposed to. The normal calibration range is plus or minus 10 percent. Similar to RCE CR-

WF3-2022-3999 and RCE CR-WF3-2022-7836, technical reviews of the change to Procedure

MI-003-389 were inadequate in order to ensure proper setup and calibration of the Main Steam

Line B Radiation Monitor after replacement to within requirements for dose assessment.

15

The inoperable radiation monitor resulted in a failure to comply with a risk significant planning

standard (RSPS), with a degraded RSPS function. This is due to there being some cases in

which the dose projection process would be incapable of providing technically adequate

estimates of radioactive material releases to the environment or projected offsite doses.

Corrective Action(s): The licensee corrected the condition and completed the necessary

calibration activities. The radiation monitor was returned to operable status on November 10,

2022. To prevent future issues with technical procedure changes being inappropriately

categorized as editorial changes, and thus receiving inadequate reviews, additional revisions

to Procedure W2.109, Procedure Development and Approval, were completed, addressing

the CAPR for RCE CR-WF3-2022-7836. Actions are documented in the licensees corrective

action program.

Corrective Action Reference(s): Condition Reports CR-WF3-2022-07376,

CR-WF3-2022-07836

Enforcement:

Severity/Significance: The staff determined the significance of the violation is not greater than

White as determined by a bounding evaluation with Manual Chapter 0609, Appendix B,

Attachment 2.

Violation: Title 10 CFR 50.54(q)(2) requires, in part, that a holder of a license under

10 CFR Part 50 shall follow and maintain the effectiveness of an emergency plan that

meets the requirements in 10 CFR Part 50, Appendix E, and the planning standards of

10 CFR 50.47(b).

Title 10 CFR 50.47(b)(9) requires, in part, that adequate methods, systems, and equipment for

assessing and monitoring actual or potential offsite consequences of a radiological emergency

condition are in use.

Contrary to the above, from October 20 to November 10, 2022, the licensee failed to follow

and maintain the effectiveness of an emergency plan in accordance with 10 CFR 50.54(q)(2),

which meets the planning standards of 10 CFR 50.47(b). Specifically, the licensee failed to

have adequate methods for assessing and monitoring offsite consequences for a radiological

release through the steam generator B release path as required by 10 CFR 50.47(b)(9).

Discretion Basis: The NRC exercised enforcement discretion in accordance with Section 3.3 of

the Enforcement Policy, because the violation was identified by Waterford Steam Electric

Station, Unit 3 staff as part of the extent of condition for a previous enforcement action, the

violation has the same or similar root causes as the violation for which enforcement action was

previously taken, the violation does not substantially change the safety significance or

character of the initial violation, and the violation was corrected.

Enforcement Discretion Enforcement Action EA-23-036: Boron Waste 95001

Management and Liquid Waste Management

Radiation Monitors (PRMIRE0627, PRMIRE0547) -

Emergency Action Level Classification (Example 2)

16

Description: During licensee extent of cause reviews associated with RCEs

CR-WF3-2022-3999 and CR-WF3-2022-6367, it was identified that the calibration of the Boron

Waste Management and Liquid Waste Management Radiation Monitors had not been done

correctly for some time. Errors in engineering conversion factors used, as well as an incorrect

background radiation assumption used in calibration caused the issues, similar to the root and

contributing causes associated with RCE CR-WF3-2022-3999. Site calibration procedures

allowed for using a background radiation level of 800 counts per minute (cpm), whereas the

primary calibration documents associated with the radiation monitors allow for a maximum of

100 cpm. Background radiation at the time was roughly 700 cpm. For the two monitors, during

the affected time, they read 16.4 percent lower than they were supposed to. The normal

calibration range is plus or minus 15 percent.

The non-functional radiation monitor resulted in a failure to comply with a risk significant

planning standard (RSPS), with no loss of PS function or a degraded RSPS function. This is

due to an emergency action level being rendered ineffective such that an Unusual Event

(AU1.1) would be declared in a degraded manner.

Corrective Action(s): The licensee initiated compensatory measures for their emergency

preparedness function while the calibration issues were being resolved. The licensee entered

these issues into the corrective action program.

Corrective Action Reference(s): Condition Reports CR-WF3-2022-07572,

CR-WF3-2023-00243

Enforcement:

Severity/Significance: The staff determined the significance of the violation is not greater than

Green as determined by a bounding evaluation with Manual Chapter 0609, Appendix B,

Attachment 2.

Violation: Title 10 CFR 50.54(q)(2) requires, in part, that a holder of a license under

10 CFR Part 50 shall follow and maintain the effectiveness of an emergency plan that

meets the requirements in 10 CFR Part 50, Appendix E, and the planning standards of

10 CFR 50.47(b).

Title 10 CFR 50.47(b)(4) requires, in part, that a standard emergency classification and action

level scheme is in use by the nuclear facility licensee, and State and local response plans call

for reliance on information provided by facility licensees for determinations of minimum initial

offsite response measures.

Contrary to the above, from January 1, 1989, to May 16, 2023, the licensee failed to follow and

maintain the effectiveness of an emergency plan in accordance with 10 CFR 50.54(q)(2),

which meets the planning standards of 10 CFR 50.47(b). Specifically, the licensee failed to

have a standard emergency classification and action level scheme in use by the nuclear facility

licensee as required by 10 CFR 50.47(b)(4).

Discretion Basis: The NRC exercised enforcement discretion in accordance with Section 3.3 of

the Enforcement Policy, because the violation was identified by Waterford Steam Electric

Station, Unit 3 staff as part of the extent of condition for a previous enforcement action, the

violation has the same or similar root causes as the violation for which enforcement action was

previously taken, the violation does not substantially change the safety significance or

character of the initial violation, and the violation was corrected.

17

Enforcement Discretion Enforcement Action EA-23-036: Fuel Handling 95001

Building WRGM Mid-Range Detector

(PRMIRE3032) - Emergency Action Level

Classification and Dose Assessment (Example 3)

Description: During licensee extent of cause reviews associated with RCEs CR-WF3-2022-

3999 and CR-WF3-2022-6367, the licensee identified that the Fuel Handling Building WRGM

mid-range detector was out of calibration. Past operability review established that it had been

inoperable since November 11, 1987. The cause was found to be the removal of the

requirement to use a multi-channel analyzer during the calibration from the controlling

procedure, similar to the cause identified in RCE CR-WF3-2022-3999. A calibration of the Fuel

Handling Building WRGM mid-range detector was conducted using appropriate equipment

(multi-channel analyzer and a Barium-133 alignment source).

The as-found condition was that the detector was reading 18 percent higher than it was

supposed to (LER 2022-01-02, CR-WF3-2022-08104). The normal calibration range is plus or

minus 10 percent.

The inoperable radiation monitor resulted in a failure to comply with a risk significant planning

standard (RSPS), with a degraded RSPS function. This is due to there being some (but not all)

cases in which the dose projection process would be incapable of providing technically

adequate estimates of radioactive material releases to the environment or projected offsite

doses. Also, an emergency action level was rendered ineffective because it could have

resulted in an overclassification of a General Emergency (AG1.1), leading to unnecessary

protective actions being issued to the public.

Corrective Action(s): Adjustments and calibration were completed, returning it to operable

service on December 15, 2022. The licensee entered these issues into the corrective action

program.

Corrective Action Reference(s): Condition Reports CR-WF3-2022-03999,

CR-WF3-2022-08104

Enforcement:

Severity/Significance: The staff determined the significance of the violation is not greater than

White as determined by a bounding evaluation with Manual Chapter 0609, Appendix B,

Attachment 2.

Violation: Title 10 CFR 50.54(q)(2) requires, in part, that a holder of a license under

10 CFR Part 50 shall follow and maintain the effectiveness of an emergency plan that

meets the requirements in 10 CFR Part 50, Appendix E, and the planning standards

of 10 CFR 50.47(b).

Title 10 CFR 50.47(b)(4) requires, in part, that a standard emergency classification and action

level scheme is in use by the nuclear facility licensee, and State and local response plans call

for reliance on information provided by facility licensees for determinations of minimum initial

offsite response measures.

18

Title 10 CFR 50.47(b)(9) requires, in part, that adequate methods, systems, and equipment for

assessing and monitoring actual or potential offsite consequences of a radiological emergency

condition are in use.

Contrary to the above, from November 11, 1987, to December 15, 2022, the licensee failed

to follow and maintain the effectiveness of an emergency plan in accordance with

10 CFR 50.54(q)(2), which meets the planning standards of 10 CFR 50.47(b). Specifically,

the licensee failed to have adequate methods for assessing and monitoring offsite

consequences for a radiological release through the steam generator B release path as

required by 10 CFR 50.47(b)(9). In addition, the licensee failed to have a standard emergency

classification and action level scheme in use by the nuclear facility licensee as required by

10 CFR 50.47(b)(4).

Discretion Basis: The NRC exercised enforcement discretion in accordance with Section 3.3 of

the Enforcement Policy, because the violation was identified by Waterford Steam Electric

Station, Unit 3 staff as part of the extent of condition for a previous enforcement action, the

violation has the same or similar root causes as the violation for which enforcement action was

previously taken, the violation does not substantially change the safety significance or

character of the initial violation, and the violation was corrected.

Enforcement Discretion Enforcement Action EA-23-036: Containment High 95001

Range Radiation Monitors A and B

(ARMIRE5400AS, ARMIRE5400BS) - Emergency

Action Level Classification (Example 4)

Description: During licensee extent of cause reviews associated with RCE CR-WF3-2022-

3999, it was identified that Containment High Range Radiation Monitors A and B had both

been inoperable for varying time periods. For Containment High Range Monitor A, the cause

was due to a installed pico-ammeter board and a detector signal cable that were incapable

of providing for its design performance functions. The engineering conversion factors for

Containment High Range Monitor B were incorrect, negatively affecting the monitors

calibration. Further, for Containment High Range Monitors A and B, there was a failure

to account for the keep-alive source during half-life calculations, which is necessary for

correct calibration. The calibration practice issues were caused by inadequate legacy

instructions in their calibration Procedure MI-003-360, similar to the causes identified in

RCE CR-WF3-2022-3999.

The as-found condition was that Containment High Range Radiation Monitor A indication

during that affected time could not be used for reliable indication. Containment High Range

Radiation Monitor B was reading 29.8 percent lower than it was supposed to, with a normal

calibration range of plus or minus 15 percent.

The inoperable radiation monitors resulted in a failure to comply with a risk significant planning

standard (RSPS), with a degraded RSPS function. This is due to an emergency action level

rendered ineffective such that a General Emergency (FG1.1) would not be declared for a

particular off-normal event but an appropriate declaration would have been made in a

degraded manner.

Corrective Action(s): Containment High Range Radiation Monitor A was returned to operable

service on May 14, 2022. On May 11, 2022, Containment High Range Radiation Monitor B

was returned to operable service. The licensee entered these issues into the corrective action

program.

19

Corrective Action Reference(s): Condition Report CR-WF3-2022-03097

Enforcement:

Severity/Significance: The staff determined the significance of the violation is not greater than

White as determined by a bounding evaluation with Manual Chapter 0609, Appendix B,

Attachment 2.

Violation: Title 10 CFR 50.54(q)(2) requires, in part, that a holder of a license under

10 CFR Part 50 shall follow and maintain the effectiveness of an emergency plan that

meets the requirements in 10 CFR Part 50, Appendix E, and the planning standards of

10 CFR 50.47(b).

Title 10 CFR 50.47(b)(4) requires, in part, that a standard emergency classification and action

level scheme is in use by the nuclear facility licensee, and State and local response plans call

for reliance on information provided by facility licensees for determinations of minimum initial

offsite response measures.

Contrary to the above, from July 11, 2012, to May 11, 2022, the licensee failed to follow and

maintain the effectiveness of an emergency plan in accordance with 10 CFR 50.54(q)(2),

which meets the planning standards of 10 CFR 50.47(b). Specifically, the licensee failed to

have a standard emergency classification and action level scheme in use by the nuclear facility

licensee as required by 10 CFR 50.47(b)(4).

Discretion Basis: The NRC exercised enforcement discretion in accordance with Section 3.3 of

the Enforcement Policy, because the violation was identified by Waterford Steam Electric

Station, Unit 3 staff as part of the extent of condition for a previous enforcement action, the

violation has the same or similar root causes as the violation for which enforcement action was

previously taken, the violation does not substantially change the safety significance or

character of the initial violation, and the violation was corrected.

Enforcement Discretion Enforcement Action EA-23-036: Main Steam Line A 95001

Radiation Monitor (PRMIRE5500A) - Dose

Assessment (Example 5)

Description: During licensee extent of condition reviews associated with

RCE CR-WF3-2022-3999, the licensee identified that Main Steam Line A Radiation Monitor

failed numerous calibrations since detector replacement. Previous calibrations did not

correctly track new reference ion chamber output dose-rate values, which would be needed

to correctly calibrate the monitor on subsequent occasions. The cause was that calibration

Procedure MI-003-389 did not have steps directing recording these values for later use, similar

to the causes identified in RCE CR-WF3-2022-3999. Based on past reviews, the monitor had

not been operating with a satisfactory calibration, and therefore inoperable, since March 17,

2004.

The as-found condition was that the detector was reading 17 to 24 percent higher than it

was supposed to (CR-WF3-2022-03392). The normal calibration range is plus or minus

15 percent.

20

The non-functional radiation monitor resulted in a failure to comply with a risk significant

planning standard (RSPS), with a degraded RSPS function. This is due to there being some

(but not all) cases in which the dose projection process would be incapable of providing

technically adequate estimates of radioactive material releases to the environment or projected

offsite doses.

Corrective Action(s): The licensee determined the correct values and revised the calibration

procedure. With the corrected procedure, the radiation monitor was calibrated correctly and

returned to service on May 5, 2022. The licensee entered these issues into the corrective

action program.

Corrective Action Reference(s): Condition Reports CR-WF3-2022-02539, CR-WF3-2022-

03392, CR-WF3-2022-03097

Enforcement:

Severity/Significance: The staff determined the significance of the violation is not greater than

White as determined by a bounding evaluation with Manual Chapter 0609, Appendix B,

Attachment 2.

Violation: Title 10 CFR 50.54(q)(2) requires, in part, that a holder of a license under

10 CFR Part 50 shall follow and maintain the effectiveness of an emergency plan that

meets the requirements in 10 CFR Part 50, Appendix E, and the planning standards of

10 CFR 50.47(b).

Title 10 CFR 50.47(b)(9) requires, in part, that adequate methods, systems, and equipment for

assessing and monitoring actual or potential offsite consequences of a radiological emergency

condition are in use.

Contrary to the above, from March 17, 2004, to May 5, 2022, the licensee failed to follow and

maintain the effectiveness of an emergency plan in accordance with 10 CFR 50.54(q)(2),

which meets the planning standards of 10 CFR 50.47(b). Specifically, the licensee failed to

have adequate methods for assessing and monitoring offsite consequences for a radiological

release through the steam generator B release path as required by 10 CFR 50.47(b)(9).

Discretion Basis: The NRC exercised enforcement discretion in accordance with Section 3.3 of

the Enforcement Policy, because the violation was identified by Waterford Steam Electric

Station, Unit 3 staff as part of the extent of condition for a previous enforcement action, the

violation has the same or similar root causes as the violation for which enforcement action was

previously taken, the violation does not substantially change the safety significance or

character of the initial violation, and the violation was corrected.

EXIT MEETINGS AND DEBRIEFS

The inspectors verified no proprietary information was retained or documented in this report.

On May 16, 2023, the inspectors presented the 95001 supplemental inspection results to

John Ferrick, Site Vice President, and other members of the licensee staff.

21

On March 3, 2023, the inspectors presented the 95001 supplemental inspection

preliminary inspection results to Mandy Halter, General Manager of Plant Operations,

and other members of the licensee staff.

22

DOCUMENTS REVIEWED

Inspection Type Designation Description or Title Revision or

Procedure Date

95001 Corrective Action Condition Reports 2020-04019, 2022-0284, 2022-02010, 2022-02221, 2022-

Documents (CR-WF3-) 03999, 2022-06367, 2022-06378, 2022-06467, 2022-06477,

2022-06663, 2022-07326, 2022-07376, 2022-07572, 2022-

07593, 2022-07836, 2022-08104, 2023-00764, 2023-00765,

2023-00810

95001 Corrective Action Condition Reports 2023-0550, 2023-00978, 2023-00994, 2023-01001, 2023-

Documents (CR-WF3-) 01002, 2023-01003, 2023-01014, 2023-01016, 2023-01020,

Resulting from 2023-01052, 2023-01053, 2023-01055

Inspection

95001 Engineering EC 86890 Radiological Effluent EAL Values 0, 1

Changes

95001 Engineering EC 93677 Evaluate Impact of Detector Sensitivity Change For 0

Changes PRMIRE0110 & PRMIRE3032 Per CR-WF3-2022-02010 CA- 29 and Update Related Documents

95001 Miscellaneous CR-WF3-2022- Root Cause Evaluation, Condenser Wide Range Gas Monitor 1, 2, 3

03999 RD72 Incorrect Calibration Methodology

95001 Miscellaneous CR-WF3-2022- Root Cause Evaluation, Incorrect Calibration of Wide Range 1, 2, 3

6367 Gas Monitors Used in Emergency Response Procedures

95001 Miscellaneous CR-WF3-2022- Root Cause Evaluation, Waterford 3 Steam Electric Station 2, 3

7836 Collective Review of Radiation Monitor Issues

95001 Miscellaneous Work Task 2022-00095, 2023-0023, 2023-0024

Tracking

Documents (LO-

WLO-)

95001 Procedures EN-AD-106 Site Procedure Writer's Manual 2

95001 Procedures EN-HU-106 Procedure and Work Instruction Use and Adherence 9

95001 Procedures EN-LI-100 Process Applicability Determination 33

95001 Procedures EN-LI-101 10 CFR 50.59 Evaluations 21

95001 Procedures EN-LI-102 Corrective Action Program 47, 48

95001 Procedures EN-LI-118 Causal Analysis Process 35

95001 Procedures MI-003-350 Containment Purge Isolation Area Radiation Monitor Channel 302, 305

A or B Functional Test, ARMIR5024, ARMIR5025,

23

Inspection Type Designation Description or Title Revision or

Procedure Date

ARMIR5026, or ARMIR5027

95001 Procedures MI-003-360 Containment High Range Safety Channel A or B Area 309, 316

Radiation Monitor Calibration, ARMIR5400 A or ARMIR5400

B

95001 Procedures MI-003-370 Fuel Handling Building Ventilation Noble Gas Radiation 302, 304

Monitor Channel Functional Test PRMIR3032

95001 Procedures MI-003-371 Fuel Handling Building Ventilation System Emergency 311, 318

Exhaust High Range Noble Gas Radiation Monitor Channel

Calibration PRMIR3032

95001 Procedures MI-003-382 Plant Vent Stack High Range Noble Gas Radiation Monitor 6, 10

Channel Functional Test PRMIR0110

95001 Procedures MI-003-383 Plant Vent Stack High Range Noble Gas Radiation Monitor 21, 29

Channel Calibration PRMIR0110

95001 Procedures MI-003-386 Condenser Vacuum Pump Discharge High Range Noble Gas 301, 303

Radiation Monitor Channel Functional Test PRMIR0002

95001 Procedures MI-003-387 Condenser Vacuum Pump Discharge Wide Range Noble 19, 26

Gas Radiation Monitor Channel Calibration PRMIR0002

95001 Procedures MI-003-389 Main Steam Line Radiation Monitor Channel Calibration 312

ARMIR5500A or ARMIR5500B

95001 Procedures MI-005-906 Radiation Monitoring System Desk Guide 6

95001 Procedures MI-005-910 Mobile Airborne Radiation Monitor Calibration, ARMIR5132, 7, 9

ARMIR5144

95001 Procedures MI-005-919 Containment Post LOCA Area Radiation Monitor Safety 303, 309

Channel A or B Calibration, ARMIR5028, 5029, 5030, 5031

95001 Procedures UNT-007-029 Control of the Radiation Monitor System Database 4, 5, 7

95001 Procedures W2.109 Procedure Development, Review, and Approval 31, 32, 33,

35

95001 Work Orders Work Order 573242, 573245, 582053, 585706, 585710, 587031, 587955,

Number 588201, 588499

24