ML17069A133
| ML17069A133 | |
| Person / Time | |
|---|---|
| Site: | Watts Bar  |
| Issue date: | 03/10/2017 |
| From: | Joel Munday Division Reactor Projects II |
| To: | James Shea Tennessee Valley Authority |
| References | |
| EA-17-022 IR 2016013 | |
| Download: ML17069A133 (33) | |
See also: IR 05000390/2016013
Text
UNITED STATES
NUCLEAR REGULATORY COMMISSION
REGION II
245 PEACHTREE CENTER AVENUE NE, SUITE 1200
ATLANTA, GEORGIA 30303-1257
March 10, 2017
Mr. Joseph W. Shea
Vice President, Nuclear Licensing
Tennessee Valley Authority
Chattanooga, TN 37402-2801
SUBJECT: WATTS BAR NUCLEAR PLANT - NRC PROBLEM IDENTIFICATION AND
RESOLUTION INSPECTION (PART 2); AND SAFETY CONSCIOUS WORK
ENVIRONMENT ISSUE OF CONCERN FOLLOW-UP; NRC INSPECTION
REPORT 05000390/2016013, 05000391/2016013
Dear Mr. Shea:
On December 1, 2016, the U. S. Nuclear Regulatory Commission (NRC) completed Part 2 of a
Problem Identification and Resolution inspection at your Watts Bar Nuclear Plant Units 1 and 2.
On November 17, 2016, December 1, 2016, January 11, 2017, and February 21, 2017, the NRC
inspection team discussed the results of this inspection with Mr. Paul Simmons and other
members of your staff. The results of this inspection are documented in the enclosed report.
Additionally, security related activities are documented in inspection report 05000390 &
391/2016404 (ML17008A001). Results of the first part of the inspection are documented in
Inspection Report 05000390 & 391/2016007(ML16300A409).
The NRC inspection team reviewed the stations corrective action program and its
implementation to evaluate its effectiveness in identifying, prioritizing, evaluating, and correcting
problems, and to confirm that the station was complying with NRC regulations and licensee
standards for corrective action programs. The team identified weaknesses in the elements of
Problem Identification; and Problem Prioritizing and Evaluation. One finding was identified in
the area of Corrective Action Program Effectiveness.
Based on the results of this inspection, one apparent violation (AV) was identified and is being
considered for escalated enforcement action in accordance with the NRC Enforcement Policy.
The current Enforcement Policy is included on the NRCs Web site at http://www.nrc.gov/about-
nrc/regulatory/enforcement/enforce-pol.html. The apparent violation involves Tennessee Valley
Authoritys (TVAs) failure to comply with a Confirmatory Order (CO) Modifying License, (EA-09-
009,203) (ML093510993) issued by the NRC on December 22, 2009. The CO required all TVA
nuclear plants to implement actions, including reviewing processes to determine whether
adverse employment actions comport with employee protection regulations, and to determine
whether the proposed adverse actions could negatively impact the Safety Conscious Work
Environment (SCWE). The NRCs recent Problem Identification and Resolution team
inspection, completed in December 2016, identified that TVAs Watts Bar Nuclear (WBN) facility
was not implementing certain review processes required in the CO in accordance with an
J. Shea 2
implementing procedure, from November 2014 to August 2016. The details of the AV are fully
described in the enclosed inspection report.
The team also evaluated the stations processes for use of industry and NRC operating
experience information and the effectiveness of the stations audits and self-assessments.
Based on the samples reviewed, the team determined that your staffs performance in each of
these areas adequately supported nuclear safety.
Finally the team reviewed the stations programs to establish and maintain a safety-conscious
work environment, and interviewed station personnel to evaluate the effectiveness of these
programs. In a letter dated March 23, 2016, the NRC issued a Chilling Effect Letter (CEL)
entitled, Chilled Work Environment for Raising and Addressing Safety Concerns at the Watts
Bar Nuclear Plant, (ML16083A479). The NRC determined there was sufficient evidence to
support the existence of an environment within the Operations department where your
employees did not feel free to raise safety concerns to management because they feared
retaliation and did not feel that their concerns were being addressed. As a follow-up to the
issuance of the CEL, this inspection continued the focused assessment of the SCWE
documented in part 1 of the inspection. The staff evaluated the attributes of a SCWE as
described in inspection procedure (IP) 93100, Safety Conscious Work Environment Issue of
Concern Follow-up. IP 93100 identifies a SCWE as an environment in which employees are
encouraged to raise safety concerns, are free to raise concerns both to their own management
and to the NRC without fear of retaliation, where concerns are promptly reviewed, given the
proper priority, appropriately resolved, and timely feedback is provided to those raising
concerns.
The inspection team conducted focus groups and interviews with members of the Watts Bar
staff and key management. A total of 28 employees participated in the focus groups and
interviews. The information from the focus groups, interviews, and document reviews were
organized into the themes that are discussed in the attached report. The team made the
following key observations associated with the current work environment, which are explained in
more detail in the report. All employees interviewed during Part 2 of the inspection indicated
that they were willing to raise nuclear safety concerns and felt free to raise concerns to their
direct supervisors without fear of retaliation. However, the insights provided by employees
confirmed that there were site-wide challenges to the SCWE at WBN, and some of the
conditions that prompted the issuance of the CEL extended beyond the Operations department.
The team identified weaknesses in the documentation and tracking of corrective actions to
improve the SCWE in departments outside of Operations. There were also weaknesses in the
criteria used to evaluate nuclear safety culture standards, which likely contributed to the missed
opportunities to identify and address safety culture concerns prior to the development of the
chilled work environment.
Before the NRC makes its enforcement decision, we are providing you an opportunity to (1)
respond to the apparent violation addressed in this inspection report within 30 days of the date
of this letter, (2) request a Pre-decisional Enforcement Conference (PEC), or (3) request
Alternative Dispute Resolution (ADR). If a PEC is held, it will be open for public observation and
the NRC will issue a press release to announce the time and date of the conference. If you
decide to participate in a PEC or pursue ADR, please contact Alan Blamey at 404-997-4415
within 10 days of the date of this letter. A PEC should be held within 30 days and an ADR
session within 45 days of the date of this letter.
J. Shea 3
If you choose to provide a written response, it should be clearly marked as a Response to An
Apparent Violation in NRC Inspection Report (05000390/2016013 & 05000391/2016013); EA-
17-022, and should include for the apparent violation: (1) the reason for the apparent violation
or, if contested, the basis for disputing the apparent violation; (2) the corrective steps that have
been taken and the results achieved; (3) the corrective steps that will be taken; and (4) the date
when full compliance will be achieved. Your response may reference or include previously
docketed correspondence, if the correspondence adequately addresses the required response.
Additionally, your response should be sent to the NRCs Document Control Center, with a copy
mailed to Joel T. Munday, Director, Division of Reactor Projects, Region II, 245 Peachtree
Center Avenue, NE, Suite 1200, Atlanta, GA 30303-1257, within 30 days of the date of this
letter. If an adequate response is not received within the time specified or an extension of time
has not been granted by the NRC, the NRC will proceed with its enforcement decision or
schedule a PEC.
If you choose to request a PEC, the conference will afford you the opportunity to provide your
perspective on these matters and any other information that you believe the NRC should take
into consideration before making an enforcement decision. The decision to hold a predecisional
enforcement conference does not mean that the NRC has determined that a violation has
occurred or that enforcement action will be taken. This conference would be conducted to
obtain information to assist the NRC in making an enforcement decision. The topics discussed
during the conference may include information to determine whether a violation occurred,
information to determine the significance of a violation, information related to the identification of
a violation, and information related to any corrective actions taken or planned.
In lieu of a PEC, you may also request ADR with the NRC in an attempt to resolve this issue.
ADR is a general term encompassing various techniques for resolving conflicts using a third
party neutral. The technique that the NRC has decided to employ is mediation. Mediation is a
voluntary, informal process in which a trained neutral (the mediator) works with parties to help
them reach resolution. If the parties agree to use ADR, they select a mutually agreeable neutral
mediator who has no stake in the outcome and no power to make decisions. Mediation gives
parties an opportunity to discuss issues, clear up misunderstandings, be creative, find areas of
agreement, and reach a final resolution of the issues. Additional information concerning the
NRC's program can be obtained at http://www.nrc.gov/about-
nrc/regulatory/enforcement/adr.html. The Institute on Conflict Resolution (ICR) at Cornell
University has agreed to facilitate the NRC's program as a neutral third party. Please contact
ICR at 877-733-9415 within 10 days of the date of this letter if you are interested in pursuing
resolution of this issue through ADR.
In addition, please be advised that the number and characterization of the apparent violation
described in the enclosed inspection report may change as a result of further NRC review. You
will be advised by separate correspondence of the results of our deliberations on this matter.
NRC inspectors also documented one NRC-identified finding of very low safety significance
(Green or SL-IV) that did not involve a violation of NRC requirements. Additionally, NRC
inspectors documented one Severity Level IV violation with no associated finding. Further,
inspectors documented one licensee-identified violation which was determined to be of very low
safety significance in this report. The NRC is treating these violations as non-cited violations
(NCVs) consistent with Section 2.3.2.a of the Enforcement Policy.
J. Shea 4
If you contest the violations or significance of these NCVs, you should provide a response within
30 days of the date of this inspection report, with the basis for your denial, to the U.S. Nuclear
Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555-0001; with
copies to the Regional Administrator, Region II; the Director, Office of Enforcement; and the
NRC resident inspector at the Watts Bar Plant.
If you disagree with a cross-cutting aspect assignment or a finding not associated with a
regulatory requirement in this report, you should provide a response within 30 days of the date
of this inspection report, with the basis for your disagreement, to the U.S. Nuclear Regulatory
Commission, ATTN: Document Control Desk, Washington, DC, 20555-0001; with copies to the
Regional Administrator, Region II; and the NRC resident inspector at the Watts Bar Plant.
In accordance with 10 CFR 2.390 of the NRCs Rules of Practice, a copy of this letter and its
enclosure will be available electronically for public inspection in the NRC Public Document
Room or from the Publicly Available Records (PARS) component of the NRCs document
system (ADAMS). Adams is accessible from the NRC Web site at http://www.nrc.gov/reading-
rm/adams.html (the Public Electronic Reading Room).
Sincerely,
/RA/
Joel T. Munday, Director
Division of Reactor Projects
Docket Nos. 50-390, 50-391
Enclosure:
05000391/2016013 w/Attachment:
Supplemental Information
J. Shea 5
SUBJECT: WATTS BAR NUCLEAR PLANT - NRC PROBLEM IDENTIFICATION AND
RESOLUTION INSPECTION (PART 2); AND SAFETY CONSCIOUS WORK
ENVIRONMENT ISSUE OF CONCERN FOLLOW-UP; NRC INSPECTION
REPORT 05000390/2016013, 05000391/2016013 March 10, 2017
DISTRIBUTION:
M. Kowal, RII
K. Sloan, RII
S. Price, RII
S. Sparks, RII
L. Jarriel, OE
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ADAMS Accession Number: ML17069A133
OFFICE RII:DRP RII:DRP RII:DCP RII:DRS RII:DRP HQ:OE HQ:RES
NAME RTaylor JHamman CEven JWallo TStephen DWillis SMorrow
DATE: 2/27/2017 2/27/2017 2/22/2017 2/27/2017 2/21/2017 2/27/2017 2/21/2017
OFFICE RII:DRP RII:EICS RII:DRP RII:DRP
NAME CKontz SSparks ABlamey JMunday
DATE: 2/27/2017 3/10/2017 3/9/2017 3/10/2017
OFFICIAL RECORD COPY
U.S. NUCLEAR REGULATORY COMMISSION
REGION II
Docket No.: 50-390, 50-391
Report No.: 05000390/2016013, 05000391/2016013
Licensee: Tennessee Valley Authority (TVA)
Facility: Watts Bar, Units 1 and 2
Location: Spring City, TN 37381
Dates: October 31 - December 1, 2016
Inspectors: C. Kontz, Senior Project Engineer (Team Lead)
S. Morrow, Human Factors Engineer (Lead Safety Culture
Assessor)
D. Willis, Allegations Team Leader
J. Wallo, Senior Security Inspector
C. Even, Senior Construction Inspector
R. Taylor, Senior Project Inspector
J. Hamman, Resident Inspector Watts Bar
T. Stephen, Resident Inspector Browns Ferry
Approved by: Alan Blamey, Chief
Reactor Projects Branch 6
Division of Reactor Project
Enclosure
SUMMARY
IR 05000390/2016013 and 05000391/2016013; October 31 - December 1, 2016; Watts Bar,
Units 1 and 2; (Problem Identification and Resolution).
This inspection constituted the conclusion of the biennial inspection of the Problem Identification
and Resolution Program and was conducted by a senior project engineer, two resident
inspectors, human factors engineer, an allegations team leader, senior allegations coordinator,
and a senior construction inspector. One Apparent Violation (AV), one Severity Level IV (SLIV)
violation, and one Green Finding were identified. The significance of inspection findings is
indicated by their color (Green, White, Yellow, Red) using Inspection Manual Chapter (IMC) 0609, "Significance Determination Process" (SDP) dated April 29, 2015. Cross-cutting aspects
are determined using IMC 0310, Components Within the Cross Cutting Areas dated December
4, 2014. All violations of NRC requirements are dispositioned in accordance with the NRCs
Enforcement Policy dated August 1, 2016. The NRCs program for overseeing the safe
operation of commercial nuclear power reactors is described in NUREG-1649, Reactor
Oversight Process, Revision 6.
Identification and Resolution of Problems
The inspectors identified several examples that demonstrated weaknesses in the licensees
ability to identify problems and enter them into the CAP for resolution, as evidenced by the
number of deficiencies identified by external organizations (including the NRC) that had not
been previously identified by the licensee and placed into the CAP, during the review period.
The prioritization of issues was effective; however, a weakness was noted in the root cause
evaluations for significant problems. Corrective actions developed and implemented for issues
were generally effective and implemented in a timely manner. The inspectors determined that
overall, audits and self-assessments were adequate in identifying deficiencies and areas for
improvement in the CAP, and appropriate corrective actions were developed to address the
issues identified. Operating experience usage was found to be generally acceptable and
integrated into the licensees processes for performing and managing work, and plant
operations.
A. NRC-Identified Findings and Self-Revealed Findings
Cornerstone: Other
- Green. The NRC identified a Finding for the licensees failure to consistently implement
the program requirements of the CAP. Specifically, the licensee failed to implement
NPG-SPP-22.301, section 3.2.2 which required the licensees staff to initiate a Condition
Report (CR) to enter various items into their CAP. The licensee placed this issue into
their corrective action program.
The performance deficiency was more than minor because, if left uncorrected, issues
would remain unanalyzed that could represent a more significant safety concern. The
performance deficiency was screened using IMC 0609, Appendix A, Exhibit 2 Mitigating
Systems Cornerstone dated June 19, 2012. The finding screened to Green because
none of the examples were related to any structure, system, component, (SSC)
3
exceeding its technical specification allowed outage time. A cross cutting aspect of
Identification was assigned because the licensees threshold for identifying and entering
issues into their CAP was not low enough as defined by their procedures. (P.1) (Section
4OA2)
- SL-IV. The NRC identified a Non-cited Violation (NCV) of 10 CFR 50.9, Completeness
and Accuracy of Information for the licensees failure to provide accurate information in
all material respects to the Commission. The team determined on April 22, 2016, the
licensee provided inaccurate information in a letter to the NRC titled, RESPONSE TO
NRC LETTER CONCERNING A CHILLED WORK ENVIRONMENT FOR RAISING AND
ADDRESSING SAFETY CONCERNS AT THE WATTS BAR NUCLEAR PLANT
(ML16113A228). This information was material because the NRC relied on this
information to conclude that TVA was in compliance with CO-EA-09-009/203
requirements. The licensee placed this issue into their corrective action program.
The NRC determined this violation constituted a more than minor traditional enforcement
violation associated with failure to provide accurate information. The ROPs significance
determination process does not specifically consider the regulatory process impact in its
assessment of licensee performance. Therefore, it is necessary to address violations
which impede the NRCs ability to regulate using traditional enforcement. The inspector
determined that the licensees failure to provide accurate information was a violation of
10CFR50.9 which had the potential to impede or impact the regulatory process, and
therefore subject to traditional enforcement as described in the NRC Enforcement
Policy, dated November 1, 2016. This violation is characterized as a Severity Level IV
violation because it was similar to Example Section 6.9.d.1 of the NRC Enforcement
Policy. (Section 4OA5.1.b)
- TBD. The NRC identified an Apparent Violation of Confirmatory Order Modifying
License, (EA-09-009,203) Dated December 22, 2009 (ML093510993) for the licensees
failure to; (1) implement a process to review proposed licensee adverse employment
actions at Watts Bar Nuclear plant before actions were taken to determine whether the
proposed action comports with employee protection regulations, and whether the
proposed actions could negatively impact the SCWE; and (2) implement a process to
review proposed significant adverse employment actions by contractors performing
services at TVAs nuclear plant sites before the actions were taken to determine whether
the proposed action comports with employee protection regulations, and whether the
proposed action could negatively impact the SCWE.
The NRC determined this violation constituted a more than minor traditional enforcement
violation associated with failure to implement actions required by Confirmatory Order
Modifying License, (EA-09-009,203). The ROPs significance determination process
does not specifically consider the regulatory process impact in its assessment of
licensee performance. Therefore, it is necessary to address violations which impede the
NRCs ability to regulate using traditional enforcement. The inspector determined that
the licensees failure to implement the requirements of the Confirmatory Order had the
potential to impede or impact the regulatory process, and therefore subject to traditional
enforcement as described in the NRC Enforcement Policy, dated November 1, 2016.
The NRC has not made an enforcement decision on this matter. (Section 4OA5.2.b)
4
B. Licensee-Identified Violations
Violations of very low safety or security significance or Severity Level IV that were
identified by the licensee have been reviewed by the NRC. Corrective actions taken or
planned by the licensee have been entered into the licensees corrective action program.
These violations and corrective action tracking numbers are listed in Section 4OA7 of
this report.
REPORT DETAILS
4OA2 Problem Identification and Resolution
1. Corrective Action Program Effectiveness
a. Inspection Scope
The team reviewed the licensees CAP procedures, which described the administrative
process for initiating and resolving problems primarily through the use of condition
reports (CRs). To verify that problems were being properly identified, appropriately
characterized, and entered into the CAP, the inspectors reviewed CRs that had been
issued between November 2014 and October 2016. Where possible, the team
independently verified that the corrective actions were implemented as intended.
The team also reviewed selected common causes and generic concerns associated with
root cause analyses (RCA) to determine if they had been appropriately addressed. To
help ensure that samples were reviewed across all cornerstones of safety identified in
the Reactor Oversight Process (ROP), the team selected a representative number of
CRs that were identified and assigned to the major plant departments, including quality
assurance, operations, health physics, chemistry, emergency preparedness and
security. These CRs were reviewed to assess each departments threshold for
identifying and documenting plant problems, thoroughness of evaluations, and adequacy
of corrective actions. The team reviewed selected CRs, verified corrective actions were
implemented, and attended meetings where CRs were evaluated for significance to
determine whether the licensee was identifying, accurately characterizing, and entering
problems into the CAP at an appropriate threshold.
The inspectors reviewed CRs, maintenance history, corrective actions (CAs), completed
work orders (WOs) for selected systems, and reviewed associated system health
reports. These reviews were performed to verify that problems were being properly
identified, appropriately characterized, and entered into the CAP. Items reviewed
generally covered a two-year period of time; however, in accordance with the inspection
procedure, a five-year review was performed for selected systems for age-related
issues.
The main control room deficiency list was assessed to ascertain if deficiencies were
entered into the CAP and tracked to resolution. Operator workarounds and operator
burden screenings were reviewed, and the inspectors verified appropriate compensatory
measures were being implemented in the field for the deficient equipment. The
inspectors also reviewed Shift Orders, Standing Orders, and Operational Decision
making instructions.
The inspectors conducted a detailed review of selected CRs to assess the adequacy of
the root cause and apparent cause evaluations of the problems identified. The
inspectors reviewed these evaluations against the descriptions of the problem described
in the CRs and the guidance in licensee procedure NPG-SPP-22.306, Level 1
Evaluation and NPG-SPP-22.305, Level 2 Evaluation. The inspectors assessed if the
licensee had adequately determined the cause(s) of identified problems, and had
adequately addressed operability, reportability, common cause, generic concerns,
6
extent-of-condition, and extent-of-cause. The review also assessed if the licensee had
appropriately identified and prioritized corrective actions to prevent recurrence.
The inspectors reviewed selected industry operating experience (OE) items, including
NRC generic communications, to verify that they had been appropriately evaluated for
applicability and that issues identified through these reviews had been entered into the
CAP.
The inspectors reviewed site trend reports, to determine if the licensee effectively
trended identified issues and initiated appropriate corrective actions when adverse
trends were identified.
The inspectors reviewed licensee audits and self-assessments, including those which
focused on problem identification and resolution programs and processes, to verify that
findings were entered into the CAP and to verify that these audits and assessments
were consistent with the NRCs assessment of the licensees CAP. The inspectors
attended various plant meetings to observe management oversight functions of the
corrective action process. These included the Plant Screening Committee (PSC) and
Management Review Committee meetings.
Documents reviewed are listed in the Attachment.
b. Assessment
Problem Identification
The inspectors identified a weakness in the licensees ability to identify problems and
enter them into the CAP. This conclusion was based on a review of the requirements for
initiating CRs as described in licensee procedure NPG-SPP-22.300, Corrective Action
Program, and managements expectation that employees were encouraged to initiate
CRs for any reason. Additionally, the inspectors identified significant challenges to the
sites environment for raising concerns as discussed in a later section of this report.
Trending was generally effective in monitoring equipment performance. Site
management was actively involved in the CAP and focused appropriate attention on
significant plant issues. Based on reviews and walkdowns of accessible portions of the
selected systems, the inspectors determined that system deficiencies were being
identified and placed in the CAP.
The inspectors identified multiple issues surrounding the licensees review of the events
that led to the Unit 1, November 11, 2015, use of the Residual Heat Removal (RHR)
system to arrest an uncontrolled rise in Pressurizer Level as documented in CR
1199024. The licensee failed to document these events in their control room logs, they
failed to follow their procedures for placing RHR into service, and they failed to follow
their operability procedures (these issues were dispositioned in Watts Bar Inspection
Report 2016-001)(ML 16098A323). Additionally, the licensee exceeded their self-
imposed time limit for initiation of a condition report and commencement of a causal
analysis for these issues. The licensee took 55 days to generate a condition report to
begin their required causal analysis of this issue, which was in excess of the 12 hour1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br />
time limit and thus the condition report was not able to be screened promptly.
7
The inspectors identified weaknesses in the licensees ability to identify problems as
evidenced by multiple examples associated with not appropriately entering issues into
the CAP. The inspectors determined that issues identified through external reviews
were not consistently being input into the CAP but rather addressed by actions outside
of the CAP. The majority of the issues identified in the reviews met NPG-SPP-22.301
criteria for CR initiation. Additionally, the resident inspectors identified multiple examples
of issues that would not have been entered into the licensees CAP without their
involvement.
The inspectors found that the licensee had an adequate process for identifying Operator
Burdens, Workarounds, and Control Room Deficiency issues, entering them into the
corrective action program, screening them to the appropriate level per site procedures,
and generating an up to date control room deficiency list each day. The control room
deficiency list comported with the inspectors walk-down of the main control board.
Additionally, the inspectors reviewed the transition process from CR to work order for
operator burdens, workarounds, or control room deficiencies.
The inspectors noted that the CR software (MAXIMO) does not have a function to allow
a CR initiator to code an issue as either an operator burden, workaround, or control
room deficiency. The initiator must identify that the condition reported is one of these
types of issues by entering descriptive text into the CR detail or summary field. The
licensees Quality Assurance (QA) department identified four condition reports where the
condition represented a control room deficiency; however, that terminology was not used
in the detail or summary field, and the CRs were not properly screened as C Level CRs
as required by NPG-SPP-22.302 by the PSC. Instead, the CRs were screened as work
order only. The licensee entered this QA finding into their corrective action program as
CR 1152376. Once the CRs are transferred to a work order, focus codes are added and
the main control room deficiency list is then generated off the focus codes, and provided
to the control room staff each morning.
The inspectors also reviewed a failure of the Unit 1 1B-B Centrifugal Charging Pump
(CCP) room cooler on December 4, 2015. The analysis that was completed on May 13,
2016, did not identify the true cause of the failure. Following the second failure on
August 3, 2016, the licensee was able to identify the cause and appropriate corrective
actions.
Problem Prioritization and Evaluation
Based on the review of CRs sampled by the inspection team during the onsite period,
the inspectors concluded that problems were generally prioritized and evaluated in
accordance with the licensees CAP procedures as described in NPG-SPP-22.302,
Corrective Action Program Screening. One notable exception the inspectors identified
was the weakness identified in the performance of formal root cause analysis.
Inspectors concluded CRs were assigned a priority level at the CR screening meeting,
and adequate consideration was given to system or component operability and
associated plant risk.
8
The inspectors identified weaknesses in the performance of formal root cause
evaluations for significant problems. The inspectors determined that station personnel
had conducted root cause and apparent cause analyses mostly in compliance with the
licensees CAP procedures and assigned cause determinations were appropriate,
considering the significance of the issues being evaluated. A variety of formal causal-
analysis techniques were used depending on the type and complexity of the issue
consistent with licensee procedures NPG-SPP-22.300, Corrective Action Program,
NPG-SPP-22.306, Level 1 Evaluation, and NPG-SPP-22.305, Level 2 Evaluation.
There were several examples of root cause evaluations that did not meet the licensees
procedural requirement for independence. This constitutes roughly half of all the
licensees root cause evaluations performed since the last PI&R inspection. The
licensees procedures required the Responsible Manager who approved the root cause
evaluations to be independent from the organization involved in the event. The
licensees procedures also required that the members of the root cause evaluation team
not include personnel who were directly involved or immediately responsible for the
problem. Independence for personnel approving or conducting a root cause evaluation
is not a NRC requirement.
1) Chilled Work Environment Root Cause (Revision 0 and 1) (CR 1155393) was
approved by a different Watts Bar senior manager for each revision despite the fact
that Watts Bar senior management was involved in the chilling effect.
2) Scope Growth on a Safety Related Component (Revision 0 and 1) (CR 1199024)
had a member of the root cause team that was in the Outage Control Center leading
up to the event that required a causal evaluation.
3) Unit 1 Ice Bed Temperature Increasing root cause evaluation (Revision 1) (CR
974404) was approved by a manager who was responsible for the organization that
was determined to be the direct cause of the event.
4) Unit 1 Manual Reactor Trip root cause evaluation (Revision 0) (CR 991403) was
approved by a manager who was responsible for the work group that was the root
cause for the event.
5) Inoperable Source Range Detectors during Reactor Startup (Revision 1) (CR
1096405) was approved by a manager who was responsible for the work group that
was a contributing cause for the event.
6) Seal Plug Found Loose on Control Rod Drive Mechanism (Revision 0) (CR 1102231)
had a member of the root cause team that was responsible for one of the programs
that was determined to be a contributing cause for the event.
The inspector identified the licensee did not adhere to their standards for performing a
root cause analysis in completing the initial revision of the Chilled Work Environment
Root Cause (CR 1155393). The licensee received some support from an external
contractor to review the root cause and incorporated some changes into revision 1 of the
RCA. Not all recommendations or conclusions presented were accepted by the licensee.
These potential gaps were not entered into the CAP and addressed through the program
but rather addressed by revising the original RCA. Specifically, the following items were
most significant:
1) The root cause did not fully evaluate the ineffectiveness of the implementation of the
2009 NRC Confirmatory Order [EA-09-009, EA-09-203]. The root cause only
mentions this order in the timeline.
2) The root cause references the work done in a separate causal analysis for a loss of
confidence in the corrective action program (CR 1151960). However, neither
9
3) addresses the communication of why decisions were made to the disposition and
prioritization of corrective actions. This could have been a contributing cause to the
chilling effect.
4) The extent of condition of the chilling effect to other departments at Watts Bar was
dismissed without an adequate basis. The inspectors discovered substantial
weaknesses in various attributes of SCWE in other departments that were at risk of a
chilling effect.
The inspectors identified examples where CRs or actions were closed to separate CRs
causing challenges in implementing effective evaluation of issues. One example
included CR 1151962 which was initiated in response to an internal Special Review
Team report. The CR was specific and clearly worded that if the decision is made not to
perform causal evaluation, the disposition of this CR must be provided to the WBN Plant
Manager for his concurrence. CR 1151962 was approved for closure to RCA 1155393
by the Licensing Manager without the need for immediate and interim actions being
evaluated and documented in CR 1151962.
The issue was subsequently inadequately captured in CR 1155393 Root Cause
Investigation Charter as a weakness associated with implementation of the Adverse
Employment Action procedure (NPG-SPP-11.10). CR 1155393 Root Cause Analysis
did not address the knowledge weakness associated with the implementation of the
Adverse Employment Action procedure. A causal evaluation was not performed to
understand the organizational and programmatic factors that allowed this weakness to
manifest itself as required in the original CR and there was no indication that the
disposition of the original CR was provided to the WBN Plant Manager for his
concurrence.
Effectiveness of Corrective Actions
Based on a review of corrective action documents, interviews with licensee staff, and
verification of completed corrective actions, the inspectors determined that overall,
corrective actions were timely, commensurate with the safety significance of the issues,
and effective, in that conditions adverse to quality were corrected and non-recurring. For
Significant Conditions Adverse to Quality (SCAQ), the corrective actions directly
addressed the cause and effectively prevented recurrence in that a review of
performance indicators, CRs, and effectiveness reviews demonstrated that the
significant conditions adverse to quality had not recurred. Effectiveness reviews for
corrective actions to prevent recurrence (CAPRs) were generally sufficient to ensure
corrective actions were properly implemented and were effective.
The team reviewed green findings since the last PI&R along with CRs written to
document the findings. The inspectors found that the CRs had adequate corrective
actions in place, completed actions were appropriately closed, and open actions had
reasonable dates for completion. The inspectors reviewed the actions for the CRs and
noted that the majority of them were corrective actions not only for what happened, such
as the performance deficiency, but also included corrective actions for the reason why
the performance deficiency happened.
10
However, the inspectors identified several examples of corrective actions that were
inadequate, closed without an adequate basis, or CAPR actions that may not prevent
recurrence.
1. Corrective action number 6 from the licensees Security Loggable Event root cause
was ineffective in that it did not require the licensee to implement changes to the
Security Performance Improvement Plan. (CR 1228949)
2. Corrective action number 17 from the licensees CEL Response (CR 1162755) was
closed without an adequate basis. The inspectors determined that the action was
closed without providing objective evidence that an effectiveness review was
completed.
3. Corrective action number 18 from the licensees Chilled Work Environment Root
Cause Analysis (CR 1155393) was closed without an adequate basis. The
corrective action was to verify that the chilling effect in the operations department at
Watts Bar did not extend to other departments on site. The inspectors determined
that there was insufficient evidence at the time of closure to make this determination.
4. The root cause for the Unit 1 1B-B CCP room coolers failures (CR 1131520) was a
lack of procedural direction to ensure that CAPRs remain in effect to correct SCAQs.
5. The CAPR for the Scope Growth on a Safety Related Component root cause (CR
1199024) does not address the Outage Control Centers role in the event and most
likely will not preclude repetition.
These examples indicate that there are some challenges to the licensees ability to
sustain their corrective action program.
c. Findings
Introduction: The NRC identified a Green Finding for the licensees failure to consistently
implement the requirements of the CAP. Specifically, the licensee failed to implement
NPG-SPP-22.301, section 3.2.2 which required the licensees staff to initiate a CR to
enter various items into their CAP.
Description: During the preparation for the 2016 Problem Identification and Resolution
inspection the licensee contracted an outside organization to review several of their
causal analyses and CEL responses. The outside organization identified multiple
examples of issues that were not subsequently entered into the licensees corrective
action program. These issues met the CR initiation requirements of NPG-SPP-22.301,
Condition Report Initiation, section 3.2.2, When to Initiate a Condition Report, which
requires in part, any condition adverse to quality (CAQ), equipment issue, performance
concern, issue not meeting written management expectations, and identified gaps to
standards be documented in a Condition Report.
Some of these examples of the outside organizations issues are listed below:
1) The independence of the people assigned to perform the Chilled Work
Environment root cause and the Special Review Team was in question. These
teams consisted primarily of TVA managers.
2) The closure documentation for some corrective actions in the Chilled Work
Environment root cause did not include the critical thinking for closure or
decisions made regarding long term practices.
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3) The CEL response and the Chilled Work Environment Root Cause Analysis
(RCA) (CR 1155393) did not address the evaluation of the implementation of
Confirmatory Order (EA-09-009, EA-09-203) in a substantial manner. This was
required by the NRC CEL to WBN. Specifically, only 4 of the 10 required actions
had a documented review. Additionally, 2 of the 10 that were reviewed were
considered ineffective.
4) The CR 1162755 causal analysis did not address why 20% of CAP items
converted to work orders were subsequently closed with no work occurring.
5) The effectiveness of the adverse employment action procedure was not
evaluated in the CR 1155393 RCA for two events whose subsequent
management actions should have been considered adverse which were not
entered into the adverse employment action procedure. The events were the
Unit Supervisor that was pulled off shift and the training instructor who was
reassigned from the Outage Control Center back to the training center.
6) Four actions to change procedures in CR 1127691 (actions 006/009/010/016)
were incorrectly coded as enhancements vice corrective actions and were
subsequently not approved to be performed. Since these procedure changes
were enhancements, they only needed peer review and the peer disapproved the
changes.
7) CR 1102231 and the causal analysis never evaluated whether a 10 CFR 21
evaluation was done for reportability. The RCA concluded that a possible cause
for the decreased in vent plug torque was a latent design flaw. Latent design
flaws are required to be evaluated under 10 CFR 21.
Analysis: The licensees failure to implement the requirements of their CAP as required
by NPG-SPP 22.301 was a performance deficiency. Specifically, on at least seven
occasions, the licensee failed to enter issues into their CAP that would have required
corrective actions. The performance deficiency was more than minor because, if left
uncorrected, issues would remain unanalyzed that could represent a more significant
safety concern. The performance deficiency was screened using IMC 0609, Appendix A,
Exhibit 2 Mitigating Systems Cornerstone dated June 19, 2012. The finding screened to
Green because none of the examples were related to any SSC exceeding its technical
specification allowed outage time. A cross cutting aspect of Identification was assigned
because the licensees threshold for identifying and entering CAQ into their CAP was not
low enough as defined by their procedures. (P.1)
Enforcement: Inspectors did not identify a violation of regulatory requirements
associated with this finding. FIN 050000390, 391/2016013-01, Failure to Implement the
Program Requirement to Enter Issues into the CAP.
2. Use of Operating Experience (OE)
a. Inspection Scope
The team examined the licensees use of industry OE to assess the effectiveness of how
external and internal operating experience information was used to prevent similar or
recurring problems at the plant. In addition, the team selected operating experience
documents (e.g., NRC generic communications, 10 CFR Part 21 reports, licensee event
reports, vendor notifications, and plant internal operating experience items, etc.), which
had been issued since November 2014, to verify the licensee had appropriately
12
evaluated each notification for applicability to the Sequoyah Nuclear Plant, and if issues
identified through these reviews were entered into the CAP.
b. Assessment
Based on a review of selected documentation related to operating experience issues,
the inspectors determined that the licensee was generally effective in screening
operating experience for applicability to the plant. Industry OE was evaluated at either
the corporate or plant level depending on the source and type of the document. Relevant
information was then forwarded to the applicable department for further action or
informational purposes. OE issues requiring action were entered into the CAP for
tracking and closure. In addition, operating experience was included in all apparent
cause and root cause evaluations in accordance with licensee procedure NPG-SPP-
22.500, Operating Experience Program.
The team noted that the site is working on making their OE program more robust as they
self-identified some screening weaknesses prior to our inspection.
Documents reviewed are listed in the Attachment.
c. Findings
No finding were identified.
3. Self-Assessments and Audits
a. Inspection Scope
The team reviewed audit reports and self-assessment reports, including those which
focused on problem identification and resolution, to assess the thoroughness and self-
criticism of the licensee's audits and self-assessments. The team reviewed
implementation and audits of the Quality Assurance program against Nuclear Quality
Assurance Plan (NQAP) (TVA-NQA-PLN89-A Rev. 0032) and ANSI/ANS-3.2-2012:
Managerial, Administrative, and Quality Assurance Controls for the Operational Phase of
Nuclear Power Plants. Additionally, the team verified that problems identified through
those activities were appropriately prioritized and entered into the CAP for resolution in
accordance with licensee procedure NPG-SPP-22.102, NPG Self-Assessment and
Benchmarking Program.
Documents reviewed are listed in the Attachment.
b. Assessment
The team determined that the scopes of assessments and audits were adequate. Self-
assessments were generally detailed and critical. The team verified that CRs were
created to document areas for improvement and findings resulting from the self-
assessments, and verified that actions had been completed consistent with those
recommendations. Audits of the quality assurance program appropriately assessed
performance and identified areas for improvement. Generally, the licensee performed
evaluations that were technically accurate.
13
c. Findings
No finding were identified.
4. Safety-Conscious Work Environment
a. Inspection Scope
The team conducted interviews and focus groups with 28 staff, primarily at the first line
supervisor level or above to provide insights regarding the licensees safety conscious
work environment (SCWE). These interviews and focus groups were used to
supplement the information gathered during Part 1 of the PI&R inspection (IR 05000390/2016007; ML16300A409). The team also reviewed the licensees programs
and processes for assessment and monitoring of nuclear safety culture, and the
licensees Employee Concerns Program (ECP) to verify they were effective at supporting
the SCWE.
b. Assessment
Safety Conscious Work Environment
During Part 1 of the PI&R inspection, many of the non-supervisory employees
interviewed felt that their supervisors were most at risk for being retaliated against for
raising concerns. However, all supervisory staff interviewed during Part 2 of the
inspection indicated that they were willing to raise nuclear safety concerns and felt free
to raise concerns to their direct supervisors without fear of retaliation. Many supervisory
staff acknowledged that there had been challenges to the SCWE in their departments in
the past year, but that actions taken following the CEL have resulted in improvements.
However, similar to non-supervisory staff, most supervisory staff also expressed a wait
and see attitude with regard to the sustainability of positive changes. Although there
continued to be department-specific challenges to the work environment, the team
observed that senior management was aware of the challenges and taking actions to
address those challenges. However, with the exception of the Operations department,
many of the other department-specific actions taken or planned to improve the safety
culture and SCWE were not being documented and tracked within the scope of WBNs
chilled work environment improvement plan.
In addition to the feedback provided by non-supervisory staff during Part 1 of the PI&R
inspection, the insights provided by the supervisory staff confirmed that there were site-
wide challenges to the SCWE at WBN. However, managements actions to address the
chilled work environment had improved some of the most significant issues identified by
non-supervisory employees (e.g., management behaviors that discouraged the free flow
of information), and additional actions were planned to address more long-standing
concerns, such as perceptions regarding the lack of adequate resolution to problems
identified via the corrective action program. Notwithstanding these improvements, the
conditions that prompted the issuance of the CEL were confirmed to extend beyond the
Operations department, and the corrective actions to address the CEL should
appropriately be extended site-wide. However, as noted previously, the lack of
documentation and tracking of department-specific actions outside of the Operations
department may impede the sites ability to thoroughly evaluate the effectiveness of
actions to address department-specific SCWE challenges.
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Nuclear Safety Culture Assessment and Monitoring
The team identified weaknesses in the assessment and monitoring of safety culture. In
particular, the team noted a lack of clear, objective or independent criteria for evaluating
when nuclear safety culture standards were met. This was evidenced in how the site
interpreted responses from safety culture surveys and interviews, and how the Nuclear
Safety Culture Monitoring Panel (NSCMP) and Site Leadership Team (SLT) rated
nuclear safety culture traits as part of their continuous monitoring process. The lack of
clear criteria for evaluating nuclear safety culture standards likely contributed to the
missed opportunities to identify and address safety culture weaknesses prior to the
development of the chilled work environment.
- The Extent of Condition review in the Chilled Work Environment Root Cause
(RCA CR 1155393, Attachment E) noted that site-wide pulsing surveys at WBN
had a declining trend from 2015 to March of 2016. In particular, the percentage of
employees who responded favorably to the question, my work environment
encourages the voluntary expression of concerns and differing views about
nuclear safety or quality, dropped from 89% in 2015 to 69% in March of 2016.
However, the extent of condition review concluded that, there was no evidence
of a chilled work environment in any of the WBN departments outside of
Operations. Although the extent of condition was ultimately extended to the
entire site, the statement that there was no evidence of a chilled work
environment in other departments was not consistent with the data presented.
- The Extent of Condition review in RCA CR 1155393 also noted that pulsing
surveys improved for the Operations department from February 2016 to March
2016. However, an in-depth review of the ECP pulsing data and interviews with
the ECP manager revealed that the pulsing surveys in Operations were being
conducted on a shift-by-shift basis. As a result, differences in the monthly pulsing
survey results for Operations may not have indicated actual improvements or
declines in the work environment, but rather different perceptions of the work
environment held by different shifts in Operations.
- The Employee Concerns Program Conduct of Operations Manual, Rev. 1, states
that when analyzing responses to questions in the SCWE, Management, and
Precursor categories, it is ideal for responses to be greater than 90% Always.
At a minimum the aggregate of Always and Often should be greater than
90%. However, these standards for evaluating survey results were not
consistently adhered to, as the 2015 pulsing surveys results did not meet the
minimum threshold of 90% favorable for six out of seven survey questions in the
aforementioned categories. Interviews also suggested that, at times, when the
senior management team reviewed responses to the pulsing surveys, the
sometimes response was included as a favorable response, which also
suggested a relaxation of standards for evaluating safety culture data.
- Presentation materials from the nuclear safety culture and employee
engagement survey conducted in 2015 suggested an improving culture at WBN,
primarily based on one survey question that indicated 75% of the respondents
believed the safety culture at WBN had improved in the past year. However, this
limited assessment of the results did not highlight ongoing challenges to the
WBN safety culture or department-specific challenges, which were apparent in a
15
detailed review of department-specific survey results and comments. In addition,
a single positive statement from the 2015 survey was used as the basis for
determining the safety culture was improving as part of the Chilled Work
Environment RCA. Although WBN recognized the performance deficiency to
track and evaluate results from nuclear safety culture surveys, as required by
NPG-SPP-01.7.3 (CR 1186612), a detailed review of the 2015 survey results
was never performed as part of the RCA. A single indication of an improving
culture was inappropriately used as evidence of a healthy or acceptable culture.
- In September 2016, the Site Leadership Team (SLT) convened for its semi-
annual nuclear safety culture meeting. This meeting consisted of a review of the
last 6 months of information from the Nuclear Safety Culture Monitoring Panel
(NSCMP), which met monthly rather than quarterly as one of the interim
corrective actions the site took due to the issuance of the CEL in March 2016.
Although the NSCMP never rated the environment for raising concerns as a
strength during the previous 6 month period, the SLT chose to rate this safety
culture trait as a strength (the NSCMP rated the trait as an improvement
opportunity on three occasions, and acceptable on two occasions from April-
August). The SLT meeting minutes noted that the environment for raising
concerns was rated as a strength because all employees feel comfortable raising
concerns and no examples could be provided where individuals did not raise
concerns. There was no mention of ECP pulsing surveys, which continued to
indicate challenges to the SCWE in Operations, extent of condition reviews that
identified SCWE challenges in other departments, or ongoing actions to respond
to the Chilling Effect Letter issued by the NRC.
- Also during the September 2016 meeting the SLT rated the problem identification
and resolution trait as acceptable, even though the NSCMP consistently rated
problem identification and resolution as an improvement opportunity from April-
August. The basis for the acceptable rating was noted to be because the site
does well at identifying issues and trending of issues had improved. However,
this rating did not reflect longstanding concerns employees had voiced with
regard to the effective resolution of issues. Overall, the SLT rated six traits as
acceptable, three as improvement opportunities, and one trait as a strength.
- The October 2016 meeting of the NSCMP resulted in lower ratings for many of
the nuclear safety culture traits as compared to previous meetings. However, the
decline in the ratings was not believed to reflect a decline in the site-wide safety
culture, but rather a more accurate indication of the current status of the safety
culture. The basis for the change in the index was attributed to the inclusion of
more craft (non-supervisory) employees at the NSCMP meeting. Six traits were
rated as improvement opportunities, and four traits were rated as acceptable. As
a result, previous NSCMP ratings of safety culture were speculated to be overly
positive.
- The overall effectiveness measure for CAPR closure in the Chilled Work
Environment RCA (CR 1155393) had multiple weaknesses that could challenge
the integrity of the effectiveness review.
16
o Some success criteria were vague and open to interpretation. For
instance, one of the success criteria was favorable results from
employee engagement surveys, yet it was not clear what constituted
favorable results. The 2015 employee engagement survey was
evaluated as favorable, yet further review revealed substantial negative
write-in comments and selected departments with lower scores on key
safety culture measures. In addition, it was not clear what constituted a
satisfactory interim effectiveness review.
o Some success criteria only required evidence that a corrective action had
been completed, not whether the action achieved its intended result. For
example, completion of training and non-training actions from the RCA.
o Some success criteria included vague qualifiers, such as applicable or
selected.
o The effectiveness measure did not stipulate whether all, or only some, of
the success criteria must be met.
The team also identified weaknesses in the training provided to employees who are
responsible for providing inputs to the nuclear safety culture monitoring process, and
employees who are analyzing and making assessments based on these inputs, such as
the participants on the NSCMP. The team noted that all managers and staff receive
computer-based training (CBT) on safety culture and SCWE as part of their initial
training upon hire. In addition, employees were required to take refresher CBT in 2016
as part of the chilled work environment corrective actions. The CBT primarily focused on
defining safety culture terms and emphasizing employees rights and responsibilities to
raise nuclear safety concerns. However, there was no additional training for NSCMP
members to assist them in preparing inputs to the panel meetings or evaluating the
inputs provided at the panel meetings. The lack of training to develop a common
understanding of what to look for in the work environment that could indicate a declining
safety culture may continue to challenge the effectiveness of safety culture self-
assessments.
One of the changes made to the NSCMP meeting format as part of the chilled work
environment improvement plan was to include craft and other non-supervisory
employees in the NSCMP meetings. Interviews indicated that this change was viewed
by management and employees as an improvement to the culture monitoring process.
The safety culture ratings from the October 2016 meeting also appeared to be more self-
critical. However, the NSCMP ratings of the sites safety culture were still susceptible to
large fluctuations in ratings (e.g., over-weighting recent activities rather than taking a
holistic view of the overall state of the safety culture). The sustainability of positive
changes to the sites safety culture may continue to be challenged without independent
checks to ensure that self-assessments are appropriately self-critical.
Employee Concerns Program
The team determined that the documentation in ECP files was sufficiently detailed to
demonstrate appropriate processing of concerns by ECP staff. However, within the ECP
files, it was difficult to track what corrective actions the site had taken as a result of ECP
recommendations. In some cases when CRs were developed to address ECP
recommendations, some of the corrective actions were later changed or cancelled. The
lack of documentation and follow-through to ensure that actions are taken as a result of
ECP substantiated concerns may continue to challenge the perceived effectiveness of
17
ECP, particularly in cases where employees who raise concerns are not getting
feedback regarding how their concerns were addressed.
c. Findings
No findings were identified.
4OA5 Other
1. Review of TVA Response to the Chilled Work Environment For Raising And Addressing
Safety Concerns At The Watts Bar Nuclear Plant
a. Inspection Scope
On March 23, 2016, the NRC issued CHILLED WORK ENVIRONMENT FOR RAISING
AND ADDRESSING SAFETY CONCERNS AT THE WATTS BAR NUCLEAR PLANT
letter (ML16083A479). The NRC requested, in part, that the licensee provide their plan
of action for addressing the chilled work environment to the NRC within 30 days of the
date of the letter. Included in the plan the NRC requested TVA evaluate effectiveness of
the implementation of Confirmatory Order (EA-09-009, EA-09-203) requirements relative
to the current conditions. The Confirmatory Order (CO) Item #1 required the licensee to
implement a process to review proposed adverse employment actions before actions are
taken to determine whether the proposed action comports with employee protection
regulations, and whether the proposed actions could negatively impact the SCWE.
The inspectors reviewed TVAs April 22, 2016, response, entitled RESPONSE TO NRC
LETTER CONCERNING A CHILLED WORK ENVIRONMENT FOR RAISING AND
ADDRESSING SAFETY CONCERNS AT THE WATTS BAR NUCLEAR PLANT
(ML16113A228).
b. Findings:
Introduction: The inspector identified a Severity Level IV NCV of 10 CFR 50.9 (a),
Completeness and accuracy of information, for the licensees failure to provide
accurate information associated with TVAs response to the CHILLED WORK
ENVIRONMENT FOR RAISING AND ADDRESSING SAFETY CONCERNS AT THE
WATTS BAR NUCLEAR PLANT letter dated March 23, 2016. Specifically, on April 22,
2016, the licensee provided information to the Commission that inaccurately indicated
that the licensee completed an evaluation of the effectiveness of the implementation of
CO (EA-09-009, EA-09-203) requirements relative to the current conditions at Watts Bar.
The licensee entered this issue into the corrective action program as CR 1263417.
Description: On March 23, 2016 the NRC issued CHILLED WORK ENVIRONMENT
FOR RAISING AND ADDRESSING SAFETY CONCERNS AT THE WATTS BAR
NUCLEAR PLANT (ML16083A479) after determining that a chilled work environment
existed in the Operations Department at Watts Bar Nuclear Plant. The NRC requested a
response to the letter which included, in part, that the licensee provide their plan of
action for addressing the chilled work environment to the NRC within 30 days of the date
of the letter. Included in the plan we requested TVA evaluate effectiveness of the
implementation of Confirmatory Order (EA-09-009, EA-09-203) requirements relative to
the current conditions.
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On April 22, 2016, the licensee provided, RESPONSE TO NRC LETTER CONCERNING
A CHILLED WORK ENVIRONMENT FOR RAISING AND ADDRESSING SAFETY
CONCERNS AT THE WATTS BAR NUCLEAR PLANT (ML16113A228). In response to
the NRCs request the licensee provided the following response:
Requested Attribute 3: Evaluate effectiveness of the implementation of
Confirmatory Order (EA-09-009, EA-09 203) requirements relative to the current
conditions. A review was conducted to determine the effectiveness of the actions
required by Confirmatory Order EA-09-009/203. The review found that there are
two potential gaps and two additional corrective actions that need follow-up
review. Furthermore, in Table 3 this action was reported as complete.
The inspector reviewed the actions taken by the licensee which were identified as the
basis for making these assertions to the NRC. The inspector reviewed the evaluation
performed associated with CO Item #1. The action the licensee had taken credit for as
an effectiveness review indicated an audit of the adverse action program was in
progress and would be completed in April 2016. It detailed that afterwards, the licensee
would review the audit to determine the effectiveness of this item and in the interim TVA
drafted changes to the adverse action process to ensure safety conscious work
environment issues were thoroughly reviewed prior to taking action. The licensee further
documented completion of an effectiveness review of the CO in CR 1162755 Action 17.
The inspector determined the licensee based their April 22, 2016, response to the NRC
on a report of the completion of these actions. Although these actions were intended to
evaluate the effectiveness of the CO item #1, the licensee failed to recognize that this
activity was not completed prior to their April 22, 2016, letter. Subsequent to the
April 22, 2016, letter the licensee had not completed these actions and closed the action
in the CAP.
Analysis: The NRC determined this constituted a more than minor traditional
enforcement violation associated with failure to provide accurate information. A cross-
cutting aspect was not assigned because traditional enforcement violations are not
assessed for cross-cutting aspects. The ROPs significance determination process does
not specifically consider the regulatory process impact in its assessment of licensee
performance. Therefore, it is necessary to address violations which impede the NRCs
ability to regulate, using traditional enforcement. The inspector determined that the
licensees failure to provide accurate information to the NRC was a violation of the
requirements of 10 CFR 50.9, which had the potential to impede or impact the regulatory
process, and therefore subject to traditional enforcement as described in the NRC
Enforcement Policy, dated November 1, 2016. This violation is characterized as a
Severity Level IV violation because it was similar to Example Section 6.9.d.1 of the NRC
Enforcement Policy and was appropriate for the circumstances.
Enforcement: 10 CFR 50.9, Completeness and Accuracy of Information states, in part,
that information provided to the Commission by a licensee shall be accurate in all
material respects.
Contrary to the above, on April 22, 2016, TVA provided a letter to the Commission that
was not accurate in all material respects. Specifically, TVAs letter was inaccurate in
that it stated that (1) A review was conducted to determine the effectiveness of the
actions required by Confirmatory Order EA-09-009/203; and (2) in Table 3: Focus
19
Area: Willingness to Raise Concerns, Assessment Activity, Effectiveness review of CO
EA-09-203, TVA will conduct an effectiveness review of the applicable corrective
actions completed in accordance with CO-EA-09-009/203 to; Determine whether those
corrective actions were effective in preventing or minimizing recurrence of the issue.
This Table 3 item was annotated as Complete.
These statements were not accurate, in that the licensee failed to complete a review to
determine the effectiveness of action #1 required by Confirmatory Order EA-09-009/203.
This information was material because the NRC relied on this information to determine if
TVA was in compliance with Confirmatory Order EA-09-009/203 requirements, and was
relied on to determine the need, extent, and scheduling of additional regulatory
oversight. This issue has been entered into the licensees CAP as CR 1263417 and is
being treated as an NCV consistent with Section 2.3.2.a of the Enforcement Policy, NCV
0500390,05000391/2016013-02, Failure to Provide Accurate Information.
.2 Implementation of the Confirmatory Order EA-09-009/203 at Watts Bar Nuclear Plant
a. Inspection Scope:
The inspectors reviewed the licensees implementation of Confirmatory Order EA-09-
009/203 and NPG-SPP-11.10 R4, Adverse Employment Action procedure. The
inspector reviewed the licensees documentation of issues associated with the Adverse
Employment Action procedure implementation in CR 1162755.
Background
The inspector reviewed TVA documentation of issues associated with the Adverse
Employment Action procedure implementation in CR 1162755 Action 27.
- Although process requirements were met referencing NPG-SPP-11.10 R4, it
was recognized that the Site VP did not perform reviews of the HR reviews for
disciplinary actions taken, as compared to VPs at SQN and BFN performing the
reviews, considering SCWE. Per WBN HR, these reviews were not required if
SCWE elements were not identified. As a result, industry procedures were
reviewed for comparison of methods used.
The NRC inspector reviewed NPG-SPP-11.10 R4. The CR 1162755 documentation
incorrectly indicated that process requirements used to implement the CO were met.
Specifically, this procedure required a review of HR disciplinary actions for SCWE
implications, even if SCWE elements were not identified. The inspectors reviewed the
following procedural sections of NPG-SPP-11.10, Revision 0004, that provide the site
VP review requirements.
3.1.5 Roles and Responsibilities - TVA Vice President (VP)
A. At nuclear sites, the Site Vice President (or designee) will review certain
proposed actions as described in this SPP to determine if those actions
may be viewed as harassment, intimidation, retaliation or discrimination
(HIRD) or will likely create a chilling effect in the affected organization, or in
other organizations.
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3.2.2 Review Process - Personnel Actions Impacting TVA Employees
D. The Vice President (or designee) will complete section 3, Vice President
Record of Action of form 41175.
E. If the Vice President (or designee) determines that the proposed personnel
action may be viewed as HIRD or will likely create a chilling effect in the
affected organization, or in other organizations, the Vice President (or
designee) will direct the Line Manager to prepare a Chilling Effect Mitigation
Plan (section 4 of form 41175) for Vice President (or designee) review and
approval before taking any proposed personnel action.
F. For NPG employees, if documentation indicates protected activity, the Line
Manager proposing a personnel action under review may not take such action
through the discipline review process unless the Vice President (or designee)
has rendered a determination of "no objection."
G. For employees outside of NPG, no proposed action may be initiated until the
Vice President (or designee) has rendered a determination of "no objection."
3.2.3 Review Process - Personnel Actions Impacting Contractors
C. The TVA HR Representative ensures that the Vice President (or designee)
reviews the package before action is taken and that Vice President Record of
Action is completed. The Vice President (or designee) must review all
proposed actions affecting Staff Augmented or Task Managed Contractors
unless those actions are covered by an exclusion.
D. For proposed actions brought for review to the Vice President (or designee),
the Vice President will complete section 3: Vice President Record of Action.
The Vice President (or designee) will consider all relevant information including
any extenuating or mitigating information.
The inspector also performed an independent review of the implementation of NPG-
SPP-11.10, Adverse Employment Action procedure, because of the inconsistencies in
CR 1162755. The inspector reviewed the implementing procedure and 9 samples
(containing 15 actions) of the application of the Adverse Action Program from the past
24 months at Watts Bar. All of the samples that were reviewed were inadequate to meet
the intent of the Confirmatory Order requirements.
An integrated review and grouping of the deficiencies from the review of the CR and
interviews with site staff responsible for implementation indicated the existence of a
more significant programmatic breakdown as compared to a collection of random
individual implementer errors. These deficiencies were exhibited by the three
fundamental groups primarily responsible for successful implementation of NPG-SPP-
11.10, Attachment 2, TVA 41175 Adverse Employment Action Review process:
Managers; Human Resources; and ECP staff. The deficiency grouping is listed below.
1. The inspector identified deficiencies in the ability of the licensee to determine if
the subject employee had engaged in protected activity. NPG-SPP-11.10,
21
Section 3.2.2 Review Process - Personnel Actions Impacting TVA Employees,
step B includes the following:
As part of completing the Human Resources Review, the HR Representative will
do an independent verification of the employee's activity regarding Employee
Concerns and Problem Evaluation Reports (PERs). The HR Representative shall
contact the Employee Concerns Program regarding Employee Concern issues to
verify if ECP contact has been made within the last twelve months. The
applicable HR Representative shall contact the Performance Improvement group,
or validate through Maximo, to identify if PERs have been generated within the
last twelve months.
During review of the HR activities associated with independent verification of the
employee's activity regarding Employee Concerns and PERs, the inspector
identified multiple examples, of the following activities, which were inconsistent
with the procedure requirements and each resulted in incorrect determinations if
the subject employee had engaged in protected activity:
a. HR was adding a qualifying criteria that PERs generated by the subject
employee be safety related for them to be considered in the evaluation
of potential protected activity. This distinction inappropriately excluded
activities that should have been accounted for as participation in
protected activity. This demonstrates a potential fundamental
misunderstanding of applicability and purpose of the process.
b. In addition to identifying if PERs had been generated by the subject
employee, HR was making determinations if the PERs constituted a
protected activity through review of a simple list of CRs and not a review
of their content.
c. ECP was adding a qualifying criteria that ECP concerns raised by the
subject employee needed to be associated with the adverse action being
proposed for them to be considered in the evaluation of protected activity.
It was also not recognized that ECP contact does not need to be the
subject of the adverse action for it to have a potential adverse effect on
the SCWE.
2. There was a lack of rigor in implementing the process based on the quality of
processing that was observed.
3. Supervisors & HR representatives did not demonstrate an understanding of what
was acceptable for the various required evaluations.
4. Internal review of the program did not identify the widespread issues with
implementation.
5. After receiving feedback about the program implementation from internal
reviews, issues were not identified and entered into the corrective action
program. For example, the inspector identified that in the past 24 months no
chilling effect mitigation plans were developed at Watts Bar. This condition was
not viewed as significant or investigated more deeply as part of the investigation
22
into the Chilled Work Environment at WBN even though adverse actions and the
perceptions they propagated were part of the identified causes. Additionally, a
corporate TVA-wide audit in April 2016 highlighted a concern that none of the
adverse actions sampled during that review had SCWE mitigation plans
developed.
b. Findings
Introduction: The inspector identified an Apparent Violation of Confirmatory Order, (EA-
09-009,203) Dated December 22, 2009 (ML093510993) for the licensees failure to
implement the requirements of the Order. Specifically, the licensee failed to; (1)
implement a process to review proposed licensee adverse employment actions at Watts
Bar Nuclear plant before actions were taken to determine whether the proposed action
comports with employee protection regulations, and whether the proposed actions could
negatively impact the SCWE; and (2) implement a process to review proposed
significant adverse employment actions by contractors performing services at TVAs
nuclear plant sites before the actions were taken to determine whether the proposed
action comports with employee protection regulations, and whether the proposed action
could negatively impact the SCWE. The NRC has not made an enforcement decision on
this matter.
Description: Based on questions concerning the licensees evaluation of the
effectiveness of the implementation of Confirmatory Order (EA-09-009, EA-09-203)
requirements relative to the current conditions, the inspector performed an independent
review of the implementation of NPG-SPP-11.10, Adverse Employment Action
procedure. The inspector reviewed the implementing procedure and 9 samples
(containing 15 action evaluations, sample #2 contained 2 action evaluations and sample
- 3 contained 6 action evaluations) of the application of the Adverse Action Program
from the past 24 months at Watts Bar. (Due to the sensitive nature of the information
reviewed, the inspector reviewed the results of the inspection activities with the HR
manager and will only reference the records inspected as samples 1-9.)
The review of these records identified the following deficiencies:
- All samples were found to be inadequate and not meeting the intent of the Order.
- All were missing required documentation / evaluations. NPG-SPP-11.10 Sections
3.2.2, subsections A, B, C, E, F, G
- 6 samples did not have any VP/ERB review documented (Samples 1, 2, 3, 4, 8,
9) NPG-SPP-11.10 Sections 3.2.2, subsections C, E, F, G
- 8 samples indicated incorrect determinations of engagement in protected activity
(Samples 1, 2, 3, 4, 5, 6, 7, 9) NPG-SPP-11.10 Sections 3.2.2, subsections A
and B.
- Most did not have adequate, if any, assessment of potential effect on SCWE.
(Samples 3, 4, 6, 7, 8, 9) NPG-SPP-11.10 Sections 3.2.2, subsections A and B
The inspector determined this constituted a failure to comply with requirement 1
contained in Confirmatory Order EA-09-009; 203. The licensee failed to implement a
process to review proposed adverse employment actions before actions were taken to
determine whether the proposed action comports with employee protection regulations,
and whether the proposed actions could negatively impact the SCWE. The inspector
23
based this determination on every example reviewed included deficiencies that
represented either an inadequacy or failure to make determinations of whether the
proposed action comports with employee protection regulations and/or make
determinations of whether proposed actions could negatively impact the SCWE.
Additionally, the inspector identified issues during the inspection which indicated the
existence of a more significant programmatic breakdown as compared to a collection of
individual implementer errors. These deficiencies were exhibited by the three
fundamental groups primarily responsible for successful implementation of the Adverse
Employment Action Review process (NPG-SPP-11.10, Attachment 2, TVA 41175):
Managers; Human Resources; and ECP staff.
Analysis: The NRC determined this violation constituted a more than minor traditional
enforcement violation associated with failure to implement actions required by
Confirmatory Order Modifying License, (EA-09-009,203). A cross-cutting aspect was not
assigned because traditional enforcement violations are not assessed for cross-cutting
aspects. The ROPs significance determination process does not specifically consider
the regulatory process impact in its assessment of licensee performance. Therefore, it is
necessary to address violations which impede the NRCs ability to regulate, using
traditional enforcement. The inspector determined that the licensees failure to
implement actions as required by Confirmatory Order Modifying License, (EA-09-
009,203) dated December 22, 2009 (ML093510993), was an apparent violation. This
violation had the potential to impede or impact the regulatory process, and therefore is
subject to traditional enforcement as described in the NRC Enforcement Policy, dated
November 1, 2016. The NRC has not made an enforcement decision on this matter.
Enforcement: Confirmatory Order Modifying License, (EA-09-009,203) dated
December 22, 2009, (ML093510993) states, in part, that by no later than ninety (90)
calendar days after the issuance of this Confirmatory Order, TVA shall implement a
process to review proposed licensee adverse employment actions at TVAs nuclear plant
sites before actions are taken to determine whether the proposed action comports with
employee protection regulations, and whether the proposed actions could negatively
impact the Safety Conscious Work Environment (SCWE). Such a process should
consider actions to mitigate a potential chilling effect if the employment action, despite its
legitimacy, could be perceived as retaliatory by the workforce.
Additionally, by no later than one hundred twenty (120) calendar days after the issuance
of the confirmatory order, TVA shall implement a process to review proposed significant
adverse employment actions by contractors performing services at TVAs nuclear plant
sites before the actions are taken to determine whether the proposed action comports
with employee protection regulations, and whether the proposed action could negatively
impact the SCWE. Such a process will likewise consider actions to mitigate a potential
chilling effect if the employment action, despite its legitimacy, could be perceived as
retaliatory by the workforce.
TVA implements the above process through procedure NPG-SPP-11.10, Adverse
Employment Action. NPG-SPP-11.10, Section 3.2.2, entitled Review Process -
Personnel Actions Impacting TVA Employees, paragraph D, states that the Vice
President (or designee) will complete section 3, Vice President Record of Action of form
41175 (attachment 2 to NPG-SPP-11.10). Form 41175, entitled TVA 41175 Adverse
Employment Action Review, states that the purpose of the review is to ensure that
24
proposed actions (1) are warranted; (2) do not occur because an individual has engaged
in a protected activity; and (3) do not create the perception that persons were retaliated
against because they engaged in a protected activity.
Additional actions are delineated in NPG-SPP-11.10 Sections 3.2.2, subsections A, B,
C, E, F, G, related to the positions of the Vice President, Line Manager and the Human
Resource Representative, and in Section 3.2.3, entitled Review Process - Personnel
Actions Impacting Contractors.
Contrary to the above, from November 2014 to August 2016, the licensee failed to
comply with Confirmatory Order (EA-09-009,203), in that the site; (1) failed to implement
a process to review proposed licensee adverse employment actions at Watts Bar
Nuclear plant before actions were taken to determine whether the proposed action
comports with employee protection regulations, and whether the proposed actions could
negatively impact the SCWE; and (2) failed to implement a process to review proposed
significant adverse employment actions by contractors performing services at TVAs
nuclear plant sites before the actions were taken to determine whether the proposed
action comports with employee protection regulations, and whether the proposed action
could negatively impact the SCWE. Watts Bar failed to comply with the CO because the
site failed to implement procedure NPG-SPP-11.10, Adverse Employment
Action. Specifically, the Vice President (or designee) failed to complete Form 41175,
entitled TVA 41175 Adverse Employment Action Review as required by Section
3.2.3.D, for multiple adverse employment actions taken against TVA and contractor
personnel during this time period. Additionally, the Vice President, Line Management,
and HR Representatives did not perform procedural steps that were required by
procedure NPG-SPP-11.10, subsection 3.2.2.A, B, C, E, F, and G, and in Section
3.2.3. AV 0500390,05000391/2016013-03, Failure to Implement Confirmatory Order
Requirements for Adverse Employment Action
4OA6 Exit Meeting Summary
On November 17, 2016, December 1, 2016, January 11, 2017, and February 21, 2017,
the inspectors presented the inspection results to Mr. Simmons and other members of
the site staff.
4OA7 Licensee-Identified Violations
The following violations of very low safety significance (Green) were identified by the
licensee and are violations of NRC requirements which meet the criteria of the NRC
Enforcement Policy, for being dispositioned as a Non-Cited Violation.
Technical Specification 3.5.2 Emergency Core Cooling Systems (ECCS) - Operating
Condition A required, in part, that while in Mode 1 that if one train becomes inoperable
that it be restored to an operable status in 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br />. Condition B required action to
place the unit in Mode 3 in 6 hours6.944444e-5 days <br />0.00167 hours <br />9.920635e-6 weeks <br />2.283e-6 months <br /> and Mode 4 in 12 hours1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br /> if that train is not restored in
72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br />. Contrary to the above, the Unit 1 1B-B CCP was inoperable from July 24,
2016, until August 5, 2016, in excess of the allowed outage time of Condition A without
the unit being placed in Mode 3 in 6 hours6.944444e-5 days <br />0.00167 hours <br />9.920635e-6 weeks <br />2.283e-6 months <br /> and Mode 4 in 12 hours1.388889e-4 days <br />0.00333 hours <br />1.984127e-5 weeks <br />4.566e-6 months <br /> as required by
Condition B. This issue was documented in the licensees corrective action program as
CR 1199024. The finding was screened using IMC 0609 Appendix A, Exhibit 2,
Mitigating Systems Screening Questions, dated June 19, 2012. The finding required a
25
detailed risk evaluation because a single train of CCP was inoperable for greater than its
allowed outage time. The regional Senior Reactor Analyst reviewed the inspector
provided detailed risk evaluation that was performed using the Saphire SDP
module. The finding was determined to be Green.
ATTACHMENT: SUPPLEMENTAL INFORMATION
SUPPLEMENTAL INFORMATION
KEY POINTS OF CONTACT
Licensee personnel:
S. Connors, Watts Bar Plant Manager
P. Summers, Browns Ferry Director of Safety and Licensing
B. Dungan, TVA Operations CFAM
J. Callie, TVA Corporate Developmental Manager
R. Seipel, Senior Manager, Corporate QA
D. Tesar, Watts Bar Performance Improvement
G. Arent, Watts Bar Licensing Manager
B. J. Allen, Watts Bar Shift Manager
M. Miller, Watts Bar Shift Manager
S. Delk, Watts Bar Performance Improvement
K. McCormick, Watts Bar Human Resources Manager
I. Hagins-Dyer, TVA Employee Concerns Program Manager
LIST OF REPORT ITEMS
Opened
05000390,391/2016013-01 FIN Failure to Implement the Program
Requirement to Enter Issues into the CAP
(4OA2.1.c)
05000390,391/2016013-02 NCV Failure to Provide Accurate Information
(4OA5.1.b)
05000390,391/2016013-03 AV Failure to Implement Confirmatory Order
Requirement for Adverse Employment
Action (4OA5.2.b)
Attachment
LIST OF DOCUMENTS REVIEWED
Procedures
NPG-SPP-01.7, Nuclear Safety Culture Rev. 3
NPG-SPP-01.7.1, Employee Concerns Program Rev. 2
NPG-SPP-01.7.2, Nuclear Safety Culture Monitoring, Rev. 6
NPG-SPP-01.7.3, Conduct of Nuclear Safety Culture Assessments and Organizational
Effectiveness Surveys, Rev. 2
NPG-SPP-03.19, Conduct of Quality Assurance Internal Audits Rev. 0003
NPG-SPP-07.2.5, Outage Control Center, Rev. 12
NPG-SPP-07.2.11, Shutdown Risk Management, Rev. 10
NPG-SPP 07.3 Work Management Process, Rev. 19
NPG-SPP-11.10, Adverse Employment Action, Rev. 4 and 5
NPG-SPP-22.300, Corrective Action Program, Rev. 5 and 6
NPG-SPP-22.301, Service Request Initiation, Rev. 5
NPG-SPP-22.302, Corrective Action Program Screening, Rev. 10
NPG-SPP-22.303, CR Actions, Closures, and Approvals, Rev. 9
NPG-SPP-22.305, Level 2 Evaluation, Rev. 5
NPG-SPP-22.306, Level 1 Evaluation, Rev. 5
NPG-SPP-22.500, Operating Experience Program, Rev 3
0-MI-0.16, Maintenance Guidelines for Belt Driven Equipment, Rev. 14
NIEP-GUID-002 Nuclear Industry Evaluation Program Guidelines Rev 7
Condition Reports
CR 1006456 CR 1111791 CR 1138400 CR 1159529
CR 1022739 CR 1114410 CR 1138406 CR 1159531
CR 1022869 CR 1114975 CR 1138407 CR 1159570
CR 1037157 CR 1116741 CR 1138408 CR 1159574
CR 1038059 CR 1116743 CR 1138411 CR 1159576
CR 1051686 CR 1117683 CR 1138414 CR 1159577
CR 1058300 CR 1117704 CR 1141520 CR 1159579
CR 1064721 CR 1118195 CR 1143483 CR 1159583
CR 1068912 CR 1118632 CR 1144186 CR 1160796
CR 1077284 CR 1120553 CR 1145320 CR 1160910
CR 1078464 CR 1121520 CR 1145455 CR 1162210
CR 1080513 CR 1123625 CR 1148640 CR 1162422
CR 1082102 CR 1125040 CR 1148722 CR 1163150
CR 1082469 CR 1125256 CR 1150853 CR 1163431
CR 1086438 CR 1126079 CR 1151910 CR 1166564
CR 1089482 CR 1127691 CR 1151954 CR 1167102
CR 1090220 CR 1127786 CR 1152029 CR 1167216
CR 1092415 CR 1129322 CR 1152033 CR 1168120
CR 1096405 CR 1131256 CR 1152376 CR 1168996
CR 1096590 CR 1131257 CR 1153507 CR 1168997
CR 1098240 CR 1131261 CR 1155393 CR 1172114
CR 1099011 CR 1133776 CR 1155665 CR 1173130
CR 1105960 CR 1134949 CR 1156304 CR 1173643
CR 1110852 CR 1136395 CR 1159526 CR 1174000
Attachment
3
CR 1174328 CR 1192192 CR 1205689 CR 1225006
CR 1174648 CR 1193846 CR 1205697 CR 1225007
CR 1174766 CR 1193848 CR 1205700 CR 1225008
CR 1175968 CR 1196925 CR 1205701 CR 440533
CR 1178230 CR 1198401 CR 1205702 CR 586986
CR 1178855 CR 1198406 CR 1205704 CR 597045
CR 1179264 CR 1198407 CR 1206000 CR 688380
CR 1180094 CR 1199001 CR 1206140 CR 858640
CR 1180388 CR 1199024 CR 1206191 CR 925734
CR 1183115 CR 1201623 CR1209096 CR 962894
CR 1183877 CR 1201749 CR 1214844 CR 967927
CR 1184858 CR 1202562 CR 1215887 CR 967929
CR 1186612 CR 1203785 CR 1216892 CR 970267
CR 1186886 CR 1205684 CR 1225001 CR 984600
CR 1191927 CR 1205685 CR 1225004
Condition Reports Generated
CR 1228949
116843219
117375376
Self-Assessments & Trends
Contractor review of the RCA for CR 1155393
1028286, WBN-RP-SSA-15-009 snapshot self assessment of PER effectiveness, 05/20/2015
1028291, WBN-RP-SSA-15-009 snapshot self assessment finding, 05/20/2015
1138943, Potential Trend for Training in "Zero Effectiveness" for SA/BMs in trimester,
02/18/2016
1174000, Cognitive Adverse Trend - Station LCO Entries, 5/23/2016
1175070, Trend of reactivity management related issues, 5/25/2016
1175805, Cognitive Adverse Trend - eSOMS violations, 5/27/2016
1139470, Monitoring Trend - PSC Performance, 02/19/2016
1132777, Trend in Engineering CRs being Closed to WOs without a PA focus being applied
to the WO, 6/22/2016
1131109, Modification Impact Reviews Performance Improvement Plan, 6/22/2016
1154532, QA ID, Negative trend associated with TI-65 breaches, 03/28/2016
1101733, Adverse Trend for Timeliness of Engineering Operating Experience (OE) Reviews,
11/06/2015
1199378, QA identified - Adverse Trend in OCC Logkeeping, 08/04/2016
QA-WB-16-004, Corrective Action program (Self-Assessment/ Benchmarking, Trending, and
OE) Watts Bar Nuclear (WBN) 3/28/16 thru 5/16/16
4
Other Documents
Apparent Cause Evaluation for CR 1121520, Rev. 0 Inappropriate Management of an Emergent
Issue Results in a Challenge to Plant Operation
Root Cause Analysis for CR 1127691, Rev. 0 and Rev. 1 Inappropriate Management of an
Emergent Issue Results in a Challenge to Plant Operation
Root Cause Analysis for CR 1155393, Rev. 0 Chilling Effect Letter Causal Analysis
Root Cause Analysis for CR 1206140, Rev. 0 Inappropriate closure of a compensatory measure
Root Cause Analysis for CR 1199024, Rev. 0 1BB CCP Room Cooler Shaft and Bearing
Degradation
Past Operability Evaluation for CR 1199024, Rev. 0
CAP Training Manual section on Correcting Behaviors and Behavior Observation Plans
Control room and OCC staffing watch bill from November 9, 2015 until November 12, 2015
Watts Bar Unit 1 Technical Specifications, Amendment 107
Watts Bar Chilling Effect Letter Review Meeting Minutes from July 18, 2016, August 23, 2016,
and October 4, 2016
Watts Bar Senior Manager mentorship of Shift Managers Program Guidance, Rev. 1
Effectiveness Review results from corrective action 1155393-024
Employee Concerns Program Conduct of Operations, Rev. 1
Gelfond Employee Engagement Survey, dated Summer 2015
Gelfond Nuclear Supplement to Employee Engagement Survey, dated Summer 2015
Nuclear Safety Culture Monitoring Panel Meeting Minutes, 10/13/2016
Nuclear Safety Culture Site Leadership Team Meeting Minutes, 09/07/2016
WBN Safety Conscious Work Environment/CEL Refresher Training, Rev. 0
Shift Order 16-05, 2/19/16
Shift Order 16-15, 8/27/16
Shift Order 16-39, 12/27/16
QA Records
NC-WB-14-016 Assessment Report
1209096 CR Summary Report
1080513 CR Summary Report
QA-WB-16-004 CAP Assessment Report
QA-WB-15-015 Quality Assurance - Oversight Report
QA-WB-14-016 Pre PI and R Assessment Report
SSA 1502 CAP Audit Report - WBN
SSA 1502 CAP Audit Fleet Comparative Report
SSA 1302 WBN CAP Audit Report.