IR 05000382/2025040: Difference between revisions

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{{Adams
{{Adams
| number = ML25349A028
| number = ML26014A028
| issue date = 12/16/2025
| issue date = 01/14/2026
| title = 95001 Supplemental Inspection Supplemental Report 05000382/2025040 and Follow-Up Assessment Letter
| title = Waterford Steam Electric Station, Unit 3 - Amended 95001 Supplemental Inspection Report 05000382/2025040 and Follow-Up Assessment Letter
| author name = Dixon J
| author name = Dixon J
| author affiliation = NRC/RGN-IV/DORS/PBD
| author affiliation = NRC/RGN-IV/DORS/PBD
Line 10: Line 10:
| license number = NPF-038
| license number = NPF-038
| contact person =  
| contact person =  
| case reference number = EAF-RIV-2025-0090
| document report number = IR 2025040
| document report number = IR 2025040
| package number = NRC-002:ML26014A013
| document type = Inspection Report, Letter
| document type = Inspection Report, Letter
| page count = 0
| page count = 0
Line 18: Line 20:


=Text=
=Text=
{{#Wiki_filter:December 16, 2025
{{#Wiki_filter:January 14, 2026


==SUBJECT:==
==SUBJECT:==
WATERFORD STEAM ELECTRIC STATION, UNIT 3 - 95001 SUPPLEMENTAL INSPECTION SUPPLEMENTAL REPORT 05000382/2025040 AND FOLLOW-UP ASSESSMENT LETTER
WATERFORD STEAM ELECTRIC STATION, UNIT 3 - AMENDED 95001 SUPPLEMENTAL INSPECTION REPORT 05000382/2025040 AND FOLLOW-UP ASSESSMENT LETTER


==Dear Joseph Sullivan:==
==Dear Joseph Sullivan:==
On September 25, 2025, 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, and discussed the results of the inspection and the implementation of your corrective actions with David Oertling, General Manager Plant Operations, and other members of your staff.
On September 25, 2025, 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, and discussed the results of the inspection and the implementation of your corrective actions with David Oertling, General Manager Plant Operations, and other members of your staff.


Due to the temporary cessation of government operations, which commenced on October 1, 2025, the NRC began operating under its Office of Management and Budget-approved plan for operations during a lapse in appropriations. Consistent with that plan, the NRC operated at reduced staffing levels throughout the duration of the shutdown. However, the NRC continued to perform critical health and safety functions and make progress on other high-priority activities associated with the ADVANCE Act and Executive Order 14300. On November 13, 2025, following the passage of a continuing resolution, the NRC resumed normal operations.
The NRC identified the need to reissue NRC Inspection Report 05000382/2025040, dated December 16, 2025 (ADAMS Accession Number ML25349A028). Specifically, the inspection report did not include the notice of violation (NOV) discussed in Inspection Report 05000382/2025091, dated June 5, 2025 (ML25149A059) in the section titled Additional Tracking Items. The notice of violation should have been included as a closed NOV to indicate that it is no longer considered as an action matrix input as of the date of the exit meeting. Also, additional wording was included in the inspection report conclusion to more clearly indicate that the associated NOV is closed.


However, due to the 43-day lapse in normal operations, the Office of Nuclear Reactor Regulation granted the Regional Offices an extension on the issuance of the calendar year 2025 inspection reports that should have been issued by November 13, 2025, to December 31, 2025. The NRC resumed the routine cycle of issuing inspection reports on November 13, 2025.
No findings or violations of more than minor significance were identified during this inspection. This letter, its enclosure, and your response (if any) will be made available for public inspection and copying at http://www.nrc.gov/reading-rm/adams.html and at the NRC Public Document Room in accordance with Title 10 of the Code of Federal Regulations 2.390, Public Inspections, Exemptions, Requests for Withholding.
 
The NRC performed this inspection to review your stations actions in response to degraded performance that led to a violation of 10 CFR 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings and subsequent White finding regarding the failure to properly develop and implement adequate maintenance instructions for the fuel linkage connection to the mechanical governor for emergency diesel generator A. On August 20, 2025, you informed the NRC that your station was ready for the supplemental inspection (ADAMS Accession No.
 
ML25232A254). The NRC determined that your staffs evaluation of the degraded performance that led to the White finding identified a root cause. Specifically, your staffs evaluation identified that insufficient details were included in the preventive maintenance job plan for emergency diesel generator A.
 
The inspectors determined that the licensee appropriately identified the root cause and contributing causes using systematic methodologies, considered prior occurrences and operating experience and documented their analyses in sufficient detail. Based on the results of the inspection, the inspectors concluded that the objectives of the inspection procedure were met.
 
The NRC determined that the completed and planned corrective actions were sufficient to address the performance issue that led to the White finding. Therefore, the performance issue will be closed and no longer be considered as an Action Matrix input as of the date of the exit meeting. Based on the results of the inspection and our Action Matrix assessment, the NRC made the determination to transition Waterford Steam Electric Station, Unit 3 to the Licensee Response Column (Column 1) of the Action Matrix on September 25, 2025, considering the absence of additional Action Matrix inputs.


Sincerely, John L. Dixon, Jr., Chief Reactor Projects Branch D Division of Operating Reactor Safety Docket No. 05000382 License No. NPF-38
Sincerely, John L. Dixon, Jr., Chief Reactor Projects Branch D Division of Operating Reactor Safety Docket No. 05000382 License No. NPF-38
Line 68: Line 62:
Division of Operating Reactor Safety
Division of Operating Reactor Safety


=SUMMARY=
SUMMARY
The U.S. Nuclear Regulatory Commission (NRC) continued monitoring the licensees performance by conducting a 95001 supplemental inspection at 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.
The U.S. Nuclear Regulatory Commission (NRC) continued monitoring the licensees
 
performance by conducting a 95001 supplemental inspection at Waterford Steam Electric
===List of Findings and Violations===
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.
No findings or violations of more than minor significance were identified.
Additional Tracking Items
Type
Issue Number
Title
Report Section
Status
NOV
05000382/2025091-01
Emergency Diesel
Generator A Failure to Run
EAF-RIV-2025-0090
95001
Closed
CAPR
05000382/2025040-01
Waterford 95001 CAPR
CR-WF3-2024-04960-00017
Create and Implement a
Mechanical Maintenance
Procedure for Replacement
of the Mechanical Governor
for the Emergency Diesel
Generators
95001
Discussed


===Additional Tracking Items===
INSPECTION SCOPES
Type Issue Number Title Report Section Status CAPR 05000382/2025040-01 Waterford 95001 CAPR CR-WF3-2024-04960-00017 Create and Implement a Mechanical Maintenance Procedure for Replacement of the Mechanical Governor for the Emergency Diesel Generators 95001 Discussed
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 degraded performance that
led to Waterford Steam Electric Station, Unit 3 being moved into Column 2 of the Action Matrix
for a violation of 10 CFR 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings
and subsequent White finding regarding the failure to properly develop and implement adequate
maintenance instructions for the fuel linkage connection to the mechanical governor for
emergency diesel generator A. The preliminary White finding is discussed in Inspection Report
05000382/2025090, dated April 9, 2025 (ML25097A205). The final significance determination
and notice of violation are discussed in Inspection Report 05000382/2025091, dated
June 5, 2025 (ML25149A059).
Objective: Ensure that the root and contributing causes of individual and collective white
performance issues are understood.
Under this objective, the inspectors reviewed the root cause evaluation the licensee
conducted for a White finding regarding the failure to properly develop and implement
adequate maintenance instructions for the fuel linkage connection to the mechanical
governor for emergency diesel generator (EDG) A, as documented in Final Significance
Determination of a White Finding, Notice of Violation, and Follow-Up Assessment Letter for
Waterford Steam Electric Station, Unit 3, dated June 5, 2025 (Report 05000382/2025091
(ML25149A059)). Their review consisted of an evaluation of the following: the licensees
identification of the issue, when and how long the issue existed, prior opportunities for
identification, documentation of significant plant-specific consequences and compliance
concerns, use of systematic methodology to identify causes with a sufficient level of
supporting detail, consideration of prior occurrences, identification of extent-of-condition and
extent-of-cause, and identification of any potential programmatic weaknesses in
performance.
NRC Assessment: The inspectors concluded that this objective was Met. The inspectors
determined that the licensee appropriately identified the root cause and contributing cause
using systematic methodologies, considered prior occurrences and operating experience,
and documented their analyses in sufficient detail.


=INSPECTION SCOPES=
The licensee used multiple techniques to analyze the performance issue and identified the
following root cause and contributing cause:
*
Root cause: Insufficient details included in the preventive maintenance job plan for
EDG A. Specifically, details needed to perform work on a critical component, such as
guidance on proper alignment of the lever arm, torque values, and recommendations
for thread locking compounds, were not included in the preventive maintenance job
plan.
*
Contributing cause: An organizational performance gap in the planning department
did not ensure workers were in rule-based performance and represented a missed
opportunity for the maintenance organization to raise standards and improve
performance in planning.
a. Identification. The performance issue was self-revealed and identified during a
walkdown of EDG A following a mechanical overspeed trip on October 10, 2024. The
inspectors did not identify any concerns with the licensee characterization of the event.
b. Exposure Time. The licensee determined that an exposure time of 94 days plus one
day of repair time was applicable. The licensee concluded that EDG A would have failed to
run for its 24-hour mission time starting on July 8, 2024. The inspectors determined that the
licensee appropriately assessed the exposure time.
c. Identification Opportunities. The licensee identified additional opportunities for
identification as follows:
*
The licensee identified an opportunity for identification of the missing technical
information in the EDG governor replacement work order. The licensee had
previously replaced the EDG A governor in 2014. Following this replacement, system
engineers provided handwritten feedback on the work order with recommendations
to add steps to use a thread locking compound and include vendor specified torque
values. This feedback was not incorporated into the model work order used for the
governor replacement in 2024 contributing to the lack of sufficient technical
information in the work order.
*
The licensee identified a potential missed opportunity for identification of contact
between the EDG governor lever arm and the rod end during required quarterly
system walkdowns. The licensee determined that the fretting damage on the corner
of the lever could have potentially been identified, but the likelihood is low due to the
small area of damage that was visible.
The inspectors determined that the licensee appropriately identified missed identification
opportunities for the performance issue.
d. Risk and Compliance. The inspectors determined that the licensee had identified and
understood the plant-specific risk and compliance concerns associated with the
performance issue. The risk included continued inoperability of EDG A, although additional
alternate power sources were available for use at the time. Compliance concerns were
addressed by mitigating actions taken to enhance the work instructions for replacing the
EDG governor.


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.
e. Methodology. The licensee employed systematic evidence-based causal analysis to
reliably and transparently determine the root and contributing causes of the White
performance issue. The methods included equipment failure evaluation, failure modes
analysis, organizational and programmatic screening, common cause review, and a why
staircase.
f. Level of Detail. The inspectors determined the root cause evaluation was conducted and
documented to a level of detail commensurate with the significance and complexity of the
issue and regulatory requirements.
g. Operating Experience. The licensee reviewed operating experience for the performance
issue, and the following internal and external operating experience was relevant to the
diesel linkage failure.
The licensee performed an internal operating experience search and found three applicable
events related to diesel generators and inadequate work order quality. The licensee
identified one event from Waterford in 2016, which described a mechanical linkage that
disengaged from an auxiliary component cooling water valve due to an incorrectly installed
nut. The licensee documented two applicable events from Arkansas Nuclear One. In 2016,
an emergency diesel generator experienced a generator bearing failure due to inadequate
lubrication caused by an oil level sight glass that was installed upside down. In 2021, a
diesel generator experienced an inadvertent overspeed trip due to inadequate vendor
technical information in a test procedure. These events supported the licensees conclusion
regarding the importance of work order quality for successful task completion.
The licensee determined that external operating experience identified similar events related
to emergency diesel generators and fuel rack linkages.
*
In 2013, the EDG at Salem Hope Creek experienced frequency oscillations during a
monthly surveillance. The most likely apparent cause was determined to be
mechanical binding in the fuel rack linkage.
*
In 2003 at Susquehanna, the EDG fuel control linkage separated from the governor
terminal shaft lever causing loading to unexpectedly decrease during a surveillance
run. The bolt that attached the fuel control linkage to the governor terminal shaft
lever had backed out, likely due to not being tightened adequately during
maintenance.
The licensee determined that while the operating experience supported the conclusions
related to the failure of EDG A, it would not have prevented the event from occurring. The
inspectors determined that the licensee appropriately considered past operating experience
related to the failure of EDG A.
h. Safety Culture Traits. The inspectors determined that the licensee performed a safety
culture assessment and appropriately considered the safety culture traits in NUREG-2165,
Safety Culture Common Language. For the root cause, the licensee identified a weakness
in the work management process of planning, controlling, and executing work activities,
which led to the deficient preventive maintenance job plan for EDG A. For the contributing
cause, the licensee identified weaknesses in corrective action resolution and complacency
of station personnel. A weakness in corrective action resolution was identified due to the


==OTHER ACTIVITIES==
licensee identifying multiple previous opportunities to address planning organization
- TEMPORARY INSTRUCTIONS, INFREQUENT AND ABNORMAL 95001 - Supplemental Inspection Response to Action Matrix Column 2 (Regulatory Response)
performance gaps prior to the failure of EDG A. The licensee identified complacency of
Inputs The inspectors reviewed and selectively challenged aspects of the licensees problem identification, causal analysis, and corrective actions in response to degraded performance that led to Waterford Steam Electric Station, Unit 3 being moved into Column 2 of the Action Matrix for a violation of 10 CFR 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings and subsequent White finding regarding the failure to properly develop and implement adequate maintenance instructions for the fuel linkage connection to the mechanical governor for emergency diesel generator A. The preliminary White finding is discussed in Inspection Report 05000382/2025090, dated April 9, 2025 (ML25097A205). The final significance determination and notice of violation are discussed in Inspection Report 05000382/2025091, dated June 5, 2025 (ML25149A059).
station personnel because the preventive maintenance job plan for EDG A had been used
several times prior to the failure of EDG A, and station personnel failed to identify and
communicate deficiencies in the job plan. The inspectors determined the licensee
established corrective actions to address these weaknesses.
i. Common Cause. Common Cause is not applicable for this report because there is only
one White performance deficiency.
Objective: Ensure that the extent-of-condition and extent-of-cause of individual and collective
white performance issues are identified.
Under this objective, the inspectors independently assessed the extent of condition and
extent of cause evaluations that were performed in relation to the White performance issue
to ensure the licensees evaluation was sufficiently comprehensive.
NRC Assessment: The inspectors concluded that this objective was Met. The inspectors
found that the licensee appropriately identified the extent of condition and, generally,
appropriately identified the extent of cause for the performance issue.
The extent of condition for the performance issue identified other diesel-driven safety-related
components, backup to safety-related components, and augmented quality program
components that had the potential for a governor linkage to become bound or disconnected.
Diesel-driven safety-related and backup to safety-related components were classified as
medium risk and included the EDGs, the turbine-driven emergency feed pump, and the
permanent temporary emergency diesel. Augmented quality program components were
classified as low risk and included the security diesel, FLEX diesel, and diesel-driven fire
pumps. The inspectors reviewed the extent of condition analysis and did not identify
concerns.
The extent of cause reviewed a sample of other preventive maintenance work orders and
work orders associated with both critical and non-critical components. Specifically, the
extent of cause ensured the sampled work orders included the proper vendor technical
information, the correct work order level, and appropriate operating experience related to the
work order subject matter. During this review, the inspectors identified that the extent of
cause did not specifically include a review of work orders associated with the diesel-driven
components classified as medium risk in the extent of condition analysis. This is
documented below as Minor Weakness 1.
Minor Weakness 1
The inspectors identified a minor weakness associated with the extent of cause review
performed by the licensee. The extent of cause actions sampled work orders associated
with critical and non-critical components to ensure specific technical elements were included
properly. As part of the extent of cause, the licensee did not specifically review the work
orders associated with the medium risk extent of condition diesel-driven components. The
inspectors determined that unless a work order associated with a medium risk component
was picked as part of an extent of cause sample then the work order would not be reviewed.
This created a potential gap for a work order associated with a medium risk diesel-driven


Objective: Ensure that the root and contributing causes of individual and collective white performance issues are understood.
component to include inadequate technical information and not be corrected. The licensee
documented this weakness in condition report CR-WF3-2025-04439.
Objective: Ensure that completed corrective actions to address and preclude repetition of white
performance issues are timely and effective.
Under this objective, the inspectors assessed the appropriateness and timeliness of the
licensee's corrective actions.
NRC Assessment: The inspectors concluded that this objective was Met. The inspectors
determined that the completed corrective actions the licensee had implemented were timely
and effective.
a. Completed Corrective Actions to Preclude Repetition
The licensee has one open corrective action to preclude repetition (CAPR) associated with
the root cause. This CAPR will be discussed in the planned corrective actions section below.


Under this objective, the inspectors reviewed the root cause evaluation the licensee conducted for a White finding regarding the failure to properly develop and implement adequate maintenance instructions for the fuel linkage connection to the mechanical governor for emergency diesel generator (EDG) A, as documented in Final Significance Determination of a White Finding, Notice of Violation, and Follow-Up Assessment Letter for Waterford Steam Electric Station, Unit 3, dated June 5, 2025 (Report 05000382/2025091 (ML25149A059)). Their review consisted of an evaluation of the following: the licensees identification of the issue, when and how long the issue existed, prior opportunities for identification, documentation of significant plant-specific consequences and compliance concerns, use of systematic methodology to identify causes with a sufficient level of supporting detail, consideration of prior occurrences, identification of extent-of-condition and extent-of-cause, and identification of any potential programmatic weaknesses in performance.
b. Other Completed Corrective Actions
The inspectors sampled other completed corrective actions (non-CAPRs) for the root cause
and contributing cause to determine the appropriateness and timeliness of the actions to
correct each cause documented in condition report CR-WF3-2024-04960. The inspectors
reviewed these completed corrective actions and did not have any concerns.
Cause
Corrective Action
Root Cause
The licensee updated controlled technical documents to
include vendor recommendations regarding alignment of the
lever arm; updated EDG job plans to include updated vendor
technical information, torque requirements, and thread
locking compounds; evaluated the design of the lever and
rod end to determine if a change would allow for greater
clearance margin; and evaluated adding a step to the EDG
pre-startup check procedure for operators to visually inspect
the governor and associated linkages.
Contributing Cause
The licensee developed and implemented a teach and learn
to reset and reinforce ownership and engagement in
improving maintenance department performance standards
and performed a benchmark to identify areas for improved
planning performance.
Objective: Ensure that pending corrective action plans direct prompt and effective actions to
address and preclude repetition of white performance issues.
Under this objective, the inspectors assessed the appropriateness and timeliness of the
licensees planned corrective actions.
NRC Assessment: The inspectors concluded that this objective was Met. The licensee
established one CAPR that addressed the root cause of insufficient details in the preventive
maintenance job plan for EDG A. When complete, the NRC plans to inspect and assess the
planned CAPR identified in Section a.


NRC Assessment: The inspectors concluded that this objective was Met. The inspectors determined that the licensee appropriately identified the root cause and contributing cause using systematic methodologies, considered prior occurrences and operating experience, and documented their analyses in sufficient detail.
a. Planned Corrective Actions to Preclude Repetition
 
The licensee established one open CAPR that addressed the root cause of insufficient
The licensee used multiple techniques to analyze the performance issue and identified the following root cause and contributing cause:
details in the preventive maintenance job plan for EDG A. The inspectors reviewed the plan
* Root cause: Insufficient details included in the preventive maintenance job plan for EDG A. Specifically, details needed to perform work on a critical component, such as guidance on proper alignment of the lever arm, torque values, and recommendations for thread locking compounds, were not included in the preventive maintenance job plan.
for implementation and determined the licensee established an acceptable plan. The
* Contributing cause: An organizational performance gap in the planning department did not ensure workers were in rule-based performance and represented a missed opportunity for the maintenance organization to raise standards and improve performance in planning.
planned implementation date for the CAPR is December 18, 2025, and the CAPR will
 
remain open pending further review by NRC inspectors.
a. Identification. The performance issue was self-revealed and identified during a walkdown of EDG A following a mechanical overspeed trip on October 10, 2024. The inspectors did not identify any concerns with the licensee characterization of the event.
Cause
 
CAPR
b. Exposure Time. The licensee determined that an exposure time of 94 days plus one day of repair time was applicable. The licensee concluded that EDG A would have failed to run for its 24-hour mission time starting on July 8, 2024. The inspectors determined that the licensee appropriately assessed the exposure time.
Root Cause
 
Open CAPR 1: CR-WF3-2024-04960-00017
c. Identification Opportunities. The licensee identified additional opportunities for identification as follows:
Create and implement a mechanical maintenance safety-related
* The licensee identified an opportunity for identification of the missing technical information in the EDG governor replacement work order. The licensee had previously replaced the EDG A governor in 2014. Following this replacement, system engineers provided handwritten feedback on the work order with recommendations to add steps to use a thread locking compound and include vendor specified torque values. This feedback was not incorporated into the model work order used for the governor replacement in 2024 contributing to the lack of sufficient technical information in the work order.
continuous use procedure for replacement of the mechanical
* The licensee identified a potential missed opportunity for identification of contact between the EDG governor lever arm and the rod end during required quarterly system walkdowns. The licensee determined that the fretting damage on the corner of the lever could have potentially been identified, but the likelihood is low due to the small area of damage that was visible.
governor and governor linkage rod ends for EDGs (A and B). Ensure
 
section 1.0 of the new procedure includes reference to this CAPR.
The inspectors determined that the licensee appropriately identified missed identification opportunities for the performance issue.
Incorporate all vendor documents (TD-C629 series, TD-W290.0075,
 
Woodward Manual 82340, and any other identified) including the
d. Risk and Compliance. The inspectors determined that the licensee had identified and understood the plant-specific risk and compliance concerns associated with the performance issue. The risk included continued inoperability of EDG A, although additional alternate power sources were available for use at the time. Compliance concerns were addressed by mitigating actions taken to enhance the work instructions for replacing the EDG governor.
implementation of vendor standards (torque values, locking
 
compounds, configurations, and freedom of movement checks), listed
e. Methodology. The licensee employed systematic evidence-based causal analysis to reliably and transparently determine the root and contributing causes of the White performance issue. The methods included equipment failure evaluation, failure modes analysis, organizational and programmatic screening, common cause review, and a why staircase.
steps and sequence of steps, troubleshooting methods, and include
 
this root cause evaluation as operating experience.
f. Level of Detail. The inspectors determined the root cause evaluation was conducted and documented to a level of detail commensurate with the significance and complexity of the issue and regulatory requirements.
Intent: Create a standard for the replacement of the mechanical
 
governor and rod ends for EDGs and to create consistent instructions
g. Operating Experience. The licensee reviewed operating experience for the performance issue, and the following internal and external operating experience was relevant to the diesel linkage failure.
for successful outcomes in all future evolutions.
 
b. Other Planned Corrective Actions
The licensee performed an internal operating experience search and found three applicable events related to diesel generators and inadequate work order quality. The licensee identified one event from Waterford in 2016, which described a mechanical linkage that disengaged from an auxiliary component cooling water valve due to an incorrectly installed nut. The licensee documented two applicable events from Arkansas Nuclear One. In 2016, an emergency diesel generator experienced a generator bearing failure due to inadequate lubrication caused by an oil level sight glass that was installed upside down. In 2021, a diesel generator experienced an inadvertent overspeed trip due to inadequate vendor technical information in a test procedure. These events supported the licensees conclusion regarding the importance of work order quality for successful task completion.
The inspectors reviewed a sample of other planned corrective actions (non-CAPRs) for each
 
cause to determine the appropriateness and timeliness of the actions to correct each cause
The licensee determined that external operating experience identified similar events related to emergency diesel generators and fuel rack linkages.
documented in condition report CR-WF3-2024-04960. The inspectors did not have any
* In 2013, the EDG at Salem Hope Creek experienced frequency oscillations during a monthly surveillance. The most likely apparent cause was determined to be mechanical binding in the fuel rack linkage.
concerns with the planned corrective actions.
* In 2003 at Susquehanna, the EDG fuel control linkage separated from the governor terminal shaft lever causing loading to unexpectedly decrease during a surveillance run. The bolt that attached the fuel control linkage to the governor terminal shaft lever had backed out, likely due to not being tightened adequately during maintenance.
Cause
 
Corrective Action
The licensee determined that while the operating experience supported the conclusions related to the failure of EDG A, it would not have prevented the event from occurring. The inspectors determined that the licensee appropriately considered past operating experience related to the failure of EDG A.
Root Cause
 
The licensee planned actions to obtain higher quality vendor
h. Safety Culture Traits. The inspectors determined that the licensee performed a safety culture assessment and appropriately considered the safety culture traits in NUREG-2165, Safety Culture Common Language. For the root cause, the licensee identified a weakness in the work management process of planning, controlling, and executing work activities, which led to the deficient preventive maintenance job plan for EDG A. For the contributing cause, the licensee identified weaknesses in corrective action resolution and complacency of station personnel. A weakness in corrective action resolution was identified due to the licensee identifying multiple previous opportunities to address planning organization performance gaps prior to the failure of EDG A. The licensee identified complacency of station personnel because the preventive maintenance job plan for EDG A had been used several times prior to the failure of EDG A, and station personnel failed to identify and communicate deficiencies in the job plan. The inspectors determined the licensee established corrective actions to address these weaknesses.
documents to enhance document searchability and visual
 
clarity of drawings; actions for managers to review completed
i. Common
critical component work orders and provide feedback to the
 
planning department; and actions to perform testing and
=====Cause.=====
inspection of governor linkages associated with components
Common Cause is not applicable for this report because there is only one White performance deficiency.
identified in the extent of condition review.
 
Contributing Cause
Objective: Ensure that the extent-of-condition and extent-of-cause of individual and collective white performance issues are identified.
The licensee planned actions to perform a common cause
 
evaluation of the issues identified by the contributing cause to
Under this objective, the inspectors independently assessed the extent of condition and extent of cause evaluations that were performed in relation to the White performance issue to ensure the licensees evaluation was sufficiently comprehensive.
determine why previous action plans did not result in
 
sustained improvement in the maintenance organizations
NRC Assessment: The inspectors concluded that this objective was Met. The inspectors found that the licensee appropriately identified the extent of condition and, generally, appropriately identified the extent of cause for the performance issue.
standards.
 
The extent of condition for the performance issue identified other diesel-driven safety-related components, backup to safety-related components, and augmented quality program components that had the potential for a governor linkage to become bound or disconnected.
 
Diesel-driven safety-related and backup to safety-related components were classified as medium risk and included the EDGs, the turbine-driven emergency feed pump, and the permanent temporary emergency diesel. Augmented quality program components were classified as low risk and included the security diesel, FLEX diesel, and diesel-driven fire pumps. The inspectors reviewed the extent of condition analysis and did not identify concerns.
 
The extent of cause reviewed a sample of other preventive maintenance work orders and work orders associated with both critical and non-critical components. Specifically, the extent of cause ensured the sampled work orders included the proper vendor technical information, the correct work order level, and appropriate operating experience related to the work order subject matter. During this review, the inspectors identified that the extent of cause did not specifically include a review of work orders associated with the diesel-driven components classified as medium risk in the extent of condition analysis. This is documented below as Minor Weakness 1.
 
Minor Weakness 1 The inspectors identified a minor weakness associated with the extent of cause review performed by the licensee. The extent of cause actions sampled work orders associated with critical and non-critical components to ensure specific technical elements were included properly. As part of the extent of cause, the licensee did not specifically review the work orders associated with the medium risk extent of condition diesel-driven components. The inspectors determined that unless a work order associated with a medium risk component was picked as part of an extent of cause sample then the work order would not be reviewed.
 
This created a potential gap for a work order associated with a medium risk diesel-driven component to include inadequate technical information and not be corrected. The licensee documented this weakness in condition report CR-WF3-2025-04439.
 
Objective: Ensure that completed corrective actions to address and preclude repetition of white performance issues are timely and effective.
 
Under this objective, the inspectors assessed the appropriateness and timeliness of the licensee's corrective actions.
 
NRC Assessment: The inspectors concluded that this objective was Met. The inspectors determined that the completed corrective actions the licensee had implemented were timely and effective.
 
a. Completed Corrective Actions to Preclude Repetition The licensee has one open corrective action to preclude repetition (CAPR) associated with the root cause. This CAPR will be discussed in the planned corrective actions section below.
 
b. Other Completed Corrective Actions The inspectors sampled other completed corrective actions (non-CAPRs) for the root cause and contributing cause to determine the appropriateness and timeliness of the actions to correct each cause documented in condition report CR-WF3-2024-04960. The inspectors reviewed these completed corrective actions and did not have any concerns.
 
Cause Corrective Action Root Cause The licensee updated controlled technical documents to include vendor recommendations regarding alignment of the lever arm; updated EDG job plans to include updated vendor technical information, torque requirements, and thread locking compounds; evaluated the design of the lever and rod end to determine if a change would allow for greater clearance margin; and evaluated adding a step to the EDG pre-startup check procedure for operators to visually inspect the governor and associated linkages.
 
Contributing Cause The licensee developed and implemented a teach and learn to reset and reinforce ownership and engagement in improving maintenance department performance standards and performed a benchmark to identify areas for improved planning performance.
 
Objective: Ensure that pending corrective action plans direct prompt and effective actions to address and preclude repetition of white performance issues.
 
Under this objective, the inspectors assessed the appropriateness and timeliness of the licensees planned corrective actions.
 
NRC Assessment: The inspectors concluded that this objective was Met. The licensee established one CAPR that addressed the root cause of insufficient details in the preventive maintenance job plan for EDG A. When complete, the NRC plans to inspect and assess the planned CAPR identified in Section a.
 
a. Planned Corrective Actions to Preclude Repetition The licensee established one open CAPR that addressed the root cause of insufficient details in the preventive maintenance job plan for EDG A. The inspectors reviewed the plan for implementation and determined the licensee established an acceptable plan. The planned implementation date for the CAPR is December 18, 2025, and the CAPR will remain open pending further review by NRC inspectors.
 
Cause CAPR Root Cause Open CAPR 1: CR-WF3-2024-04960-00017 Create and implement a mechanical maintenance safety-related continuous use procedure for replacement of the mechanical governor and governor linkage rod ends for EDGs (A and B). Ensure section 1.0 of the new procedure includes reference to this CAPR.
 
Incorporate all vendor documents (TD-C629 series, TD-W290.0075, Woodward Manual 82340, and any other identified) including the implementation of vendor standards (torque values, locking compounds, configurations, and freedom of movement checks), listed steps and sequence of steps, troubleshooting methods, and include this root cause evaluation as operating experience.
 
Intent: Create a standard for the replacement of the mechanical governor and rod ends for EDGs and to create consistent instructions for successful outcomes in all future evolutions.
 
b. Other Planned Corrective Actions The inspectors reviewed a sample of other planned corrective actions (non-CAPRs) for each cause to determine the appropriateness and timeliness of the actions to correct each cause documented in condition report CR-WF3-2024-04960. The inspectors did not have any concerns with the planned corrective actions.
 
Cause Corrective Action Root Cause The licensee planned actions to obtain higher quality vendor documents to enhance document searchability and visual clarity of drawings; actions for managers to review completed critical component work orders and provide feedback to the planning department; and actions to perform testing and inspection of governor linkages associated with components identified in the extent of condition review.
 
Contributing Cause The licensee planned actions to perform a common cause evaluation of the issues identified by the contributing cause to determine why previous action plans did not result in sustained improvement in the maintenance organizations standards.
 
Conclusion Overall, the inspectors determined that the licensees problem identification, causal analysis, and corrective actions sufficiently addressed the performance issue that led to the White finding regarding the failure to properly develop and implement adequate maintenance instructions for the fuel linkage connection to the mechanical governor for EDG A. All inspection objectives listed in Inspection Procedure 95001 were met, and this inspection is closed. The open corrective action to preclude repetition will be inspected as part of the ongoing NRC baseline inspection program.
 
==INSPECTION RESULTS==
CAPR (Discussed)
Waterford 95001 CAPR CR-WF3-2024-04960-00017 Create and Implement a Mechanical Maintenance Procedure for Replacement of the Mechanical Governor for the Emergency Diesel Generators CAPR 05000382/2025040-01 95001
 
=====Description:=====
Create and implement a mechanical maintenance safety-related continuous use procedure for replacement of the mechanical governor and governor linkage rod ends for emergency diesel generators (A and B). Ensure section 1.0 of the new procedure includes reference to this CAPR.
 
Incorporate all vendor documents (TD-C629 series, TD-W290.0075, Woodward manual 82340, and any other identified) including the implementation of vendor standards (torque values, locking compounds, configurations, and freedom of movement checks), listed steps and sequence of steps, troubleshooting methods, and include this root cause evaluation as operating experience.
 
Intent: Create a standard for the replacement of the mechanical governor and rod ends for emergency diesel generators and to create consistent instructions for successful outcomes in all future evolutions."
 
The inspectors reviewed the plan for implementation of this CAPR and determined that the licensee established an acceptable plan. The licensee was tracking this CAPR in their corrective action program as CR-WF3-2024-04960-00017 and had planned to implement this CAPR by December 18, 2025, at the time of the onsite inspection.


Conclusion
Overall, the inspectors determined that the licensees problem identification, causal analysis,
and corrective actions sufficiently addressed the performance issue that led to the White
finding regarding the failure to properly develop and implement adequate maintenance
instructions for the fuel linkage connection to the mechanical governor for EDG A. All
inspection objectives listed in Inspection Procedure 95001 were met, and this inspection is
closed. The White finding and associated notice of violation will be closed and no longer
considered as an action matrix input as of the date of the exit meeting. The open corrective
action to preclude repetition will be inspected as part of the ongoing NRC baseline
inspection program.
INSPECTION RESULTS
CAPR
(Discussed)
Waterford 95001 CAPR CR-WF3-2024-04960-00017
Create and Implement a Mechanical Maintenance
Procedure for Replacement of the Mechanical Governor
for the Emergency Diesel Generators
CAPR 05000382/2025040-01
95001
Description:
Create and implement a mechanical maintenance safety-related continuous use procedure
for replacement of the mechanical governor and governor linkage rod ends for emergency
diesel generators (A and B). Ensure section 1.0 of the new procedure includes reference to
this CAPR.
Incorporate all vendor documents (TD-C629 series, TD-W290.0075, Woodward manual
82340, and any other identified) including the implementation of vendor standards (torque
values, locking compounds, configurations, and freedom of movement checks), listed steps
and sequence of steps, troubleshooting methods, and include this root cause evaluation as
operating experience.
Intent: Create a standard for the replacement of the mechanical governor and rod ends for
emergency diesel generators and to create consistent instructions for successful outcomes in
all future evolutions."
The inspectors reviewed the plan for implementation of this CAPR and determined that the
licensee established an acceptable plan. The licensee was tracking this CAPR in their
corrective action program as CR-WF3-2024-04960-00017 and had planned to implement this
CAPR by December 18, 2025, at the time of the onsite inspection.
This CAPR will remain open pending further review.
This CAPR will remain open pending further review.
EXIT MEETINGS AND DEBRIEFS
The inspectors verified that no proprietary information was retained or documented in this
report.
*
On September 25, 2025, the inspectors presented the 95001 supplemental inspection
results to David Oertling, General Manager Plant Operations, and other members of the
licensee staff.


==EXIT MEETINGS AND DEBRIEFS==
DOCUMENTS REVIEWED
The inspectors verified that no proprietary information was retained or documented in this report.
* On September 25, 2025, the inspectors presented the 95001 supplemental inspection results to David Oertling, General Manager Plant Operations, and other members of the licensee staff.
 
=DOCUMENTS REVIEWED=
 
Inspection
Inspection
Procedure
Procedure
Line 211: Line 419:
Documents
Documents
CR-WF3-
CR-WF3-
20-03193, 2021-03144, 2023-00197, 2024-02159, 2024-
2020-03193, 2021-03144, 2023-00197, 2024-02159, 2024-
03700, 2024-03809, 2024-04960, 2025-01498, 2025-03905,
03700, 2024-03809, 2024-04960, 2025-01498, 2025-03905,
25-03919, 2025-03921, 2025-03928, 2025-04410, 2025-
2025-03919, 2025-03921, 2025-03928, 2025-04410, 2025-
04439
04439
Engineering
Engineering
Line 219: Line 427:
0054260328
0054260328
EDG Linkage Washer Installation Detail Update
EDG Linkage Washer Installation Detail Update
JA-PI-16
JA-PI-16
Sample Size Selection Guidance
Sample Size Selection Guidance
Job Plan
Job Plan
00062289
00062289
Line 236: Line 446:
Plant Emergency Stand-By Operation and Maintenance
Plant Emergency Stand-By Operation and Maintenance
Manual
Manual
EN-DC-132
EN-DC-132
Control of Engineering Documents
Control of Engineering Documents
EN-DC-153
EN-DC-153
Preventive Maintenance Component Classification
Preventive Maintenance Component Classification
EN-LI-102
EN-LI-102
Corrective Action Program
Corrective Action Program
EN-LI-118
EN-LI-118
Causal Analysis Process
Causal Analysis Process
EN-MA-106
EN-MA-106
Planning
Planning
EN-WM-102
EN-WM-102
Work Implementation and Closeout
Work Implementation and Closeout
EN-WM-105
EN-WM-105
Planning
Planning
Procedures
Procedures
OP-009-002
OP-009-002

Revision as of 00:29, 21 February 2026

Waterford Steam Electric Station, Unit 3 - Amended 95001 Supplemental Inspection Report 05000382/2025040 and Follow-Up Assessment Letter
ML26014A028
Person / Time
Site: Waterford 
Issue date: 01/14/2026
From: John Dixon
NRC/RGN-IV/DORS/PBD
To: Sullivan J
Entergy Operations
Shared Package
NRC-002:ML26014A013 List:
References
EAF-RIV-2025-0090 IR 2025040
Download: ML26014A028 (0)


Text

January 14, 2026

SUBJECT:

WATERFORD STEAM ELECTRIC STATION, UNIT 3 - AMENDED 95001 SUPPLEMENTAL INSPECTION REPORT 05000382/2025040 AND FOLLOW-UP ASSESSMENT LETTER

Dear Joseph Sullivan:

On September 25, 2025, 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, and discussed the results of the inspection and the implementation of your corrective actions with David Oertling, General Manager Plant Operations, and other members of your staff.

The NRC identified the need to reissue NRC Inspection Report 05000382/2025040, dated December 16, 2025 (ADAMS Accession Number ML25349A028). Specifically, the inspection report did not include the notice of violation (NOV) discussed in Inspection Report 05000382/2025091, dated June 5, 2025 (ML25149A059) in the section titled Additional Tracking Items. The notice of violation should have been included as a closed NOV to indicate that it is no longer considered as an action matrix input as of the date of the exit meeting. Also, additional wording was included in the inspection report conclusion to more clearly indicate that the associated NOV is closed.

No findings or violations of more than minor significance were identified during this inspection. This letter, its enclosure, and your response (if any) will be made available for public inspection and copying at http://www.nrc.gov/reading-rm/adams.html and at the NRC Public Document Room in accordance with Title 10 of the Code of Federal Regulations 2.390, Public Inspections, Exemptions, Requests for Withholding.

Sincerely, John L. Dixon, Jr., Chief Reactor Projects Branch D Division of Operating Reactor Safety Docket No. 05000382 License No. NPF-38

Enclosure:

As stated

Inspection Report

Docket Number:

05000382

License Number:

NPF-38

Report Number:

05000382/2025040

Enterprise Identifier:

I-2025-040-0007

Licensee:

Entergy Operations, Inc.

Facility:

Waterford Steam Electric Station, Unit 3

Location:

Killona, LA 70057

Inspection Dates:

September 22, 2025, to September 26, 2025

Inspectors:

E. Tinger, Resident Inspector

G. Pick, Senior Reactor Inspector

Approved By:

John L. Dixon, Jr., Chief

Reactor Projects Branch D

Division of Operating Reactor Safety

SUMMARY

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

performance by conducting a 95001 supplemental inspection at 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

05000382/2025091-01

Emergency Diesel

Generator A Failure to Run

EAF-RIV-2025-0090

95001

Closed

CAPR

05000382/2025040-01

Waterford 95001 CAPR

CR-WF3-2024-04960-00017

Create and Implement a

Mechanical Maintenance

Procedure for Replacement

of the Mechanical Governor

for the Emergency Diesel

Generators

95001

Discussed

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 degraded performance that

led to Waterford Steam Electric Station, Unit 3 being moved into Column 2 of the Action Matrix

for a violation of 10 CFR 50, Appendix B, Criterion V, Instructions, Procedures, and Drawings

and subsequent White finding regarding the failure to properly develop and implement adequate

maintenance instructions for the fuel linkage connection to the mechanical governor for

emergency diesel generator A. The preliminary White finding is discussed in Inspection Report 05000382/2025090, dated April 9, 2025 (ML25097A205). The final significance determination

and notice of violation are discussed in Inspection Report 05000382/2025091, dated

June 5, 2025 (ML25149A059).

Objective: Ensure that the root and contributing causes of individual and collective white

performance issues are understood.

Under this objective, the inspectors reviewed the root cause evaluation the licensee

conducted for a White finding regarding the failure to properly develop and implement

adequate maintenance instructions for the fuel linkage connection to the mechanical

governor for emergency diesel generator (EDG) A, as documented in Final Significance

Determination of a White Finding, Notice of Violation, and Follow-Up Assessment Letter for

Waterford Steam Electric Station, Unit 3, dated June 5, 2025 (Report 05000382/2025091

(ML25149A059)). Their review consisted of an evaluation of the following: the licensees

identification of the issue, when and how long the issue existed, prior opportunities for

identification, documentation of significant plant-specific consequences and compliance

concerns, use of systematic methodology to identify causes with a sufficient level of

supporting detail, consideration of prior occurrences, identification of extent-of-condition and

extent-of-cause, and identification of any potential programmatic weaknesses in

performance.

NRC Assessment: The inspectors concluded that this objective was Met. The inspectors

determined that the licensee appropriately identified the root cause and contributing cause

using systematic methodologies, considered prior occurrences and operating experience,

and documented their analyses in sufficient detail.

The licensee used multiple techniques to analyze the performance issue and identified the

following root cause and contributing cause:

Root cause: Insufficient details included in the preventive maintenance job plan for

EDG A. Specifically, details needed to perform work on a critical component, such as

guidance on proper alignment of the lever arm, torque values, and recommendations

for thread locking compounds, were not included in the preventive maintenance job

plan.

Contributing cause: An organizational performance gap in the planning department

did not ensure workers were in rule-based performance and represented a missed

opportunity for the maintenance organization to raise standards and improve

performance in planning.

a. Identification. The performance issue was self-revealed and identified during a

walkdown of EDG A following a mechanical overspeed trip on October 10, 2024. The

inspectors did not identify any concerns with the licensee characterization of the event.

b. Exposure Time. The licensee determined that an exposure time of 94 days plus one

day of repair time was applicable. The licensee concluded that EDG A would have failed to

run for its 24-hour mission time starting on July 8, 2024. The inspectors determined that the

licensee appropriately assessed the exposure time.

c. Identification Opportunities. The licensee identified additional opportunities for

identification as follows:

The licensee identified an opportunity for identification of the missing technical

information in the EDG governor replacement work order. The licensee had

previously replaced the EDG A governor in 2014. Following this replacement, system

engineers provided handwritten feedback on the work order with recommendations

to add steps to use a thread locking compound and include vendor specified torque

values. This feedback was not incorporated into the model work order used for the

governor replacement in 2024 contributing to the lack of sufficient technical

information in the work order.

The licensee identified a potential missed opportunity for identification of contact

between the EDG governor lever arm and the rod end during required quarterly

system walkdowns. The licensee determined that the fretting damage on the corner

of the lever could have potentially been identified, but the likelihood is low due to the

small area of damage that was visible.

The inspectors determined that the licensee appropriately identified missed identification

opportunities for the performance issue.

d. Risk and Compliance. The inspectors determined that the licensee had identified and

understood the plant-specific risk and compliance concerns associated with the

performance issue. The risk included continued inoperability of EDG A, although additional

alternate power sources were available for use at the time. Compliance concerns were

addressed by mitigating actions taken to enhance the work instructions for replacing the

EDG governor.

e. Methodology. The licensee employed systematic evidence-based causal analysis to

reliably and transparently determine the root and contributing causes of the White

performance issue. The methods included equipment failure evaluation, failure modes

analysis, organizational and programmatic screening, common cause review, and a why

staircase.

f. Level of Detail. The inspectors determined the root cause evaluation was conducted and

documented to a level of detail commensurate with the significance and complexity of the

issue and regulatory requirements.

g. Operating Experience. The licensee reviewed operating experience for the performance

issue, and the following internal and external operating experience was relevant to the

diesel linkage failure.

The licensee performed an internal operating experience search and found three applicable

events related to diesel generators and inadequate work order quality. The licensee

identified one event from Waterford in 2016, which described a mechanical linkage that

disengaged from an auxiliary component cooling water valve due to an incorrectly installed

nut. The licensee documented two applicable events from Arkansas Nuclear One. In 2016,

an emergency diesel generator experienced a generator bearing failure due to inadequate

lubrication caused by an oil level sight glass that was installed upside down. In 2021, a

diesel generator experienced an inadvertent overspeed trip due to inadequate vendor

technical information in a test procedure. These events supported the licensees conclusion

regarding the importance of work order quality for successful task completion.

The licensee determined that external operating experience identified similar events related

to emergency diesel generators and fuel rack linkages.

In 2013, the EDG at Salem Hope Creek experienced frequency oscillations during a

monthly surveillance. The most likely apparent cause was determined to be

mechanical binding in the fuel rack linkage.

In 2003 at Susquehanna, the EDG fuel control linkage separated from the governor

terminal shaft lever causing loading to unexpectedly decrease during a surveillance

run. The bolt that attached the fuel control linkage to the governor terminal shaft

lever had backed out, likely due to not being tightened adequately during

maintenance.

The licensee determined that while the operating experience supported the conclusions

related to the failure of EDG A, it would not have prevented the event from occurring. The

inspectors determined that the licensee appropriately considered past operating experience

related to the failure of EDG A.

h. Safety Culture Traits. The inspectors determined that the licensee performed a safety

culture assessment and appropriately considered the safety culture traits in NUREG-2165,

Safety Culture Common Language. For the root cause, the licensee identified a weakness

in the work management process of planning, controlling, and executing work activities,

which led to the deficient preventive maintenance job plan for EDG A. For the contributing

cause, the licensee identified weaknesses in corrective action resolution and complacency

of station personnel. A weakness in corrective action resolution was identified due to the

licensee identifying multiple previous opportunities to address planning organization

performance gaps prior to the failure of EDG A. The licensee identified complacency of

station personnel because the preventive maintenance job plan for EDG A had been used

several times prior to the failure of EDG A, and station personnel failed to identify and

communicate deficiencies in the job plan. The inspectors determined the licensee

established corrective actions to address these weaknesses.

i. Common Cause. Common Cause is not applicable for this report because there is only

one White performance deficiency.

Objective: Ensure that the extent-of-condition and extent-of-cause of individual and collective

white performance issues are identified.

Under this objective, the inspectors independently assessed the extent of condition and

extent of cause evaluations that were performed in relation to the White performance issue

to ensure the licensees evaluation was sufficiently comprehensive.

NRC Assessment: The inspectors concluded that this objective was Met. The inspectors

found that the licensee appropriately identified the extent of condition and, generally,

appropriately identified the extent of cause for the performance issue.

The extent of condition for the performance issue identified other diesel-driven safety-related

components, backup to safety-related components, and augmented quality program

components that had the potential for a governor linkage to become bound or disconnected.

Diesel-driven safety-related and backup to safety-related components were classified as

medium risk and included the EDGs, the turbine-driven emergency feed pump, and the

permanent temporary emergency diesel. Augmented quality program components were

classified as low risk and included the security diesel, FLEX diesel, and diesel-driven fire

pumps. The inspectors reviewed the extent of condition analysis and did not identify

concerns.

The extent of cause reviewed a sample of other preventive maintenance work orders and

work orders associated with both critical and non-critical components. Specifically, the

extent of cause ensured the sampled work orders included the proper vendor technical

information, the correct work order level, and appropriate operating experience related to the

work order subject matter. During this review, the inspectors identified that the extent of

cause did not specifically include a review of work orders associated with the diesel-driven

components classified as medium risk in the extent of condition analysis. This is

documented below as Minor Weakness 1.

Minor Weakness 1

The inspectors identified a minor weakness associated with the extent of cause review

performed by the licensee. The extent of cause actions sampled work orders associated

with critical and non-critical components to ensure specific technical elements were included

properly. As part of the extent of cause, the licensee did not specifically review the work

orders associated with the medium risk extent of condition diesel-driven components. The

inspectors determined that unless a work order associated with a medium risk component

was picked as part of an extent of cause sample then the work order would not be reviewed.

This created a potential gap for a work order associated with a medium risk diesel-driven

component to include inadequate technical information and not be corrected. The licensee

documented this weakness in condition report CR-WF3-2025-04439.

Objective: Ensure that completed corrective actions to address and preclude repetition of white

performance issues are timely and effective.

Under this objective, the inspectors assessed the appropriateness and timeliness of the

licensee's corrective actions.

NRC Assessment: The inspectors concluded that this objective was Met. The inspectors

determined that the completed corrective actions the licensee had implemented were timely

and effective.

a. Completed Corrective Actions to Preclude Repetition

The licensee has one open corrective action to preclude repetition (CAPR) associated with

the root cause. This CAPR will be discussed in the planned corrective actions section below.

b. Other Completed Corrective Actions

The inspectors sampled other completed corrective actions (non-CAPRs) for the root cause

and contributing cause to determine the appropriateness and timeliness of the actions to

correct each cause documented in condition report CR-WF3-2024-04960. The inspectors

reviewed these completed corrective actions and did not have any concerns.

Cause

Corrective Action

Root Cause

The licensee updated controlled technical documents to

include vendor recommendations regarding alignment of the

lever arm; updated EDG job plans to include updated vendor

technical information, torque requirements, and thread

locking compounds; evaluated the design of the lever and

rod end to determine if a change would allow for greater

clearance margin; and evaluated adding a step to the EDG

pre-startup check procedure for operators to visually inspect

the governor and associated linkages.

Contributing Cause

The licensee developed and implemented a teach and learn

to reset and reinforce ownership and engagement in

improving maintenance department performance standards

and performed a benchmark to identify areas for improved

planning performance.

Objective: Ensure that pending corrective action plans direct prompt and effective actions to

address and preclude repetition of white performance issues.

Under this objective, the inspectors assessed the appropriateness and timeliness of the

licensees planned corrective actions.

NRC Assessment: The inspectors concluded that this objective was Met. The licensee

established one CAPR that addressed the root cause of insufficient details in the preventive

maintenance job plan for EDG A. When complete, the NRC plans to inspect and assess the

planned CAPR identified in Section a.

a. Planned Corrective Actions to Preclude Repetition

The licensee established one open CAPR that addressed the root cause of insufficient

details in the preventive maintenance job plan for EDG A. The inspectors reviewed the plan

for implementation and determined the licensee established an acceptable plan. The

planned implementation date for the CAPR is December 18, 2025, and the CAPR will

remain open pending further review by NRC inspectors.

Cause

CAPR

Root Cause

Open CAPR 1: CR-WF3-2024-04960-00017

Create and implement a mechanical maintenance safety-related

continuous use procedure for replacement of the mechanical

governor and governor linkage rod ends for EDGs (A and B). Ensure

section 1.0 of the new procedure includes reference to this CAPR.

Incorporate all vendor documents (TD-C629 series, TD-W290.0075,

Woodward Manual 82340, and any other identified) including the

implementation of vendor standards (torque values, locking

compounds, configurations, and freedom of movement checks), listed

steps and sequence of steps, troubleshooting methods, and include

this root cause evaluation as operating experience.

Intent: Create a standard for the replacement of the mechanical

governor and rod ends for EDGs and to create consistent instructions

for successful outcomes in all future evolutions.

b. Other Planned Corrective Actions

The inspectors reviewed a sample of other planned corrective actions (non-CAPRs) for each

cause to determine the appropriateness and timeliness of the actions to correct each cause

documented in condition report CR-WF3-2024-04960. The inspectors did not have any

concerns with the planned corrective actions.

Cause

Corrective Action

Root Cause

The licensee planned actions to obtain higher quality vendor

documents to enhance document searchability and visual

clarity of drawings; actions for managers to review completed

critical component work orders and provide feedback to the

planning department; and actions to perform testing and

inspection of governor linkages associated with components

identified in the extent of condition review.

Contributing Cause

The licensee planned actions to perform a common cause

evaluation of the issues identified by the contributing cause to

determine why previous action plans did not result in

sustained improvement in the maintenance organizations

standards.

Conclusion

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

and corrective actions sufficiently addressed the performance issue that led to the White

finding regarding the failure to properly develop and implement adequate maintenance

instructions for the fuel linkage connection to the mechanical governor for EDG A. All

inspection objectives listed in Inspection Procedure 95001 were met, and this inspection is

closed. The White finding and associated notice of violation will be closed and no longer

considered as an action matrix input as of the date of the exit meeting. The open corrective

action to preclude repetition will be inspected as part of the ongoing NRC baseline

inspection program.

INSPECTION RESULTS

CAPR

(Discussed)

Waterford 95001 CAPR CR-WF3-2024-04960-00017

Create and Implement a Mechanical Maintenance

Procedure for Replacement of the Mechanical Governor

for the Emergency Diesel Generators

CAPR 05000382/2025040-01

95001

Description:

Create and implement a mechanical maintenance safety-related continuous use procedure

for replacement of the mechanical governor and governor linkage rod ends for emergency

diesel generators (A and B). Ensure section 1.0 of the new procedure includes reference to

this CAPR.

Incorporate all vendor documents (TD-C629 series, TD-W290.0075, Woodward manual

82340, and any other identified) including the implementation of vendor standards (torque

values, locking compounds, configurations, and freedom of movement checks), listed steps

and sequence of steps, troubleshooting methods, and include this root cause evaluation as

operating experience.

Intent: Create a standard for the replacement of the mechanical governor and rod ends for

emergency diesel generators and to create consistent instructions for successful outcomes in

all future evolutions."

The inspectors reviewed the plan for implementation of this CAPR and determined that the

licensee established an acceptable plan. The licensee was tracking this CAPR in their

corrective action program as CR-WF3-2024-04960-00017 and had planned to implement this

CAPR by December 18, 2025, at the time of the onsite inspection.

This CAPR will remain open pending further review.

EXIT MEETINGS AND DEBRIEFS

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

report.

On September 25, 2025, the inspectors presented the 95001 supplemental inspection

results to David Oertling, General Manager Plant Operations, and other members of the

licensee staff.

DOCUMENTS REVIEWED

Inspection

Procedure

Type

Designation

Description or Title

Revision or

Date

Corrective Action

Documents

CR-WF3-

2020-03193, 2021-03144, 2023-00197, 2024-02159, 2024-

03700, 2024-03809, 2024-04960, 2025-01498, 2025-03905,

2025-03919, 2025-03921, 2025-03928, 2025-04410, 2025-

04439

Engineering

Changes

0054260328

EDG Linkage Washer Installation Detail Update

JA-PI-16

Sample Size Selection Guidance

Job Plan

00062289

Emergency Diesel Generator B Engine Control Governor B

Replacement

09/30/2025

Job Plan

00062291

Emergency Diesel Generator A Engine Control Governor A

Replacement

09/30/2025

Miscellaneous

TD-C629.0045

Cooper Bessemer KSV Diesel Generator Nuclear Power

Plant Emergency Stand-By Operation and Maintenance

Manual

EN-DC-132

Control of Engineering Documents

EN-DC-153

Preventive Maintenance Component Classification

EN-LI-102

Corrective Action Program

EN-LI-118

Causal Analysis Process

EN-MA-106

Planning

EN-WM-102

Work Implementation and Closeout

EN-WM-105

Planning

Procedures

OP-009-002

Emergency Diesel Generator

363

Self-Assessments

LO-WF3-2025-

00072

Pre-Inspection Assessment Worksheet for IP 95001

Inspection

08/15/2025

95001

Work Orders

WO 54199975, 54240437