Text

Pilgrim Nuclear Power Station - Supplemental Inspection Report 05000293/2016008 (Inspection Procedure 95003 Phase 'A'), January 11, 2016 through January 15, 2016
	ML16060A018
Person / Time
Site:	Pilgrim
Issue date:	02/29/2016
From:	Dorman D H; Region 1 Administrator
To:	Dent J; Entergy Nuclear Operations
	Burritt A L
References
	IR 2016008
	Download: ML16060A018 (15)
	v • d • e

February 29, 2016 Mr. John Dent Site Vice President Entergy Nuclear Operations, Inc. Pilgrim Nuclear Power Station 600 Rocky Hill Road Plymouth, MA 02360-5508

SUBJECT: PILGRIM NUCLEAR POWER STATION - SUPPLEMENTAL INSPECTION REPORT (PHASE 'A') 05000293/2016008

Dear Mr. Dent:

On January 15, 2016, the U.S. Nuclear Regulatory Commission (NRC) completed Phase 'A' of Inspection Procedure (IP) 95003, "Supplemental Inspection for Repetitive Degraded Cornerstones, Multiple Degraded Cornerstones, Multiple Yellow Inputs or One Red Input," at your Pilgrim Nuclear Power Station (Pilgrim). The enclosed inspection report documents the inspection results, which were discussed with you and members of your staff.

Consistent with the NRC Reactor Oversight Process Action Matrix in Inspection Manual Chapter 0305, "Operating Reactor Assessment Program," the NRC is performing this supplemental inspection because Pilgrim transitioned into the Repetitive Degraded Cornerstone Column (Column 4), as discussed in the mid-cycle assessment letter, dated September 1, 2015 (ML15243A2591). This phase of the inspection reviewed Entergy Nuclear Operations, Inc. (Entergy's) progress in addressing corrective action program weaknesses identified during previous inspections. Its objectives were to verify that Entergy's evaluations of, and corrective actions for, significant performance deficiencies were sufficient to correct the deficiencies and prevent recurrence. Additionally, the inspection assessed whether Entergy's evaluations into these significant deficiencies were of a depth commensurate with the significance of the issue, root and contributing causes of risk-significant deficiencies were identified, and corrective actions were taken to correct immediate problems and to prevent recurrence. To accomplish these objectives, this inspection reviewed long-standing open corrective actions.

It also reviewed a sample of NRC violations that were not reviewed by other inspections to determine if Entergy had taken appropriate actions to address the issue. It reviewed Entergy's program for classification of adverse versus non-adverse condition reports, a sample of non-adverse condition reports to ensure they were categorized correctly, and any condition reports documenting misclassification (i.e., adverse vs. non-adverse) of condition reports. 1 Designation in parentheses refers to an Agencywide Documents Access and Management System (ADAMS) accession number. Documents referenced in this report are publicly available using the accession number in ADAMS. Based on the samples selected for review, the inspectors determined that there were no long-standing risk-significant issues documented in the corrective action program that were not addressed, or assigned appropriate corrective actions and due dates. The inspectors concluded that, in general, Entergy classified, evaluated, and developed appropriate actions to correct past NRC violations. The inspectors also determined that Entergy appropriately classified condition reports as adverse or non-adverse. As such, based on the results of this inspection, as well as a review of performance indicators and inspection results from the fourth quarter of 2015, the NRC concluded that Pilgrim continues to operate safely, and additional regulatory actions beyond those prescribed for plants in Column 4 are not required at this time.

This inspection served as a partial completion of IP 95003, Section 02.02.a. Accordingly, Pilgrim will remain in the Repetitive Degraded Cornerstone Column of the Action Matrix until the NRC completes the required scope of IP 95003. This report documents one finding of very low safety significance (Green), which was also determined to be a violation of NRC requirements. However, because of the very low safety significance and because it has been entered into your corrective action program, the NRC is treating this finding as a non-cited violation (NCV), consistent with Section 2.3.2.a of the NRC Enforcement Policy. If you contest the NCV in this report, you should provide a response within 30 days of the date of this inspection report, with the basis for your denial, to the Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555-0001; with copies to the Regional Administrator, Region I; the Director, Office of Enforcement, United States Nuclear Regulatory Commission, Washington, DC 20555-0001; and the NRC Resident Inspector at Pilgrim. In addition, if you disagree with the cross-cutting aspect assignment discussed in the enclosure, you should provide a response within 30 days of the date of this inspection report, with the basis for your disagreement, to the Regional Administrator, Region I, and the NRC Resident Inspector at Pilgrim. In accordance with Title 10 of the Code of Federal Regulations (10 CFR) 2.390 of the NRC's "Rules of Practice," a copy of this letter, its enclosure, and your response (if any) will be available electronically for public inspection in the NRC's Public Document Room or from the Publicly Available Records component of the NRC's 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 David C. Lew for/ Daniel H. Dorman Regional Administrator Docket No. 50-293 License No. DPR-35

Enclosure:

Inspection Report 05000293/2016008

w/Attachment:

Supplementary Information

cc w/encl: Distribution via ListServ

SUMMARY

Inspection Report 05000293/2016008; 01/11/2016 - 01/15/2016; Pilgrim Nuclear Power Station (Pilgrim); Supplemental Inspection - Inspection Procedure (IP) 95003.

The inspection was conducted by a senior resident inspector, an operations engineer, a reactor inspector, and a project engineer. The inspectors identified one non-cited violation (NCV),

which was of very low safety significance (Green). The significance of most findings is indicated by their color (i.e., greater than Green, or Green, White, Yellow, Red) and determined using Inspection Manual Chapter (IMC) 0609, "Significance Determination Process," dated April 29, 2015. Cross-cutting aspects are determined using IMC 0310, "Aspects Within the Cross-Cutting Areas," dated December 4, 2014. All violations of U.S. Nuclear Regulatory Commission (NRC)requirements are dispositioned in accordance with the NRC's Enforcement Policy, dated February 4, 2015. The NRC's program for overseeing the safe operation of commercial nuclear power reactors is described in NUREG-1649, "Reactor Oversight Process," Revision 5.

The NRC performed this supplemental inspection in accordance with IP 95003, "Supplemental Inspection for Repetitive Degraded Cornerstones, Multiple Degraded Cornerstones, Multiple Yellow Inputs or One Red Input," to review Energy's progress in addressing corrective action program (CAP) weaknesses identified in previous inspections. This inspection served as partial completion of IP 95003, Section 02.02.a.

Cornerstone: Mitigating Systems

Green.

The inspectors identified a Green NCV of Title 10 of the Code of Federal Regulations (10 CFR) 50, Appendix B, Criterion XVI, "Corrective Action," because Entergy did not promptly correct a condition adverse to quality for the core spray system. Specifically, though Entergy identified in March 2015 that core spray system leakage was the likely cause of voiding in the system, Entergy had not taken timely action to identify the source of the leakage and address the issue. Entergy's immediate corrective actions included entering the issue into the CAP as a condition report (CR)-PNP-2016-00201 and generating a work order to repair seat leakage from the core spray test return line motor-operated valve, MO-1400-4A. The inspectors reviewed IMC 0612, Appendix B, "Issue Screening," and determined this issue is more than minor because if left uncorrected, the performance deficiency would have the potential to lead to a more significant safety concern. Specifically, an unmonitored increase in core spray system leakage could result in an unanalyzed condition where the operability of the core spray system cannot be assured. In accordance with IMC 0609, Appendix A, "The Significance Determination Process (SDP) for Findings At-Power," dated July 1, 2012, the inspectors determined the finding was of very low safety significance (Green) because it did not represent an actual loss of function of one or more non-technical specification (TS) trains of equipment designated as high safety-significant in accordance with the licensee's maintenance rule program. This finding had a cross-cutting aspect in the area of Problem Identification and Resolution, Evaluation, because Entergy did not thoroughly evaluate issues to ensure that resolutions address causes and extent of conditions commensurate with their safety significance. Specifically, Entergy failed to fully evaluate the source of core spray system leakage identified in CR-PNP-2015-01406 because they closed out the CR to another CR with a different focus. [P.2] (Section 4OA4.2)3

REPORT DETAILS

OTHER ACTIVITIES

4OA4 Supplemental Inspection

Main article: IP 95003

.1 Inspection Scope

The NRC performed this supplemental inspection in accordance with IP 95003, "Supplemental Inspection for Repetitive Degraded Cornerstones, Multiple Degraded Cornerstones, Multiple Yellow Inputs or One Red Input," to review Entergy's progress in addressing CAP weaknesses identified in previous inspections. This inspection served as partial completion of IP 95003, Section 02.02.a. The objectives of this inspection were to verify that Entergy's evaluations of, and corrective actions for, significant performance deficiencies have been sufficient to correct the deficiencies and prevent recurrence. IP 95003 provides specific guidance for this objective and directs the inspectors to evaluate whether Entergy's evaluations into significant deficiencies are of a depth commensurate with the significance of the issue; that root and contributing causes of risk-significant deficiencies are identified; and corrective actions are taken to correct immediate problems and to prevent recurrence. Specifically, inspectors: (1) sampled long-standing open corrective actions; (2) reviewed a sample of NRC violations that have not been reviewed by other inspections to determine if Entergy has taken appropriate actions to address the issues; and (3) reviewed Entergy's program for classification of adverse versus non-adverse CRs, reviewed a sample of non-adverse CRs to ensure they are categorized correctly, and reviewed any CRs documenting misclassification (i.e., adverse vs. non-adverse) of CRs;

.2 Evaluation of the Inspection Requirements

2.01 Review of Licensee Control Systems for Identifying, Assessing, and Correcting Performance Deficiencies a. Determine whether licensee evaluations of, and corrective actions to, significant performance deficiencies have been sufficient to correct the deficiencies and prevent recurrence.

.1 Review of Long-Standing Open Corrective Actions

The inspectors reviewed Entergy's CAP procedures which described the administrative process for initiating and resolving problems, primarily through the use of CRs. To verify that corrective actions were being properly evaluated, assigned a significance commensurate with their safety importance, and appropriately completed or extended, inspectors reviewed CRs initiated prior to October 1, 2013, with corrective actions that were still open at the time of the inspection. The inspectors determined that for the CRs reviewed, Entergy, in general, was effective in completing corrective actions or assigning appropriate due date extensions for these issues. The team identified one example, listed below, where the corrective actions for an issue were not taken in a timely manner.

In the documentation for CR-PNP-2008-02638, a heat load analysis determined that the control room temperature would reach 114°F with a loss of normal heating, ventilation, and air conditioning, and potentially cause an operator habitability issue.

As a corrective action, Entergy staff developed a modification to install an augmented cooling system in order to mitigate the high temperatures. The corrective actions for this condition were extended multiple times until final suspension of the modification project in 2015. The inspectors evaluated this issue using IMC 0612, Appendix B, "Issue Screening," and determined that this issue was minor. The inspectors noted that there are no current licensing or design basis documents that establish control room temperature limitations for operator habitability; however, there would be increased staffing challenges due to heat stress management and the resultant short stay times. Entergy entered this observation into their CAP for further evaluation as CR-PNP-2016-00276.

.2 Review of Corrective Actions for Past NRC Violations

The inspectors reviewed Entergy's CAP procedures which described the administrative process for initiating the review of issues, specifically inspection report findings identified by the NRC, primarily through the use of CRs. The inspectors reviewed a sample of CRs initiated as a result of NRC violations issued since October 1, 2013. The inspectors determined that, in general, Entergy appropriately initiated CRs as a result of NRC violations. CRs were classified in accordance with procedure guidance, investigations were conducted at the level specified by the CAP, and suitable corrective actions were developed. The inspectors reviewed corrective actions and determined that, in general, they were completed or appropriately extended. The inspectors identified an issue where the corrective actions for NRC violations were not adequately completed.

NRC Inspection Report 05000293/2014002 (Agencywide Documents Access and Management System (ADAMS) Accession No. ML14129A282) documents an NCV (2014002-02) related to an inadequate procedure for determining operability of the shutdown transformer. Specifically, an NSTAR calculation concluded that certain alternative offsite power lines did not satisfy Pilgrim's minimum voltage criteria for the shutdown transformer, but this information was never incorporated into the degraded 23kV line procedure for determining the operability of the shutdown transformer. Entergy procedure EN-LI-102, "Corrective Action Program," requires Entergy staff to document the receipt of NRC violations as a CR; however, this did not occur. The inspectors noted that EN-LI-102 would have likely directed performance of an apparent cause evaluation and could have prevented the receipt of a second NCV for a similar issue in 2015. NRC Inspection Report 05000293/2015003 (ADAMS Accession No. ML15317A030) documents an NCV (2015003-03) issued for an inadequate operability assessment of the shutdown transformer because Entergy staff did not appropriately evaluate changes made to the shutdown transformer when an alternate offsite power configuration was used that resulted in the transformer being inoperable. The inspectors noted that the degraded 23kV procedure contained incorrect information at that time, which the operations staff used during the operability evaluation. The inspectors determined that Entergy's failure to document NCV 2014002-02 as a CR and perform a cause evaluation in accordance with EN-LI-102 was a performance deficiency. Because this issue is an additional contributor to the inadequate operability assessment, and the enforcement aspects of the inadequate operability assessment are already addressed as NCV 2015003-03, this issue is not being documented as a separate finding. Entergy entered this issue into their CAP as CR-PNP-2016-00302 for further evaluation.

.3 Review of Classification of Adverse Versus Non-Adverse Condition Reports

The inspectors reviewed Entergy's CAP procedures which described the administrative process for initiating the review of problems, primarily through the use of CRs. In Entergy procedure EN-LI-102, "Corrective Action Program," adverse conditions are defined as those conditions which include conditions adverse to quality plus conditions related to areas such as design basis, licensing basis, NRC regulations and commitments, and equipment required to support safety-related equipment. Non-adverse conditions are those conditions that do not fall within the definition of adverse conditions and are not required to be tracked in the CAP.

The inspectors reviewed a sample of CRs generated since September 2014, when Entergy implemented the process for classifying CRs as adverse or non-adverse. The inspectors determined that Entergy appropriately classified CRs as adverse or non-adverse. The inspectors did identify a gap in the guidance contained in procedure EN-LI-102 for the classification of CRs as adverse or non-adverse. Specifically, the inspectors identified that guidance for classifying CRs as adverse tended to require an actual adverse impact. No clear guidance exists for those situations where an actual adverse impact does not occur (i.e., close calls or near misses). This has the effect of creating a gap in the guidance where the classification of CRs is at the discretion of the reviewing body. The inspectors identified that in these situations, the reviewing body tended to classify CRs as non-adverse. The inspectors did not identify any CRs where the classification as non-adverse was subjective and resulted in a negative consequence. Entergy documented this observation in their CAP as CR-HQN-2016-00039.

b. Findings

Introduction.

The inspectors identified a Green NCV of 10 CFR 50, Appendix B, Criterion XVI, "Corrective Action," because Entergy did not promptly correct a condition adverse to quality for the core spray system. Specifically, though Entergy identified in March 2015 that core spray system leakage was the likely cause of voiding in the system, Entergy had not taken timely action to identify the source of the leakage and address the issue.

Description.

On January 27, 2015, during a loss of offsite power event, the 'A' loop of core spray experienced indications of voiding in the discharge line. Following an inquiry by NRC inspectors, Entergy entered the issue into their CAP as CR-PNP-2015-01406. Subsequent engineering analysis, completed in March 2015, confirmed the presence of voiding and assessed the impacts of the voiding on core spray system operability. The inspectors reviewed CR-PNP-2015-01406 and noted that Entergy determined the core spray system remained operable, and also identified core spray system leakage as a likely cause of the voiding. The enforcement aspects associated with the failure to identify partial voiding in the core spray system are documented in NRC Inspection Report 05000293/2015007 (ADAMS Accession No. ML15147A412) as NCV 2015007-05.

Entergy entered this NCV into the CAP as CR-PNP-2015-05537. Entergy procedure EN-LI-102, "Corrective Action Program," Revision 25, requires a 'B' level apparent cause evaluation be performed for NRC-documented NCVs. The inspectors reviewed CR-PNP-2015-05537 and noted it was closed to a root cause evaluation documented in CR-PNP-2015-05533, which was originally initiated to address programmatic issues regarding failures to identify conditions adverse to quality. The inspectors noted that CR-PNP-2015-05533 did not evaluate the technical issue of core spray system leakage and the potential for system voiding if the non-safety-related condensate transfer system was lost, as was identified in CR-PNP-2015-01406.

In November 2015, Entergy initiated CR-PNP-2015-09156 as a result of an identified increase of leakage into the torus and elevated temperatures in the test return line of the

'A' loop of core spray header. The inspectors reviewed CR-PNP-2015-09156 and noted that Entergy documented the elevated temperatures could be an indication of condensate transfer leaking out of the core spray system through the test return line. In December 2015, Entergy identified the core spray test return line motor operated valve, MO-1400-4A, as the source of leakage from the core spray system into the torus.

Though the valve leakage was documented in a work order, the inspectors noted that this issue was not entered into the CAP until January 12, 2016. The inspectors also noted that Entergy did not have a process in place to monitor for increases in core spray system leakage which could result in an unanalyzed condition where the operability of the core spray system cannot be assured.

Entergy procedure EN-LI-102 defines a condition adverse to quality, in part, as a failure, malfunction, or deficiency that has the potential to affect safety-related functions of systems, structures, or components. The inspectors concluded core spray system leakage was a known condition adverse to quality since March 2015, based on the information documented in CR-PNP-2015-01406 and the subsequent engineering analysis. Because Entergy did not adequately evaluate the technical aspects of this issue in CR-PNP-2015-05533, identification of the source of the leakage was delayed until December 2015. Therefore, the inspectors also concluded that Entergy did not promptly correct this condition adverse to quality as required by 10 CFR 50, Appendix B, Criterion XVI. Entergy documented this issue in CR-PNP-2016-00201 and CR-PNP-2016-00311.

Analysis.

The inspectors determined that not promptly identifying and correcting a condition adverse to quality, as required by 10 CFR 50, Appendix B, Criterion XVI, was a performance deficiency. The inspectors reviewed IMC 0612, Appendix B, "Issue Screening," and determined this issue is more than minor because if left uncorrected, the performance deficiency would have the potential to lead to a more significant safety concern. Specifically, an unmonitored increase in core spray system leakage could result in an unanalyzed condition where the operability of the core spray system cannot be assured. In accordance with IMC 0609, Appendix A, "The Significance Determination Process (SDP) for Findings At-Power," dated July 1, 2012, the inspectors determined the finding was of very low safety significance (Green) because it did not represent an actual loss of function of one or more non-TS trains of equipment designated as high safety-significant in accordance with the licensee's maintenance rule program.

The inspectors determined this issue had a cross-cutting aspect in the area of Problem Identification and Resolution, Evaluation, because Entergy did not thoroughly evaluate issues to ensure that resolutions address causes and extent of conditions commensurate with their safety significance. Specifically, Entergy failed to fully evaluate the source of core spray system leakage identified in CR-PNP-2015-01406 because they closed out the CR to another CR with a different focus. [P.2]

Enforcement:

10 CFR 50, Appendix B, Criterion XVI, "Corrective Action," states, in part, that measures shall be established to assure that conditions adverse to quality are promptly corrected. Contrary to the above, from March 2015 until January 2016, Entergy failed to promptly identify and correct a condition adverse to quality involving core spray system leakage. Entergy's immediate corrective actions included entering the issue into the CAP as CR-PNP-2016-00201 and generating a work order to repair valve MO-1400-4A. Because the finding is of very low safety significance (Green) and was entered into Entergy's CAP as CR-2015-00311, this violation is being treated as an NCV, in accordance with section 2.3.2.a of the NRC Enforcement Policy. (NCV 05000293/2016008-01, Failure to Promptly Identify and Correct Core Spray System Leakage)

4OA6 Meetings, Including Exit

On January 15, 2016, the inspectors presented the inspection results to Mr. John Dent, Site Vice President, and other members of his staff. The inspectors confirmed that all proprietary information examined during the inspection had been returned to the licensee.

ATTACHMENT:

SUPPLEMENTARY INFORMATION

KEY POINTS OF CONTACT

Licensee personnel

J. Dent, Site Vice President

S. Asplin, Senior System and Components Engineer

G. Blankenbiller, Manager, Chemistry

J. Gerety, Manager, Systems and Components

D. Miller, Maintenance Department Performance Improvement Coordinator

P. Miner, Regulatory Assurance

J. O'Donnell, System Engineer

J. Ohrenberger, Manager, Maintenance

E. Perkins, Manager, Regulatory Assurance

A. Zelie, Manager, Radiation Protection

LIST OF ITEMS OPENED, CLOSED, DISCUSSED, AND UPDATED

Opened and Closed

05000293/2016008-01 NCV Failure to Promptly Identify and Correct Core Spray System Leakage (Section

4OA4.2)

LIST OF DOCUMENTS REVIEWED

Procedures

2.1.1, Startup from Shutdown, Revision 193 2.2.5, Shutdown Transformer, Revision 30

2.2.93, Main Condenser Vacuum System, Revision 76

2.2.94.5, Main Condenser Backwash, Revision 14

2.4.36, Decreasing Condenser Vacuum, Revision 35 2.4.51, Hotwell Level Control Failures, Revision 20 2.4.149, Loss of Control Room Air Conditioning, Revision 12

2.4.A.23, Loss/Degradation of 23kV Line, Revision 18

2.4.A.23, Loss/Degradation of 23kV Line, Revision 23

2.4.B.6, Loss of Bus B6, Revision 4 5.3.13, Loss of Essential DC Bus D6, Revision 30 8.C.34, Operations Technical Specifications Requirements for Inoperable Systems/Components, Revision 61

ARP-C903L-C5, RHR A Disch. Header Pressure Lo, Revision 17

ARP-C903L-E7, CS A Disch. Header Pressure Lo, Revision 17

ARP-C903R-C7, Injection Header Break Detection, Revision 27

EN-LI-101, 10

CFR 50.59 Evaluations, Revision 12

EN-LI-102, Corrective Action Program, Revision 23

EN-LI-102, Corrective Action Program, Revision 25

EN-LI-118, Cause Evaluation Process, Revision 21

EN-LI-118, Cause Evaluation Process Revision 22

EN-OM-123, Fatigue Management Program, Revision 12

EN-OP-104, Operability Determination Process, Revision 10

EN-NS-102, Fitness for Duty Program, Revision 15

EN-RP-100, Radiation Worker Expectations, Revision 9

EN-RP-101, Access Control for Radiologically Controlled Areas, Revision 11

I-NI-235 Setpoint uncertainty calculation for Core Spray header/sparger high delta P alarm, Revision 0

Drawings

M242, P&ID Core Spray System, Revision 53

Miscellaneous

Apparent Cause Evaluation titled "EDG-B Inadequate Operability Determination" (CR-PNP-2015-9218), dated December 30, 2015 Apparent Cause Evaluation titled "Inadequate EDG Common Cause Determination Result in TS Violation" (CR-PNP-2015-9543), dated January 6, 2016 Apparent Cause Evaluation titled "Incorrect Shutdown Transformer Operability Determination" (CR-PNP-2015-7787), dated November 24, 2015 Pilgrim Corrective Action Excellence Plan, dated August 2, 2015 Pilgrim Nuclear Power Station Technical Specifications, Revision 298

Pilgrim Nuclear Power Station Updated Final Safety Analysis Report, Revision 30

PNP CRG Summary Agenda Report Prescreen Meeting, dated January 14, 2016

Snapshot Assessment Report titled "PI Vulnerabilities," dated January 5, 2016

RWP 2015078, LOW Impact Work in RA's, HRA's, LHRA's and/or Areas >100,000 dpm/100 cm2. Includes System Breaches, Revision 0 SSW Pump B (P-208B) Vibration Data, 4/2015-12/21/2015

Non-Cited Violations05000293/2013008-01, Inappropriate Fatigue Rule Waiver 05000293/2014002-02, Inadequate Procedure for Determining Operability of the Shutdown Transformer 05000293/2014003-03, Failure to Follow Licensed Operator Medical Requirements.

05000293/2014008-01, Failure to Fully Derive the Cause of a Manual Scram

05000293/2014008-02, Failure to complete several corrective actions as required by program Requirements. 05000293/2015002-01, Ineffective Corrective Action Leads to Cavitation of Residual Heat Removal Pump.

05000293/2015002-02, Inadequate Operability Determination for the X017B EDG Results in TS Violation 05000293/2015003-01, Main Control Room Annunciators 10

CFR 5065(a)(2) Not Met 05000293/2015003-02, Inadequate EDG Common Cause Determination Results in TS Violation 05000293/2015003-03, Inadequate Operability Assessment of the Shutdown Transformer

05000293/2015003-05, Failure to Comply with RWP Instructions to Contact RP Prior to Dogbone Gasket Removal 05000293/2015007-04, Failure to Follow RCIC System Manual Restart Procedure

05000293/2015007-05, Failure to Identify Conditions Adverse to Quality Associated with Core Spray Discharge Header Voiding.05000293/2015010-01, Inadequate Procedures for Placing Main Turbine in Service

05000293/2015010-03, Inadequate Guidance and Invalid Compensatory Measures for Out of Service EAL Instrumentation