ML13203A329
| ML13203A329 | |
| Person / Time | |
|---|---|
| Site: | Wolf Creek  |
| Issue date: | 07/22/2013 |
| From: | O'Keefe N Division of Nuclear Materials Safety IV |
| To: | Matthew Sunseri Wolf Creek |
| O'Keefe N | |
| References | |
| IR-13-010 | |
| Download: ML13203A329 (45) | |
See also: IR 05000482/2013010
Text
N U C LE AR R E GU LA TOR Y C OM MI S S I ON
R E G IO N I V
1600 EAST LAMAR BLVD
AR L I NG TO N , TE X AS 7 60 1 1 - 4511
July 22, 2013
Matthew W. Sunseri, President and
Chief Executive Officer
Wolf Creek Nuclear Operating Corporation
P.O. Box 411
Burlington, KS 66839
SUBJECT: WOLF CREEK GENERATING STATION - NRC INSPECTION
PROCEDURE 95002 SUPPLEMENTAL INSPECTION REPORT
05000482/2013010 AND ASSESSMENT FOLLOW-UP LETTER
Dear Mr. Sunseri:
On June 7, 2013, the U.S. Nuclear Regulatory Commission (NRC) completed a supplemental
inspection pursuant to Inspection Procedure 95002, "Supplemental Inspection for One
Degraded Cornerstone or Any Three White Inputs in a Strategic Performance Area," at your
Wolf Creek Generating Station facility. This inspection included an assessment of your
actions to address each of four open substantive cross-cutting issues. The team also
performed a limited scope independent safety culture assessment follow-up in accordance
with Inspection Procedure 40100, Independent Safety Culture Assessment Follow up.
The enclosed inspection report documents the inspection results, which were discussed
during the exit meeting on June 7, 2013, with you and members of your staff.
In accordance with the NRC Reactor Oversight Process Action Matrix, this supplemental
inspection was performed to address a Yellow finding with substantial safety significance in
the Initiating Events cornerstone which was issued in the third quarter of 2012. This finding
resulted in the station being placed in Degraded Cornerstone column of the Action Matrix.
This issue was previously documented and assessed in NRC Inspection Reports
05000482/2012009 and 05000482/2012010. The NRC was informed on April 30, 2013, of
your staff's readiness for this inspection.
The objectives of this supplemental inspection were to provide assurance that: (1) the root
causes and the contributing causes for the risk-significant issues were understood; (2) the
extent of condition and extent of cause of the issues were identified; and (3) corrective actions
were or will be sufficient to address and preclude repetition of the root and contributing causes.
This inspection also included an independent NRC review of the extent of condition and extent
of cause for the Yellow finding and an assessment of whether any safety culture component
caused or significantly contributed to the performance issue. The objectives of the
independent safety culture assessment follow-up were: (1) to provide assurance that the
licensee recognizes the safety culture cross-cutting component deficiencies that caused or
significantly contributed to risk-significant performance issues and repetitive substantive cross-
cutting issues; and (2) to assess whether completed and proposed corrective actions should be
M. Sunseri -2-
considered sufficient and appropriate to address recognized cross-cutting component
deficiencies identified during the licensees independent safety culture assessment.
The objectives of the substantive cross-cutting issue review were: (1) to assess the licensees
cause evaluations for each substantive cross-cutting issue; (2) to assess whether the
corrective actions adequately addressed the causes identified; and (3) to assess the
effectiveness of corrective actions taken.
The inspectors determined that your staff performed a comprehensive evaluation to identify
appropriate causes and corrective actions associated with the Yellow finding. Your staff's
evaluation identified the root cause of the issue to be the failure to recognize the
risk/consequence of having a vendor perform work on the startup transformer, in accordance
with vendor procedures and processes, without an established verification method for ensuring
work quality, resulting in an undetected human performance error. The inspectors determined
that your staff identified appropriate corrective actions to enhance the station requirements for
oversight of supplemental workers performing contract work activities, which, if successfully
implemented, appear to be adequate to address the identified performance issues.
The NRC has determined that the inspection objectives stated above have been met. Based
on the results of this inspection, the Yellow finding is closed. Therefore, in accordance with
IMC 0305, Operating Reactor Assessment Program, because the Yellow finding is closed and
four quarters have passed, we have determined that the performance issues associated with
the Yellow finding will not be considered in the Action Matrix after the end of the second quarter
of 2013.
As a result of its continuous review of plant performance, including the results of this
inspection, the NRC has updated its assessment of Wolf Creek Generating Stations
performance. The NRCs evaluation consisted of a review of performance indicators and
inspection results. The NRC determined the performance at Wolf Creek Generating Station to
be in the Regulatory Response Column of the ROP Action Matrix as of July 1, 2013, due to one
performance indicator, the Mitigating System Performance Index - Emergency AC Power
System (MSPI - EAC), remaining White. The MSPI - EAC performance indicator will only be
considered in the Action Matrix until it returns to Green status. Your actions to address this
performance indicator have previously been inspected. Therefore, the NRC plans ROP
baseline inspections at your facility for the remainder of the assessment cycle.
The inspectors determined that your staff performed comprehensive evaluations to identify
appropriate causes and corrective actions associated with each of four open substantive cross-
cutting issues. The corrective actions identified, once fully implemented, appear to be adequate
to address the performance issues associated with these cross-cutting areas.
The inspectors also determined that your staff performed a comprehensive evaluation to identify
appropriate causes and corrective actions associated with safety culture challenges at the
station. The inspectors noted many indications of improvement in safety culture, as well as
indications of some remaining challenges in specific areas.
No findings were identified during this inspection.
M. Sunseri -3-
In accordance with 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 Public Document Room or from the Publicly Available Records (PARS) component
of NRC's Agencywide Document Access and Management System (ADAMS). ADAMS is
accessible from the NRC website at http://www.nrc.gov/reading-rm/adams.html (the Public
Electronic Reading Room).
Sincerely,
/RA/
Neil OKeefe, Chief
Project Branch B
Division of Reactor Projects
Docket: 50-482
License: NPF-42
Enclosure: Inspection Report 05000482/2013010
w/Attachment: Supplemental Information
cc w/ encl: Electronic Distribution
M. Sunseri -4-
Electronic distribution by RIV:
Regional Administrator (Art.Howell@nrc.gov)
DRP Director (Kriss.Kennedy@nrc.gov)
DRP Deputy Director (Troy.Pruett@nrc.gov)
DRS Director (Tom.Blount@nrc.gov)
DRS Deputy Director (Jeff.Clark@nrc.gov)
Senior Resident Inspector (Charles.Peabody@nrc.gov)
Acting Resident Inspector (Christopher.Hunt@nrc.gov)
WC Administrative Assistant (Carey.Spoon@nrc.gov)
Branch Chief, DRP/B (Neil.OKeefe@nrc.gov)
Senior Project Engineer, DRP/B (Mike.Bloodgood@nrc.gov)
Public Affairs Officer (Victor.Dricks@nrc.gov)
Public Affairs Officer (Lara.Uselding@nrc.gov)
Project Manager (Fred.Lyon@nrc.gov)
Branch Chief, IPAB, NRR (Rani.Franovich@nrc.gov)
Branch Chief, DRS/TSB (Ray.Kellar@nrc.gov)
RITS Coordinator (Marisa.Herrera@nrc.gov)
ACES (R4Enforcement.Resource@nrc.gov)
Regional Counsel (Karla.Fuller@nrc.gov)
Technical Support Assistant (Loretta.Williams@nrc.gov)
Congressional Affairs Officer (Jenny.Weil@nrc.gov)
RIV/ETA: OEDO (Vivian.Campbell@nrc.gov)
ROPreports
R:\_Reactors\_WC\2013\WC 2013010 95002 060713.docx
ADAMS: No Yes SUNSI Review Complete Reviewer Initials: NFO
Publicly Available Non-Sensitive
Non-publicly Available Sensitive
T. Hartman C. Osterholtz M. Bloodgood C. Young
/RA/E-OKeefe /RA/ /RA/ /RA/
TSB TSB DRP/BC:
E. Ruesch E. Uribe NOKeefe
/RA/E-Okeefe /RA/ /RA/
OFFICIAL RECORD COPY T=Telephone E=E-mail F=Fax
NUCLEAR REGULATORY COMMISSION
REGION IV
Docket: 05000482
License: NPF-42
Report: 05000482/2013010
Licensee: Wolf Creek Nuclear Operating Corporation
Facility: Wolf Creek Generating Station
Location: 1550 Oxen Lane NE
Burlington, Kansas
Dates: June 3, 2013 through June 7, 2013
Inspectors: C. Young, Senior Project Engineer (Team Leader)
T. Hartman, Senior Resident Inspector
C. Osterholtz, Senior Operations Engineer
M. Bloodgood, Senior Project Engineer
E. Ruesch, Senior Reactor Inspector
E. Uribe, Reactor Inspector
Approved By: Neil OKeefe, Chief
Project Branch B
Division of Reactor Projects
-1- Enclosure
SUMMARY OF FINDINGS
IR 05000482/2013010, 06/03/2013 - 06/07/2013, Wolf Creek Generating Station, Supplemental
Inspection (IP 95002); Independent Safety Culture Assessment Follow-up (IP 40100);
Substantive Cross-Cutting Issue Follow-up.
This supplemental inspection was conducted by four region-based inspectors and a senior
resident inspector. No findings were identified. The NRC's program for overseeing the safe
operation of commercial nuclear power reactors is described in NUREG-1649, "Reactor
Oversight Process," Revision 4, dated December 2006.
Cornerstone: Initiating Events
The NRC staff performed this supplemental inspection in accordance with Inspection
Procedure 95002, "Supplemental Inspection for One Degraded Cornerstone or Any
Three White Inputs in a Strategic Performance Area," to assess the licensee's evaluation
associated with the failure of a startup transformer due to a failure to follow maintenance
procedures, which resulted in a loss of offsite power event at the station in January 2012.
The NRC staff previously characterized this issue as having substantial safety
significance (Yellow), as documented in NRC Inspection Reports 05000482/2012009
and 05000482/2012010. A follow-up assessment letter dated September 21, 2012,
transitioned Wolf Creek to the Degraded Cornerstone Column beginning August 6,
2012, due to one Yellow input in the Initiating Events Cornerstone, and identified the
intention to perform Inspection Procedure 95002.
The inspectors determined that the licensee performed a comprehensive evaluation of
the issues related to the Yellow finding, which appropriately identified the root cause of
the issue to be the failure to recognize the risk/consequence of having a vendor perform
work, in accordance with vendor procedures and processes, without an established
verification method for ensuring work quality, resulting in an undetected human
performance error. The failure to follow maintenance procedures during a maintenance
activity in April 2011, resulted in a subsequent failure of the startup transformer and a
loss of offsite power during an event on January 13, 2012. The inspectors determined
that the licensee identified appropriate corrective actions to enhance the oversight of
supplemental workers performing work activities, which appear to be adequate to address
the identified performance issue.
In addition to assessing the licensee's evaluations, the inspection team performed an
independent extent of condition and extent of cause review and a focused inspection of
the site safety culture as it related to the root cause evaluation. The team concluded that
the licensees root cause evaluation and corrective actions, both completed and
planned, adequately addressed the extent of condition and extent of cause, and were
adequate to address the cause and prevent recurrence. Based on independent
inspection, the team also determined that the licensee's assessment of site safety culture
contribution to the issue was adequate.
-2- Enclosure
The NRC has determined that the inspection objectives stated above have been met.
Based on the results of this inspection, the Yellow finding is closed. Therefore, in
accordance with IMC 0305, Operating Reactor Assessment Program, because the
Yellow finding is closed and four quarters have passed, we have determined that the
performance issues associated with the Yellow finding will no longer be considered in the
Action Matrix after the end of the second quarter of 2013.
The inspectors determined that the licensee performed comprehensive evaluations of the
issues relating to each of four open substantive cross-cutting issues. The inspectors
determined that the licensee identified appropriate corrective actions to address these
issues, which, once fully implemented, appear to be adequate to address the performance
issues associated with these cross-cutting areas.
The inspectors also determined that the licensee performed a comprehensive evaluation to
identify appropriate causes and corrective actions associated with safety culture challenges
at the station. The inspectors noted many indications of improvement in safety culture, as
well as indications of some remaining challenges in specific areas.
A. NRC-Identified or Self-Revealing Findings
None
B. Licensee-Identified Violations
None
-3- Enclosure
REPORT DETAILS
4. OTHER ACTIVITIES
4OA4 Supplemental Inspection (95002)
.01 Inspection Scope
The NRC staff performed this supplemental inspection in accordance with Inspection
Procedure 95002, "Inspection for One Degraded Cornerstone or Any Three White Inputs
in a Strategic Performance Area," to assess the licensees evaluation of a Yellow finding,
which affected the initiating events cornerstone in the reactor safety strategic performance
area. The inspection objectives were to:
provide assurance that the root and contributing causes of risk-significant issues
were understood
provide assurance that the extent of condition and extent of cause of risk-
significant issues were identified and to independently assess the extent of
condition and extent of cause of individual and collective risk-significant issues
independently determine if safety culture components caused or significantly
contributed to the risk significant issues
provide assurance that the licensee's corrective actions for risk-significant issues
were or will be sufficient to address the root and contributing causes and to
preclude repetition
The licensee entered the Degraded Cornerstone Column of the NRCs Action Matrix in
the third quarter of 2012 as a result of one inspection finding of substantial safety
significance (Yellow). The finding was associated with the failure of a startup
transformer during a power transient which occurred on January 13, 2012, resulting in
a loss of offsite power event at the station. The startup transformer failure was the
result of an inadequately performed maintenance activity conducted by contracted
workers in April 2011, in which maintenance procedure requirements were not
adequately followed. The finding was characterized as having Yellow safety
significance, as discussed in NRC Inspection Reports 05000482/2012009 and
The licensee staff informed the NRC on April 30, 2013, that Wolf Creek was ready for the
supplemental inspection. In preparation for the inspection, the licensee performed a root
cause evaluation (RCE) to identify weaknesses that existed, which allowed for a risk-
significant finding and Degraded Cornerstone, and to determine the organizational
attributes that resulted in the Yellow finding. The licensee also conducted assessments to
determine whether safety culture aspects contributed to the performance issues that led to
the Yellow finding.
-4- Enclosure
The inspection team reviewed the licensees RCE in addition to other associated
evaluations conducted in support and as a result of the RCE. The inspection team
reviewed corrective actions that were taken or planned to address the identified causes.
The inspection team also held discussions with licensee personnel to ensure that the root
and contributing causes and the contribution of safety culture components were
understood and corrective actions taken or planned were appropriate to address the
causes and preclude repetition. The inspection team also independently assessed the
extent of condition and extent of cause of the identified issue, and performed an
assessment of whether any safety culture components caused or significantly contributed
to the finding.
.02 Evaluation of Inspection Requirements
02.01 Problem Identification
a. Identification of the issue (i.e., licensee-identified, self-revealing, or NRC-identified) and
under what conditions the issue was identified.
On January 13, 2012, the site experienced a loss of offsite power event. Wolf Creek was
operating at 100 percent rated thermal power with no plant evolutions in progress, no
transmission switching events occurring, and no severe weather conditions. The licensee
determined that the event resulted from two distinct faults. The first fault was on the C
phase of the main generator output breaker. The second fault occurred on the B phase of
the startup transformer. The inspectors determined that the issue was self-revealing as a
pair of failures which caused a plant-level event. The inspectors determined that the
licensees evaluation adequately documented who identified the issue and under what
conditions the issue was identified.
b. Issue duration and prior opportunities for identification.
The licensees root cause evaluation documented that the issue related to the startup
transformer fault existed since an inadequately performed maintenance activity was
conducted on the startup transformer in April 2011. The evaluation provided a detailed
timeline of the maintenance performed, surveillance tests conducted, and corrective
actions. The licensees timeline identified missed opportunities for earlier identification of
the issues. The licensees evaluation determined that previous visual inspections
conducted by the licensee did not recognize that the cover to the startup transformer
junction box containing the wiring terminations that were the source of the fault could be
removed for access to any wiring. The inspectors determined that the licensees
evaluation was adequate with respect to identifying how long the issue existed and prior
opportunities for identification.
c. Licensees documentation of the plant-specific risk consequences, and compliance
concerns associated with the issues, both individually and collectively.
The licensees root cause evaluation concluded that the lack of controls and oversight for
contract services caused degraded equipment reliability.
-5- Enclosure
The errors introduced as a result of a failure to comply with maintenance procedure
requirements impacted the stations ability to mitigate a switchyard transient and maintain
power to electrical buses by transferring power to an energized offsite source. This
increased the risk associated with a loss of offsite power initiating event. The licensees
evaluation provided information to describe what actions (e.g. procedure compliance)
would have prevented the error from being introduced during maintenance on the startup
transformer. The inspectors concluded that the licensee appropriately documented the
risk consequences and compliance concerns associated with the issue.
d. Findings
No findings were identified.
02.02 Root Cause, Extent of Condition, and Extent of Cause Evaluation
a. Root and contributing cause evaluation methodology.
The licensee conducted a root cause evaluation to identify the causes for the inadequate
workmanship by maintenance personnel that led to the failure to install sleeves for the
insulation of exposed wiring, which caused a failure of the startup transformer. The
licensees analysis included: a detailed description of the event, an event timeline and
decisions made, a summary of root and contributing causes, a discussion of relevant
internal and external operating experience, a discussion of Quality Assurance (QA)
oversight activities related to the issues, an extent of condition analysis and resulting
actions, an extent of cause analysis and resulting actions, and a safety culture
assessment. The licensees evaluation identified the following direct cause, root cause,
and contributing cause associated with the Yellow finding:
The direct cause for the loss of the Startup Transformer was the Startup
Transformer high voltage side current transformer (CT) wires on A and B Phase
were shorted
Wolf Creek did not recognize the risk/consequence of having a vendor perform
work, in accordance with vendor procedures and processes, without a Wolf Creek
approved verification method for ensuring work quality, resulting in an undetected
human performance error
Wolf Creek personnel, at all levels, failed to implement and enforce the companys
accountability model, primarily with respect to procedural use and adherence
The inspection team concluded that the licensee performed a comprehensive and
thorough analysis of the issue, using multiple analysis methods that were appropriate to
identify root and contributing causes of the events. Two Event and Causal Factor (E&CF)
Charts (overview and details) were developed using a detailed Sequence of Events (SOE)
report. Fault Tree Analysis, Evidence and Action Matrix, Change Analysis, Barrier
Analysis, Why Tree, and Safety Culture Analysis methods were used to identify causal
factors and determine corrective actions. A Management Oversight and Risk Tree
(MORT) analysis was used to evaluate the completeness of the analysis and to identify or
confirm areas of causality.
-6- Enclosure
The inspectors concluded that the licensees evaluation was adequate to identify
appropriate causes.
b. Root cause evaluation level of detail.
The licensee conducted a root cause analysis to evaluate causes for the inadequate
workmanship by maintenance personnel that led to the failure of the startup transformer.
The licensees analysis included: a detailed description of the event, an event timeline and
decisions made, a summary of root and contributing causes, a discussion of internal and
external operating experience, a discussion of Quality Assurance oversight activities
related to the issues, an extent of condition analysis and resulting actions, an extent of
cause analysis and resulting actions, and a safety culture assessment. The licensee
identified one direct cause, one root cause, and one contributing cause related to the
failure of the startup transformer along with various interim corrective actions and two
corrective actions to prevent recurrence. The licensee evaluation also included numerous
actions to address the extent of condition and extent of cause.
The inspectors concluded the licensees root cause evaluation was adequately performed,
and included a level of detail commensurate with the significance of the problem. The
inspectors concluded that the identified causes, corrective actions, and actions taken to
identify the extent of problems provided evidence of a process that was methodical, in-
depth, and comprehensive. The level of detail was reflected in the extensive event
timeline and the evaluation attachments of the licensees root cause evaluation.
The inspectors also noted that the licensee took the additional step to complete an
independent evaluation of the root cause evaluation to ensure that it addressed and
documented all applicable aspects of the deficiency.
c. Root cause evaluation consideration of prior occurrences and operating experience.
The inspectors confirmed that the licensees evaluation included a discussion and
consideration of similar previous plant trips and loss of offsite power events. The licensee
also performed benchmarking efforts to gauge other nuclear plants responses to
applicable generic communications and operating experience regarding current
transformer saturation levels.
The inspectors concluded that the root cause evaluation included a thorough review of
prior and precursor problems, and properly evaluated internal and industry operating
experience. The inspectors did not identify any examples where a review of prior
operating experience could have prevented the condition that led to this event from
occurring.
d. Evaluation of the extent of condition and the extent of cause.
The licensees evaluation included an analysis of the extent of condition, which consisted
of determining whether the identified conditions could exist in other plant equipment,
processes or human performance. In this case, the extent of condition review examined
whether other similar inadequate workmanship issues existed on similar equipment.
-7- Enclosure
The licensee determined that inspections of the two remaining similar startup transformer
CT junction blocks, as well as similar connections for the three main transformers, were
necessary. These inspections were performed as part of the licensees extent of condition
review. This resulted in the identification of other workmanship issues involving the
splicing of CT wires for one of the main transformers.
The licensees evaluation also included the extent of cause for the root cause to determine
if other departments or activities involving similar processes could be vulnerable to the root
causes identified in the evaluation with respect to control of contractor performed
maintenance activities. The licensee identified that the failure to recognize the risk and
consequence of having a vendor perform work under their program, without sufficient
verification, could have existed for any service labor requisitions and applicable projects.
The licensees evaluation recognized the need to determine whether other supplemental
work activities have been performed at the station without proper oversight, and determine
whether additional associated latent equipment problems may exist. The licensee initiated
a review of work completed by service labor contracts, which included a review of 92
applicable purchase requisitions approved between 2009 and 2012. These were reviewed
by the licensees Quality Assurance organization. The licensees review did not identify
any instances where other activities were performed without appropriate oversight.
Based on a review of the evaluation and discussions with licensee management and staff
personnel, the inspectors concluded that the licensees evaluation addressed the extent of
condition and the extent of cause of the problem through a disciplined process. Additional
discussion is provided in Section 02.04.
f. Findings
No findings of significance were identified.
02.03 Corrective Actions
a. Appropriateness of corrective actions for each root and contributing cause.
The licensees evaluation identified a direct cause, a root cause, and a contributing cause,
and identified corresponding interim corrective actions, two corrective actions to prevent
recurrence, and numerous extent of condition and extent of cause corrective actions. The
licensees evaluation identified a total of 50 corrective actions to address the identified
causes. The licensees principal corrective action to prevent recurrence included revision of
station procedural requirements for:
Oversight of supplemental workers performing contract work activities
Work order planning
Work order implementation
The inspectors also determined that the licensee was working with WESTAR, the
transmission and distribution company for the local grid, to take actions to improve the
overall reliability of offsite power, in light of the event which was a result of this
performance deficiency being the third loss of offsite power event that has occurred at the
station over the past five years. These actions included the performance of an
independent review of all previously identified grid reliability and switchyard enhancements
to ensure that industry best practices have been appropriately incorporated. This review
resulted in the identification of several best practices upgrade projects in areas such as:
-8- Enclosure
preventive maintenance improvement, protective relay scheme upgrades, reconfiguration
of substation layout/components and installation of additional switchyard components to
increase reliability. The inspectors also noted that the licensee had implemented
additional oversight measures to control and coordinate maintenance activities occurring in
the switchyard/substation, and that the licensee had taken action to include switchyard
components in the stations maintenance rule (10 CFR 50.65) monitoring program.
Overall, the inspectors concluded that appropriate corrective actions were developed to
address the identified causes of the performance deficiency.
b. Prioritization of corrective actions with consideration of risk significance and regulatory
compliance.
The inspectors determined that licensee has identified numerous (50) corrective actions
associated with this issue since the event occurred on January 13, 2011. All but two of
these corrective actions had been completed and were closed prior to the beginning of this
inspection (June 3, 2013). The two corrective actions remaining to be completed were
associated with future business planning actions.
The inspectors concluded the licensee had appropriately prioritized and scheduled
corrective actions for the identified direct, root and contributing causes, and had completed
them in a timely manner.
c. Schedule for implementing and completing the corrective actions.
As discussed in Section 02.03.b, the inspectors determined that the licensee has
completed all but two of the identified corrective actions as of June 3, 2013. The
inspectors determined that the assigned schedule for completion dates of these actions
was appropriate. Completion dates were assigned for the remaining two corrective actions
related to business planning and are expected to be complete later in 2013.
The inspectors concluded that an appropriate schedule was established for implementing
and completing the corrective actions.
d. Measures for determining the effectiveness of the corrective actions.
The licensee scheduled an overall effectiveness review to ensure that the problems
identified in the root cause evaluation are adequately addressed by the implementation of
the corrective actions. The evaluation was scheduled to be performed by December 27,
2013. The inspectors noted that this schedule did not appear to be timely relative to the
completion dates of the major corrective actions. The inspectors determined that the
licensee used their standard effectiveness review schedule of 6 months following
completion of the last action. The inspectors observed that the standard scheduling might
not be appropriate for this situation because the significance of the issues and the large
number and extent of corrective actions made the need for an effectiveness review
desirable, such that prompt changes could be made if needed. However, the inspectors
did note that the licensee planned and had already implemented interim effectiveness
review actions in the form of QA surveillances for activities involving contractor work
oversight.
The inspectors independently assessed the effectiveness of the licensees corrective
actions to improve oversight of contractor work by observing work in progress to install
-9- Enclosure
new essential service water piping and new diesel generators. The inspectors found that
the corrective actions implemented have been effective. The licensee personnel observed
by the inspectors demonstrated a clear understanding of the oversight requirements and
the work being performed by contractors.
The inspectors also reviewed the results of QA surveillances of maintenance activities
involving contractor oversight, which had been performed by the licensee as an interim
effectiveness review action. QA identified several instances where the corrective actions
were not fully effective and identified additional vulnerabilities regarding control of contract
services. The inspectors determined that, although the findings identified by QA were not
safety significant, the licensee was performing a separate root cause evaluation to address
these issues at the time of the inspection. The inspectors observed that this demonstrated
a heightened sensitivity to the identification of potential vulnerabilities in this area and a
high level of rigor being applied to effectiveness review efforts.
Overall, the inspectors concluded that the licensee had developed adequate evaluation
criteria for each corrective action to prevent recurrence, addressed additional interim
corrective actions following the results of recent Quality Assurance surveillances, and was
tracking completion of the reviews. The inspectors concluded this was appropriate given
the implementation schedule and the complexity of some corrective actions.
e. Adequacy of corrective actions to address the Notice of Violation (NOV).
The NRC issued a Notice of Violation, VIO 05000482/2012009-01, to the licensee on
September 21, 2012 for the failure to perform maintenance that affected safety-related
equipment in accordance with written procedures (ML12265A310). During this inspection,
the inspectors confirmed that the licensees root cause evaluation and corrective actions
adequately addressed the Notice of Violation. The licensee restored full compliance by
correcting procedures associated with the control of contract services.
The licensees principal corrective action to prevent recurrence involved the enhancement of
station procedural requirements for oversight of supplemental workers performing contract
work activities. The inspectors identified a potential vulnerability that existed in the
resulting procedures, in that the procedures contained a provision for delegation of the
oversight role to other designated qualified personnel, without any provision to ensure
these individuals would be independent of the contracted organization performing the
activity. The licensee entered this observation into their corrective action program as
Condition Report 69954. Overall, the inspectors determined that the corrective actions
taken or planned were adequate to address the NOV that was the basis for the
supplemental inspection.
f. Findings
No findings were identified.
- 10 - Enclosure
02.04 Independent Assessment of Extent of Condition and Extent of Cause
a. Inspection Scope
Inspection Procedure 95002 requires that the inspection staff perform a focused inspection
to independently assess the validity of the licensee's conclusions regarding the extent of
condition and extent of cause of the issue. The objective of this requirement is to
independently sample performance, as necessary, within the key attributes of the
cornerstones that are related to the subject issue, to ensure that the licensee's evaluation
regarding the extent of condition and extent of cause is sufficiently comprehensive.
The inspectors conducted independent extent of condition and extent of cause reviews of
the issues associated with the Yellow finding. The Yellow finding resulted from Wolf Creek
Stations failure to follow maintenance procedures in accordance with Work Order 11-
240360-006, Revision 3. The inspectors independently reviewed the licensees actions
specified in the root cause evaluation for extent of cause/extent of condition. The
inspectors also conducted additional independent sampling of activities, specifically
focusing on other documents and work activities where a failure to follow maintenance
procedure by contract services would have the potential to contribute to a significant event.
The inspectors independently sampled the documentation of selected contracted
maintenance activities completed during the most recent refueling outage. The inspectors
also observed several work activities which were in progress during the inspection
involving station oversight of contracted personnel. The inspectors independently
assessed the effectiveness of the licensees corrective actions to improve oversight of
contractor work by directly observing work activities in progress involving the installation of
new essential service water system piping, as well as new diesel generators.
In conducting this review, the inspectors interviewed station management and
personnel, reviewed program and process documentation, reviewed station program
monitoring and improvement efforts, and reviewed corrective action documents.
b. Assessment
The inspectors independent assessment of the extent of condition/extent of cause
determined that the licensee had done a comprehensive job identifying and addressing the
significant issues.
Interviews were conducted with station management and personnel to assess the
effectiveness of documented actions taken, the understanding of their implementation, as
well as the logic and justifications used for the documented extent of condition/extent of
cause actions from the licensees root cause evaluation. The interviews demonstrated a
general awareness and adequate implementation of the actions taken.
- 11 - Enclosure
The inspectors noted that the licensee was in the process of performing a high level
evaluation for three different events:
The loss of offsite power event of January 13, 2012
The Emergency Diesel Generator Performance Indicator threshold crossing of
March 12, 2012
Previous corrective actions addressed during the 95002 Inspection of May 20,
2011, for the threshold crossings of the Unplanned Scrams per 7000 Critical Hours,
Unplanned Scrams with Complications, and Safety System Functional Failures
performance indicators
The licensee has established an improvement plan to reinforce the use and effectiveness
of the sites Accountability and Culpability models to achieve improved performance.
Through interviews with a cross-section of station personnel, the inspectors determined
that this model has gained broad acceptance and was being used effectively to drive
improvement and higher standards in many different work activities.
The inspectors observations were entered into the corrective action program as
Condition Report 69954. Overall, the inspectors independent assessment concluded
that the licensee conducted an adequate RCE with respect to extent of condition and
extent of cause.
02.05 Safety Culture Consideration
a. Inspection Scope
The inspection team conducted a focused inspection to independently determine whether
the licensees root cause evaluation appropriately considered whether any safety culture
component caused or significantly contributed to any risk significant performance issues.
The inspectors reviewed corrective actions, training requests, performance indicators,
and procedures as part of the assessment. The inspection team reviewed condition
reports and procedures, and conducted interviews with licensee personnel.
b. Assessment
As part of the collective root cause evaluation, the licensee conducted a safety culture
analysis which evaluated the identified direct, root and contributing causes against the
safety culture components that could have contributed to the issue.
- 12 - Enclosure
The inspectors verified that the licensee's root cause evaluation included an assessment
and consideration of the applicable safety culture components as they applied to the
Yellow finding which affected the Initiating Events cornerstone. The licensees analysis
determined that deficiencies in the following five safety culture aspects that contributed to
the performance deficiency:
H.4.b(Work practices - personnel follow procedures)
H.1.a(Systematic process for risk-significant decision-making)
O.4.c (Organizational decisions and actions are consistent with a policy that
nuclear safety is an overriding priority)
H.3.b(Work control - coordination of work activities)
H.4.c(Work practices - supervisory oversight of work activities)
The inspectors concluded that several safety culture deficiencies provided the underlying
conditions that allowed the events of January 13, 2012, to occur. The licensee has had
multiple substantive cross-cutting issues (SCCIs) for a prolonged period of time. The
current SCCIs were evaluated during this inspection because of their relationship to the
Yellow finding, and the results of this review are discussed in later sections of this report.
In particular, the SCCIs represented the following safety culture problems:
Tolerance of longstanding equipment reliability issues and untimely corrective
actions for the same
Willingness of workers to proceed when faced with unclear procedures or
documentation, rather than stopping to get the documents corrected
Evaluations and decision-making performed without clearly identifying all needed
information and the assumptions being made
An operability assessment process that did not track degraded or non-conforming
conditions, assess them collectively, or ensure prompt corrective action
The inspection team independently confirmed the licensees conclusion that improving
safety culture behaviors should be a high priority item for the recovery effort. The
inspectors concluded that the licensees analysis appropriately considered the safety
culture components.
c. Findings
No findings were identified.
- 13 - Enclosure
02.06 Evaluation of Inspection Manual Chapter 0305 teria for Treatment of Old Design Issues
The Yellow finding did not involve any old design issues.
4OA5 Other Activities
.1 Assessment of Corrective Action to Address Substantive Cross-cutting Issues
a. Inspection Scope
The licensees letter dated April 30, 2013, informed the NRC of its readiness for inspection
of the following four substantive cross-cutting issues: P.1.c(problem evaluation), P.1.d
(timely and effective corrective action), H.1.b(conservative decision-making), and H.2.c
(complete and accurate documentation and procedures). Consideration of possible
closure of these substantive cross-cutting issues will be further assessed using information
from this inspection and guidance in Inspection Manual Chapter 0305.
The inspectors reviewed: whether the SCCIs were entered into the corrective action
program (CAP), the causes identified, the corrective actions identified to address those
causes, the measures of effectiveness used by the licensee to monitor improvement, and
actual data for those effectiveness reviews.
b. Findings and Assessment
No findings were identified.
P.1.c - Problem Identification
Wolf Creek has had an SSCI in P.1.c, problem evaluation, for a total of 5 years. The
majority of the licensees recovery actions which addressed the P.1.c SCCI were
accomplished in three main Condition Reports (CRs) in the licensees corrective action
program (CAP): CR 51952 (Latent Organizational Weakness in Management Oversight,
4/25/2012), which included an apparent cause evaluation (ACE); CR 59217 (Perform
Collective Significance Evaluation, 10/28/2012), which included a common cause analysis
(CCA); and CR 34455 (End of Cycle Letter Identifies Ongoing Substantive Issue,
03/08/2011), which included a root cause evaluation (RCE) and was in response to the
2010 end-of-cycle NRC assessment letter.
The inspectors concluded that the licensee appropriately entered this issue into the CAP.
- 14 - Enclosure
P.1.c - Evaluation of Root Causes
The licensee conducted cause evaluations under the CRs referenced above to address
this SCCI. In CR 51952, the licensee identified the apparent cause of the SCCI to be:
CAP training has not been fully effective, resulting in a lack of rigor in the extent and
depth of analysis, leading to inadequate evaluations. A common cause identified from the
issues evaluated in CR 59217 was: Station leaders and managers have failed to model
and consistently drive the individual roles, responsibilities, and accountabilities needed to
reinforce Nuclear Safety Culture behaviors within CAP. In CR 34455, the licensee
identified a root cause of: Leadership has not been successful in aligning behaviors for
timely problem identification and effective resolution in all areas across the station.
The inspectors concluded that the licensees evaluations had been effective in identifying
the causes for this SCCI.
P.1.c - Corrective Action
The licensee identified a total of 39 corrective actions to address this SCCI. The
inspectors reviewed the key corrective actions taken by the licensee.
The licensee had a contractor provide training to all cause evaluators and Corrective
Action Review Board (CARB) members. This training was being tracked in the licensees
training database, and will include annual refresher training. If fully implemented and
continued, this training should improve the quality and consistency of cause evaluation
products.
The licensee recently implemented improvements in the CARB process. These included
developing a stand-alone CARB procedure to establish clearer expectations for CARB
reviews (April 24, 2013), revising CAP procedures to increase CARB ownership of
corrective actions for significant conditions (August 13, 2012, and subsequent revisions),
and implementing divisional CARBs to pre-screen cause evaluation products prior to
presentation to CARB (April 24, 2013).
The licensee is revising its CAP procedures, particularly its root and apparent cause
evaluation procedures, to make them easier to use. Several interviewees in the safety
culture focus groups conducted during this inspection expressed frustration with the
complexity of these procedures. Based on interviews with management, the inspectors
noted that station leadership had already recognized the difficulty and undertaken
improvement efforts.
Licensee management has begun a campaign to communicate to the workforce the
changes to CAP and to improve general employee training relative to the CAP. Based on
safety culture focus group interviews, the team determined that this communication has
been effective as a change management tool.
- 15 - Enclosure
The inspectors also assessed changes that the licensee had implemented in an effort to
improve their processes for evaluating conditions that have the potential to affect
operability of plant equipment and systems. The licensee had changed their corrective
action program to utilize a sole point of entry for problems, such that a condition report
became the single method used to identify and address equipment concerns. The
licensee had implemented a requirement for a senior reactor operator (SRO) to evaluate
every condition report written and perform an operability determination and/or functionality
assessment to evaluate the impact of the identified condition on the capability of plant
systems to perform their required safety functions. The licensee had also implemented a
process by which Operations department management performs subsequent reviews and
assigns grades to every operability/functionality evaluation on a 5-point scale. Any
evaluation that does not receive a grade of five requires some sort of feedback or
correction. The inspectors observed that the licensee did not have a rigorous process in
place to ensure this feedback or correction is performed. The inspectors identified that
several evaluations with low scores were not corrected, and that the associated condition
reports still had inaccurate information in them. The licensee entered these issues in their
corrective action program as Condition Reports 70004 and 70063.
The inspectors concluded that the corrective actions identified were appropriate to address
the identified causes.
P.1.c - Corrective Action Effectiveness Measures
The inspectors noted that many of the internal metrics being monitored have not yet
shown significant improvement. This is largely because of long lead times to see changes
in certain metrics, recent process changes that established more challenging standards,
and re-baselining of some metrics.
Additionally, after implementing the majority of the corrective actions from the three CRs
referenced above, the licensee performed gap analyses to evaluate performance between
the original CR initiation and the closure of the actions. As a result of these gap analyses,
the licensee added additional actions to incorporate lessons learned during that interim
period.
The inspectors also noted that the licensee was tracking the graded results of the
operability/functionality assessment reviews in a performance metric. This metric was a
3-month rolling average for each crew and the work control SRO group, and appeared to
be adequate to determine the effectiveness of those corrective actions.
The inspectors concluded that the licensee had developed meaningful and challenging
measures to apply to the identified corrective actions. Further, the licensee had
established high standards and long review periods for metrics such that they would help
drive long-term improvement. The recent data generally showed improving trends and
prompt re-baselining when significant program changes were made.
- 16 - Enclosure
P.1.c - Results
The inspectors observed that the station had made significant progress in revising their
guidance to address several concerns previously identified by the NRC and other sources.
In particular, the licensee had made extensive efforts to benchmark and incorporate
industry best practices into their corrective action program. In addition to the CRs
referenced above, other drivers used by the licensee to focus its recent process
improvements include the 2012 CAP Audit performed by the licensees Quality Assurance
organization (CR 51952), the 2012 NRC biennial Problem Identification & Resolution
inspection (CRs 53445 & 54072), and other self- and third-party assessments.
The inspectors concluded that the licensee appears to have gained a thorough
understanding of the scope of its problems with respect to evaluation quality and
timeliness. The team confirmed that many of the licensees changes to the CARB process
had improved the quality of both the process and the final products by improving the level
and quality of management involvement. The team noted that the combination of training
and management involvement was causing active discussions about performance
standards and the quality of documentation that had broad benefit. Additionally, the CARB
ownership of significant issues was improved. On June 5, 2013, the team observed a
CARB review of a RCE and several evaluations of industry recommendations. Based on
its observations, the team noted that the licensees CARB process is effective, but that
further improvement is warranted. Specifically, the inspectors observed that the ratings
assigned by the CARB for a RCE associated with CR 68393 were not consistent with the
deficiencies which were identified in the meeting regarding appropriateness of proposed
causes and corrective actions. The inspectors also noted that the metrics for CARB
grading of document quality did not reflect situations where a document was initially
rejected but subsequently accepted, as only the final grade was tracked. The inspectors
also noted that the licensee was still developing the role of Divisional CARBs in driving
improved evaluation quality prior to bringing the issues to CARB.
The inspectors concluded that changes to the operability determination and functionality
assessment processes, if fully implemented, will improve the quality of the evaluations.
The current level of oversight and attention will likely result in sustainable improvement at
the station.
The inspectors concluded that, overall, the quality of the licensees problem evaluation
processes improved demonstrably since the biennial NRC Problem Identification &
Resolution inspection performed in 2012. The team concluded that the licensees
implemented and planned improvements to the CARB and other CAP processes will likely
result in continued improvement.
P.1.d - Problem Identification
Wolf Creek has had a an SCCI in P.1.d, adequacy and timeliness of corrective actions,
SCCI for a total of 3 years. The licensee addressed recovery efforts for the P.1.d SCCI
under the same three principal CRs as discussed in the P.1.csections above: CR 51952
(Latent Organizational Weakness in Management Oversight, 4/25/2012), which included
an apparent cause evaluation CR 59217 (Perform Collective Significance Evaluation,
10/28/2012), which included a common cause analysis; and CR 34455 (End of Cycle
Letter Identifies Ongoing Substantive Issue, 03/08/2011), which included a root cause
evaluation. The inspectors also evaluated the status of the licensees corrective actions to
- 17 - Enclosure
address improvements to the preventive maintenance program. The licensee was
addressing preventative maintenance program issues affecting equipment reliability in
CRs 24445 and 34896. The licensee identified deficiencies in the plants preventive
maintenance program in CRs 24445 and 23119.
The inspectors also evaluated the status of the licensees corrective actions to address
long-standing issues related to deficiencies in the essential service water (ESW) system.
The licensee was addressing recovery actions for ESW system degradation issues with
Incident Investigation Team (IIT) 10-01 and CR 53443.
The inspectors concluded that the licensee appropriately entered these issues related to
P.1.d - Evaluation of Root Causes
The licensees cause evaluations associated with the preventive maintenance (PM)
program issues affecting equipment reliability identified several causes. The evaluation in
CR 34896 determined that causes included: lack of detailed PM scope, inadequate PM
implementation, lack of a first time PM implementation strategy, and inadequate
management oversight. The licensee determined in RCE 24445 that the content and
timeliness of preventive maintenance activities was insufficient to support reliable plant
operation. RCE 23119 determined that the root cause for the White safety system
functional failures performance indicator was insufficient preventive maintenance. The
evaluations for the preventive maintenance program issues were self-critical, and they
documented that the preventive maintenance programs did not support reliable plant
operation. These corrective actions were incorporated into the licensees Preventive
Maintenance Optimization (PMO) project.
The licensees cause evaluations associated with the ESW system degradation issues
identified the following causes:
Through-wall leakage developed due to localized pitting developed in low flow
areas resulting in leaks during operation at normal system pressure
Failure to effectively preserve the material condition of systems exposed to lake
water, ensure plans and contingencies were in place to respond to underground
piping issues
Failure to effectively prevent pressure transients due to water hammer which
resulted in ESW piping leaks
Management was not effectively developing, overseeing or implementing priorities
to ensure regulatory issues are addressed in a timely manner, including actions to
address the adverse effects of water hammer in the ESW system
The evaluations for the ESW degradation issues were self-critical, and documented that
the station did not effectively address the degrading condition of the ESW system,
including the effects of water hammer caused by water column separation with subsequent
flow initiation, in a timely manner. The associated corrective actions were incorporated
into the licensees Essential Service Water Replacement and Management Project.
- 18 - Enclosure
The inspectors concluded that the licensees evaluations were effective in identifying the
causes associated with this SCCI.
P.1.d - Corrective Action
The inspectors reviewed the key corrective actions taken by the licensee to address the
causes described above. The licensee appeared to have a thorough understanding of the
scope of its problems and identified strategies to improve performance. The licensee had
a contractor provide training to CARB members. This training is being tracked in the
licensees training database and will include annual refresher training. If fully implemented
and continued, this training should improve the adequacy of the identified corrective
actions.
The licensee recently implemented a CR Evaluation Challenge Board and a Corrective
Action Challenge Board, which were intended to ensure that the actions associated with
the CR meet specific qualitative requirements associated with the quality of the action,
including timeliness. The inspectors observed a CAP Challenge Board which reviewed
action closure for multiple CRs. The inspectors observed that the licensee adequately
implemented the performance metrics in accordance with their guidance. The licensee
issued two CRs as the result of the board identifying instances of proposed action closure
not reasonably addressing and/or work performed not fully satisfying, the action during a
meeting observed by the inspectors.
Licensee management began a campaign to communicate to the workforce the changes
to CAP and to improve general employee training relative to the CAP. Based on safety
culture focus group interviews, the team determined that this communication has been
effective.
The licensee increased the awareness and visibility of the current CAP backlog. Having a
large backlog of corrective actions demonstrated untimely corrective action and impeded
future timeliness. The licensees division managers were providing weekly backlog reports
to the Senior Leadership Review Team which included the status of the CAP backlog
reduction curves. This was designed to provide manager accountability for reducing the
number of CAP backlog. Current CAP backlog numbers have been reduced since the
completion of the last refueling outage.
The inspectors also reviewed the status of the licensees completion of corrective actions
associated with issues that were the subject of the NRC 95002 inspection conducted at
Wolf Creek in March 2011 (NRC Inspection Report 05000482/2011006) in order to
determine whether the corrective actions associated with these regulatory issues had been
completed as planned. No significant discrepancies were identified.
The inspectors also reviewed the status of the licensees implementation of two major
improvement projects - ESW system modifications and the PMO project - to improve the
plants equipment reliability and address multiple open, long-term corrective actions. The
ESW improvement project addresses the NRC violation 05000482/2012007-03, Failure to
Take Timely Corrective Action to Preclude Repetition, issued during the 2012 Problem
Identification and Resolution (PI&R) inspection (Inspection Report 05000482/2012007).
- 19 - Enclosure
The associated actions include:
Installation of a system modification to eliminate adverse effects of water
hammer caused by water column separation due to loss of flow and
subsequent flow restoration. At the time of the inspection the modification
design and approval was still in progress.
Installation of approximately 30,000 feet of improved underground ESW piping,
scheduled for completion. The licensee designed the replacement piping to be
thicker and more accessible for condition monitoring. In areas of restricted
inspection capability, the replacement piping will be of a material less
susceptible to degradation.
Monitoring the condition of approximately 9,000 feet of above ground ESW
piping, with plans to replace approximately 2,600 feet of piping. The licensee
was conducting surveys using guided wave technology to monitor and trend the
corrosion status in the above ground piping until the piping replacement
activities are complete.
A chemical injection system upgrade was planned to reduce piping corrosion.
Improved inspection strategies and programs for monitoring the conditions of
lake water piping. System fouling, corrosion, and piping inspection program
procedures were revised to better address long term ESW system degradation
concerns due to chemistry, corrosion, and piping inspection challenges. The
licensees buried piping and tanks program procedure was also revised to
include enhanced guidance for actions in response to the identification of
leakage in buried ESW system piping.
The licensee has developed a PMO project to identify components most important to
normal plant operations and nuclear safety and then develop an improved preventive
maintenance program to improve plant equipment reliability. This program was developed
in response to recent operating history demonstrating issues with regard to reliable plant
operation, including issues captured in CRs 24445 and 23119. The inspectors reviewed
the status of associated actions to implement the PMO project, which included:
Completion of the first of three phases of the PMO project on May 1, 2013. This
phase identified the most significant plant components (described as assets),
including those included in the systems tracked by the Mitigating Systems
Performance Index (MSPI) performance indicator, portions of systems that support
MSPI systems, systems that are most likely to cause a plant trip, and a single point
vulnerability (SPV) analysis of all systems that could contain a potential SPV. The
existing preventive maintenance for these assets was then compared to the PM
templates used in an industry best practices guideline. This effort included
verifying that vendor recommendations for PM were adequately addressed. This
resulted in creating 4,700 new PM activities and improving 2,200 existing PM
activities to industry standards.
- 20 - Enclosure
The licensee commenced the second phase, which will focus on the optimization of
the remaining assets not addressed in phase one. The licensee initially scheduled
completion of phase two in December of 2013. However, phase one completion
was delayed five months resulting in delays in commencing phase two.
Phase three will consist of monitoring and reporting of the implementation of the
new PM strategies and the status of the mitigation activities for identified SPVs.
The licensee plans to complete the new PM activities for SPV by February 2015.
The licensee plans to complete new PM activities for high risk components by
October 2016.
By the time of the inspection, the licensee had completed 267 of the new PM activities.
The inspectors noted that improvement to plant equipment reliability was dependent on
completing the new and improved PM activities, not on completion of the PM documents
themselves. The delay in completing the PMO documentation contributed to performing
relatively few of the new and improved PM activities during the recently-completed
refueling outage. The inspectors determined that the licensee planned to implement the
new and improved PM activities over the 4-year period recommended in the industry
guideline. However, the inspectors pointed out that the industry guideline did not assume
that the licensee was implementing the new PM program to address a known problem with
equipment reliability. The inspectors also determined that the licensee did not prioritize
implementation of the new and improved PM activities based on the current system health
or the safety significance of the assets. The licensee documented this observation in CR
70125 and agreed to consider an implementation schedule that improved the prioritization
of new and improved PM activities.
The inspectors also noted that the PMO equipment screening process was previously
initiated in 2005. However, the screening and categorization was re-performed during the
latest effort because categories had previously been assigned at the system level, which
resulted in over-classifying many assets. The licensee identified numerous assets that
had not previously had an equipment identification number assigned, and therefore had
not been evaluated for needing PM. As a result of more detailed reviews, the number of
assets identified, evaluated, and assigned identification numbers increased from 50,000 to
137,000. Much of this increase was due to the identification of electrical components
located inside cabinets which had previously only been collectively identified with the
cabinet. The licensee identified that these assets included limited-life components, such
as relays and capacitors. The inspectors determined that the licensee did not prioritize
these components for PM or replacement based on their safety significance or age relative
to expected useful life. The licensee entered this into the CAP under CR 70060.
The inspectors also reviewed the licensees efforts to reduce significant backlogs in
maintenance work, engineering work, and the corrective action program. These backlogs
contributed to equipment reliability and procedure and document quality. The inspectors
noted significant progress in each of these areas.
- 21 - Enclosure
P.1.d - Corrective Action Effectiveness Measures
The licensee was using CAP backlog and Equipment Reliability Performance Indicators to
monitor the effectiveness of the corrective actions for the P.1.d SCCI. In addition, the
ESW and PMO projects, when implemented, will significantly reduce the number of open
long term corrective actions identified in the licensees CAP. The licensees goal was to
work off the backlog of corrective actions and shift the plant from having the need to
perform primarily corrective maintenance to having a predominantly preventive
maintenance work load.
The licensee tracked the performance of the PMO project using metrics of monthly status
reports and trending and monitoring implementation status. The inspectors reviewed the
status of the licensees implementation of their effectiveness measures and identified that
no monthly status reports were completed for February through April 2013. The licensee
did complete the status report for the month of May. The inspectors noted that this effort
tracked the completion of PM improvement paperwork, rather than completion of actual
new and improved PM items in the plant. As such, it was not monitoring the completion of
actions that directly improved plant reliability. PM effectiveness was being monitored
using the Equipment Reliability Index developed by EPRI, which uses 19 individual
weighted indicators.
The licensees effectiveness measures for the implementation of the ESW project
consisted of: successful completion of the ESW below ground piping and water hammer
modification by early 2014, zero out-of-service time due to leaking ESW piping, and
performance based self-assessments evaluating the effectiveness of inspection and
monitoring programs of underground piping and tanks scheduled in 2013. The inspectors
noted that these measures were primarily tracking milestone completion, although this was
reasonable given that the milestones were replacing degraded pipe with new pipe.
P.1.d - Results
The inspectors sampled input data and observed that Wolf Creek had self-critical internal
performance measures. The internal metrics for trends in closure of condition reports,
corrective action age, and the maintenance backlog show recent positive improvement,
but the licensee still had major efforts underway to improve known equipment reliability
issues. The licensee had extensive corrective actions in progress that will significantly
improve these metrics by reducing the amount of long term corrective action resulting from
the degraded condition of the ESW system. The licensees ESW underground piping
replacement, corrosion inhibitor injection system and water hammer modifications are
scheduled to be completed by early 2014. Completion of these corrective actions is
essential to the licensees improvement in this area.
- 22 - Enclosure
The effectiveness of increasing the plants equipment reliability due to the implementation
of the PMO program was difficult to determine because of the relatively low number of new
and improved PMs that had been implemented. When fully implemented, the inspectors
concluded that plant reliability will be improved, but the implementation schedule for
completing the Phase 1 PMs in the plant did not appear timely or appropriately prioritized
in light of the known equipment reliability issues.
In response to inspector concerns that certain key equipment reliability issues remain
incomplete, the licensee submitted a letter dated June 27, 2013, which committed to
complete the following actions by the end of the spring 2014 outage:
Install a modification to mitigate ESW system water hammer.
Install and tie-in all below-ground ESW piping.
Replace a minimum of 1200 linear feet of above-ground ESW piping.
H.1.b - Problem Identification
Wolf Creek has had an SCCI in H.1.b, conservative decision-making, for a total of 2 years.
Wolf Creek addressed the H.1.bsubstantive crosscutting issues in three condition reports.
Condition Report 23032 included a root cause evaluation completed for a second time in
September 2010. Condition Report 23032 was initiated in response to the NRCs
identification of problem identification and resolution and human performance SCCIs,
which contributed to the licensees performance that resulted in Wolf Creek being placed
in Column 3 of the NRCs Action Matrix. Condition Reports 32092 and 64785 were also
generated to specifically address conservative decision-making at the station. The
inspectors concluded that the licensee appropriately entered this issue into the CAP.
H.1.b - Evaluation of Root Causes
The inspectors determined that the root and apparent cause evaluations conducted to
address this SCCI were self-critical, and they documented a lack of management
involvement and oversight in effectively overseeing and implementing changes in
behaviors to align organizations and priorities. Another contributing cause identified by the
licensee in Condition Report 32092 was that the procedure used for directing the creation,
review, and approval of basic engineering dispositions did not provide sufficient
instructions for making and documenting assumptions. In addition, the Condition Report
64785 evaluation determined that procedural use and adherence practices were weak,
and that station leadership did not consistently enforce procedure compliance
accountability, allowing some workers to make ill-informed decisions. Also, the licensee
identified in Condition Report 64785 that the station had not developed, implemented,
trained, or enforced a consistent, well understood position-specific and hierarchical level-
specific decision making model. The inspectors concluded that the licensee effectively
identified the causes associated with this SCCI.
- 23 - Enclosure
H.1.b - Corrective Action
The inspectors reviewed the key corrective actions that were most responsive to the
identified root causes. These corrective actions included:
Conduct human performance training for Wolf Creek personnel and supplemental
work force on procedure use and adherence and document quality prior to
refueling outage 19 (Condition Report 55574-02; completed February 2013)
Conduct fundamental training on assessment techniques for operability
determinations and evaluations including extent of condition, justification, and rigor
(Condition Report 23032-02-40,-49,-50; completed March 2011)
Develop and implement a Conduct of Engineering procedure to clearly state
expectations for engineering products and guide engineers in their work with the
various tasks and activities associated with engineering decisions (Condition
Report 64146-01-08; completion planned November 2013)
Communicate key elements of established station procedures regarding usage
standards, specifically the need to stop when unsure and referencing the
accountability and culpability models (Condition Report 65524-02-06; completed
May 2013)
Develop and implement a Change Management Plan to implement the READE
decision making model (Recognize, Express, Appraise, Decide, and Evaluate) at
Wolf Creek Generating Station (Condition Report 64785-02-01; completion planned
September 2013)
Develop and deliver training to groups identified in the training needs analysis for
the READE decision making model before the start of the next planned outage
(Condition Report 64785-02-03; completion planned January 2014)
Based on a sampling review, the inspectors concluded that the corrective actions were
appropriate to address the identified causes associated with this SCCI.
H.1.b - Corrective Action Effectiveness Measures
Wolf Creeks effectiveness review associated with the root cause evaluation documented
in CR 23032 concluded that there was improvement in the decision making area as
demonstrated by:
Improved performance as reflected in site wide performance metrics
Improved performance as reflected in challenge review board data indicating an
average grade of >90%
No apparent cause evaluations or root cause evaluations that had linkage to H.1.b
aspects
- 24 - Enclosure
The final effectiveness follow-up was scheduled to be completed in early 2014. The
inspectors noted that the majority of the proposed corrective actions had only been
relatively recently implemented, and thus had yet to yield a substantial history of
measurable results. The inspectors concluded that the licensee had developed
reasonable effectiveness measures to eventually confirm sustained improvement in
making conservative assumptions and decision making.
H.1.b - Results
The inspectors sampled input data and observed that Wolf Creek had self-critical internal
performance measures because those measurement methods and inputs were found to
reflect NRC identified and licensee-identified issues.
The inspectors noted that, over the last 15 months, the licensee has demonstrated
improved conservative decision making. Inspectors have noted a deliberate effort to
identify assumptions during the decision making process and efforts to confirm or eliminate
those assumptions. This included an increase in the use of vendor representatives,
independent experts, and labs to assess failed parts or samples and help identify
appropriate corrective action. The licensee has also demonstrated an improved record of
undertaking substantial repairs for emergent equipment issues, rather than operating with
a degraded condition until the next outage. Examples included:
Following the January 13, 2012, event, the licensee evaluated each of the
equipment performance problems and completed overhauls or major work to
improve the reliability of those systems.
In response to the declining trend in emergency diesel generator (EDG) reliability
that led to the White MSPI - EAC performance indicator, the licensee undertook a
comprehensive evaluation of EDG maintenance and made improvements and
modifications to both improve reliability and reduce the risk importance of EDGs.
The latter included installation of three non-safety diesel generators to add a
diverse power source.
When a broken cylinder head bolt was identified on an EDG, the licensee sent the
bolt to a lab for analysis and obtained the assistance of an independent expert and
the vendor. The vendor provided an analysis that indicated that the EDG would be
operable with one broken bolt, but the licensee conservatively replaced the broken
bolt and both adjacent bolts, then promptly performed non-destructive
examinations of the head bolts on all EDGs.
When elevated vibrations were observed on the turbine-driven auxiliary feedwater
pump, the licensee promptly performed maintenance and conservatively replaced
the affected bearing.
On two occasions, the licensee initiated plant shutdowns due to degraded
performance of the Class 1E chillers. The licensees evaluations of the condition in
each case demonstrated conservative decision making with respect to
determinations of the equipments ability to perform for its full mission time that did
not rely on unverified assumptions.
- 25 - Enclosure
The licensee conservatively took the unit off line to promptly repair a stator cooling
water leak at a weld, in order to avoid a challenging to safety if the leak were to
degrade suddenly. This decision was made in part because the licensee could not
verify the extent of the weld flaw due to the geometry.
The inspectors noted that recent initiatives to improve plant safety margin, such as
replacement of reactor coolant pump seal packages, and proposed addition of station
blackout diesel generators as well as adding a fourth auxiliary feedwater pump,
demonstrated an increase in conservative philosophy.
The licensees metrics established for monitoring performance trends show recent positive
improvement. The inspectors concluded that the identified corrective actions, when fully
implemented, should be adequate to appropriately address the identified problems in
conservative assumptions and decision making. The inspectors also noted that the
number of NRC findings caused by non-conservative decision making has significantly
improved for the most recent 12 month period. While the licensee has scheduled further
corrective actions to improve the stations culture for making decisions at all levels, station
management has clearly had a positive impact on decision making in high-visibility
examples.
H.2.c - Problem Identification
Wolf Creek has had an SCCI in H.2.c, complete and accurate documentation, procedures
and work packages, substantive crosscutting issue for a total of 2 1/2 years. Wolf Creek
addressed the H.2.csubstantive crosscutting issue in two main condition reports.
Condition Report 65224 included a common cause evaluation performed as a result of
numerous previous condition reports to ensure the previously identified incorrect behaviors
and products are identified and resolved. Condition Report 59217 involved a collective
significance evaluation to address the inability to sustain improved performance following
the 2011 IP 95002 NRC inspection. The inspectors concluded that the licensee
appropriately entered this issue into the CAP.
- 26 - Enclosure
H.2.c - Evaluation of Root Causes
The licensees evaluations identified that the common and contributing causes involved
operations, engineering and maintenance department procedures that lacked clarity and
accuracy, and that management had established a culture that promoted harmony rather
than performance improvement, accountability, and adherence to standards. Additionally,
the licensee identified that personnel were willing to work around procedure adequacy
issues and perform the task as they assumed it should be done, rather than stopping to
get the procedure fixed. The Condition Report 59217 evaluation identified similar common
causes of leadership not aligning station behaviors. The inspectors determined that the
licensees evaluations appropriately identified the causes associated with this SCCI.
H.2.c - Corrective Action
The inspectors reviewed the key corrective actions in this area. The licensee implemented
a Procedure Upgrade Project, in which a review of all the maintenance procedures
currently in use (approximately 1,550) is planned, including revisions if necessary. This
plan included prioritization of the procedures into six groups. The plan will work from the
highest priority to the lowest with a expected completion in 2016. At the time of this
inspection, the licensee had approximately 1,062 maintenance procedures remaining to
review.
Additionally, the licensee implemented an in-line review process for all work orders. This
review evaluates all work orders for adequacy once they have been placed in the
planning complete status prior to the applicable work group performing in-plant
walkdowns of the work orders. As discussed, the licensee was also addressing PM
instructions through the PMO project. The licensee also created a process for workers to
provide feedback for procedure improvement.
The licensee also implemented an Operations Procedure Optimization Project to address
concerns within the operations procedures. This project is focused on human factoring of
the procedures, specifically related to ambiguity and wordiness of procedure steps. This
effort was primarily focused on general operating procedures because their evaluation
identified that most operator procedure issues involved these complex and infrequently
used procedures. The team noted that the licensee had recently upgraded their
emergency operating procedures and related support procedures. An evaluation showed
that other procedures were written to industry standards. The licensee also planned to
upgrade their system operating procedures and surveillance procedures by 2016.
The inspectors assessed workers willingness to stop when they identify procedure
problems through interviews and focus group discussions. The inspectors determined that
the licensee has successfully ingrained in workers the expectation that they should not
accept poorly written procedures, and to stop and get the procedure fixed. Additionally,
the inspectors observed that station management is more engaged with aligning the
station to be more focused on accountability and procedure adherence, and not accepting
sub-standard performances.
- 27 - Enclosure
H.2.c - Corrective Action Effectiveness Measures
The licensee developed internal performance indicators for evaluation quality, including
the results from the operations, engineering, and maintenance procedure quality feedback
processes. These metrics were noted to have a declining trend, but this was indicative of
station personnel being less tolerant of procedure issues, and more sensitive to the
identification of potential procedure problems. This trend is expected during the onset of
the change in process and will provide insight into the effectiveness of the corrective
actions. Additionally, the station will rely on feedback from challenge review boards such
as the Nuclear Safety Review Board (NSRB), Management Review Meeting (MRM) and
the Plant Safety Review Committee (PSRC).
H.2.c - Results
The inspectors concluded that the actions identified by the licensee have the potential to
be effective if completed as planned. The corrective action to review and upgrade
procedures is scheduled to be completed through 2016. The inspectors expressed
concern that this might not be appropriately prioritized or timely. However, the inspectors
noted that the licensee had clearly strengthened the first line of defense, namely getting
workers to identify unclear procedures and stop work in order to get the document
corrected. This action has been effective in reducing the number of NRC findings
involving inadequate procedures.
In response, the license submitted a letter dated June 27, 2013, committing to completing
the reviews of the highest priority procedures below by the end of the spring 2014 outage:
General operating procedures that direct operation from full power to cold
shutdown, and cold shutdown back to full power. These procedures were involved
in the majority of NRC findings involving inadequate operations procedures.
Forty percent (107 of 267) of the technical specification surveillance procedures
performed by maintenance personnel will be reviewed and prioritized on the basis
of importance and frequency so that the most commonly performed procedures will
be reviewed first.
The inspectors concluded that the identified corrective actions, when fully implemented,
should be adequate to appropriately address the identified problems in the area of
complete and accurate documentation. While a substantial portion of the reviews to
ensure that procedures are up to industry standards have not been completed, the
inspectors noted that the number of NRC findings caused by inadequate procedures and
documentation has significantly improved for the most recent 12 months. This was likely
caused by changes in the culture that had previously tolerated unclear procedures.
- 28 - Enclosure
.2 Independent Safety Culture Assessment Follow-up
a. Inspection Scope
Due to the potential causal contributions of safety culture issues to the Yellow finding, a
limited scope independent safety culture assessment follow-up inspection using the
guidance in IP 40100, Independent Safety Culture Assessment Follow-up, was included
in this supplemental inspection. The purpose of the assessment was to follow-up on the
results of independent safety culture assessments that had been performed by the
licensee. The inspection team assessed the licensees response to the results of its
independent safety culture assessments, including whether improvement has been
demonstrated in areas of concern. The inspectors also independently assessed the state
of safety culture at the station, including its safety-conscious work environment (SCWE)
through a series of focus group interviews conducted during the inspection.
b. Findings and Assessment
No findings were identified.
To assess Wolf Creeks safety culture, the team conducted five focus groups, interviewing
a total of 46 licensee personnel at the individual contributor level. These personnel had
been at Wolf Creek for as long as 35 years and as short as six months (mean tenure was
17.5 years; median 20.5 years). The team also met with several managers to discuss the
status of the stations safety culture improvement efforts.
The inspectors determined that the licensees nuclear safety culture was adequate to
support nuclear safety, and was improving. However, the team noted a number of safety
culture challenges within a few work groups, primarily in the communication of supervisor
expectations and in the ability and willingness of some personnel to document potential
issues in the CAP. This is supported by the following examples:
During a CARB meeting observed by the inspection team, the CARB observed that
an individual had failed to initiate CRs for several conditions identified during an
evaluation.
A small minority of individuals expressed hesitation with using the CAP. In a
survey conducted by the licensee the week of April 2, 2013, the vast majority (96%)
of respondents indicated that their supervisors encourage them to write CRs for
adverse conditions. However, a number of write-in comments indicated that some
individuals may feel differently. The licensee administered the survey and
addressed these comments under CR 66222. In response to the survey, actions
were assigned to several managers to reinforce managements expectation that
CRs be initiated for all adverse conditions. On May 16 and 22, 2013, the licensees
Nuclear Safety Culture Monitoring Panel reviewed the results of these discussions.
Based on the panels review, the licensees senior leadership team initiated
additional follow-up actions on May 31, 2013, under CR 69884.
- 29 - Enclosure
Several individuals (both survey respondents and focus group interviewees) noted
that some supervisors expect that they be consulted before individuals initiate CRs.
It was not clear whether the intent of this expectation is to ensure clarity or to avoid
issues being placed into the CAP. However, it is possible that this could result in
some issues not being documented in the CAP. Further, on April 2, 2013, in a
licensee safety culture survey, 17.6% of respondents agreed with the statement I
work with my supervisor to fix problems without having to document it in the
corrective action program.
The difficulty of responding to CRs, mostly because of the unwieldiness of the
software, intimidates many individuals and likely prevents some CRs from being
initiated when it would be appropriate.
The inspectors noted that the licensee was taking actions to address individuals hesitancy
to initiate CRs, as documented in CRs 66222 and 69884. Licensee management had
recognized a weakness in CR initiation and was taking actions to attempt to remedy the
problem. However, not all first-line supervisors appear to have accepted the philosophy;
this appears to be largely due to high workload and limited resources, though part of the
problem appears to be the licensees CAP software.
Several individuals expressed frustration with both the quantity and quality of procedure
changes implemented in response to station events:
Individuals who will implement the procedures are not always consulted in their
development. This has led to some potential improvements being overlooked.
The large number of procedures results in unwieldy processes. Several individuals
noted that they often have to have as many as five procedures open at once while
accomplishing work tasks on their job sites.
To address the overall station safety culture, licensee management implemented an
accountability model. This model includes expectations that leaders and individual
contributors work together to establish and meet expectations. The licensee noted that
when this model was initially implemented in August 2011, it was not universally accepted.
The inspectors determined that station management has since reestablished the
expectation that the model be used. While most workgroups at the station use the model,
the team identified two groups that have not fully implemented it:
The Quality group does not effectively implement the accountability model.
Individuals interviewed by the team noted that at least one supervisor in QA
specifically declined to explicitly define expectations for the workgroup.
The Clearance Order group has also not fully implemented the accountability
model. Licensee personnel noted that this may be due to a large number of long-
term contractors in the group.
- 30 - Enclosure
Additionally, even in the groups that fully use the model, the implementation of the model
is not always consistent. Several focus group interviewees noted that though the model
includes involving employees in setting expectations, some supervisors simply dictate
these expectations. The interviewees noted that this made the model less effective. This
lack of involvement of employees in setting expectations and the previously discussed lack
of involvement of individual contributors in drafting or changing procedures both indicate a
potential challenge in communication at non-management levels of the organization.
Following the licensees 2012 safety culture survey, licensee management identified two
work groups as needing to improve their safety culture due to responses on the 2012
safety culture assessment. The inspectors selected these groups for two of the focus
group sessions. The focus group discussions indicated significant improvement in one of
the groups, primarily due to the manager of that organization using an inclusive method to
identify the issues and identify ways to improve. However, improvement was not apparent
in the Quality group. The Quality management team apparently did not conduct an
evaluation of the causes, or involve workers in assessing challenges and corrective action.
The inspectors noted that the licensee created a program to identify and improve safety
culture, but failed to provide resources or tools to assess the causes or identify
improvement items. Additional actions will be needed to improve the safety culture
challenges in the Quality group.
Additionally, the inspectors determined that the licensee has challenges in the safety-
conscious work environment (SCWE) in its Quality organization. The inspectors identified
that individuals in this group do not feel free to raise some types of concerns in condition
reports or to discuss some types of issues with their management. Individuals in the QA
organization also stated that they feel that they have been discouraged from initiating CRs.
This was also indicated by the licensees survey results and was corroborated by focus
group interviews conducted by the inspection team. However, despite these challenges,
individuals in the Quality organization indicated no hesitance to raise nuclear safety
concerns and to enter such concerns into CAP.
The team also identified an issue with the licensees training program. During two focus
groups, interviewees identified that there were problems with training across the
organization. The identified challenges mostly fell into two categories: instructor quality in
some training groups and implementation of the on-the-job training/task performance
evaluation (OJT/TPE) program. Interviewees also noted specific problems with some of
the licensees initial training, particularly for outage contractors, in that the training is not
designed for workers who are new or unfamiliar with nuclear plants, but is still given to
individuals who are new to the nuclear industry.
Overall, the inspectors concluded that the licensee was aware of its safety culture
problems, beyond just those indicated by its substantive cross-cutting issues. The
licensee was taking significant actions to remedy the problems. These actions included
implementing periodic training for all employees, establishing a Nuclear Safety Culture
Monitoring Team, and lowering thresholds for identification of safety culture precursors.
However, based on its focus group interviews and recent survey results, the team
concluded that these process improvements have not been in place long enough to be
fully effective, and that additional action is needed in the QA Group. Despite these specific
challenges, the inspectors concluded that the licensee was maintaining a SCWE that was
adequate to support nuclear safety.
- 31 - Enclosure
4OA6 Meetings
Exit Meeting Summary
On June 7, 2013, the inspectors presented the inspection results to Mr. M. Sunseri and
other members of the licensee staff. The licensee acknowledged the issues presented.
The inspectors identified that proprietary information was reviewed but would not be
retained following report issuance or included in the inspection report.
- 32 - Enclosure
SUPPLEMENTAL INFORMATION
KEY POINTS OF CONTACT
Licensee Personnel
T. Baban, Manager Systems Engineering
P. Bedgood, Manager, Radiation Protection
R. Bowie, Senior Project Manager, Major Modifications
J. Broschak, Vice President, Engineering
A. Camp, Plant Manager
R. Clemens, Vice President, Strategic Projects
S. Henry, Manager Operations
W. Muilenburg, Supervisor Licensing
G. Pendergrass, Manager Station Recovery
L. Ratzlaff, Manager Maintenance
R. Rumas, Manager Quality Assurance
R. Smith, Site Vice President
M. Sunseri, President and CEO
M. Westman, Manager Regulatory Affairs
J. Yunk, Manager Corrective Actions
NRC Personnel
C. Peabody, Senior Resident Inspector
A1-1 Attachment
LIST OF ITEMS OPENED, CLOSED, AND DISCUSSED
Opened
None
Closed
05000482/2012009-01 NOV Failure to Provide Adequate Oversight of Contractors During
Maintenance on the Startup Transformer (Section 4OA4)
Discussed
05000482/2012007-03 NOV Failure to Take Timely Corrective Action to Preclude
Repetition (Section 4OA4)
LIST OF DOCUMENTS REVIEWED
PROCEDURES
NUMBER TITLE REVISION
AP 15C-001 Procedure Writers Guide 26
AP 15C-002 Procedure Use and Adherence
AP 22C-004 Operability Determination and Functionality 27
Assessment
AP 27-007 Nonconforming and Degraded Conditions 9
AI 28A-018 Corrective Action Review Board 0
AI 22C-010 Operation Work Control 16
AI 22C-012 Quality Review Team (QRT) for Maintenance Work 3
Planning
AP 09F-001 Business Planning Draft
GEN 00-003 Hot Standby to Minimum Load 91
AI 28A-018 Corrective Action Review Board 0
AI 36-001 Nuclear Safety Culture Monitoring 1 (with
OTSC 13-
0022)
AP 36-001 Nuclear Safety Culture 3
AP 20B-001 Plant Safety Review Committee 12
AI 13E-015 Wolf Creek Leadership and Accountability Model 5A
AI 13E-015 Wolf Creek Leadership and Accountability Model 0
AI 34-010 Human Performance Tools 0
AP 28A-100 Condition Reports 20A
AI 28A-100 Cause Analysis 4
AI 28A-010 Screening Condition Reports 15
A1-2 Attachment
AI 28A-017 Effectiveness Follow-up 3
APF 24-002-09 WCNOC Service Requisition Check List 16
AP 24-002 Requisition and Procurement Process 26
AP 20A-008 QA Surveillance and Station Monitoring Program 13
AI 24A-009 Non-Stock Requisition Processing for Service Labor 16
Items
AP 05-013 Review of Vendor Technical Documents 8
CONDITION REPORTS
23032 23119 24445 32092 34886
55574 59217 59491 60371 60460
60929 61559 64146 64785 65524
66222 68760 69139 34281 54136
50009 47670 47653 49386 37200
22444 49616 33692 47937 56134
68875 54083 54084 54085 54086
66459 68680 66719 67789 68165
60767 25062 33909 34465 46105
64183 64992 66350 67272 68137
67318 68345 15409 69250 69251
62999 63128 34455 55994 69777
53445 54994 59762 59760 59761
25662 36789 38165 68393 69884
36743 38520 42367 65249 68482
25887 28474 31111 31455 33102
33869 38517 34609 34896 36724
42357 42362 42363 42364 42365
42366 48636 42368 42369 51952
52419 52694 53443 23852 63969
65178 26805 66982 68108 68111
68355 68479 25896 68685 68487
68489 68751 69067 25817 19245
34280 33435 33750 33395 39844
68801 32705 68115 43710 41915
A1-3 Attachment
34279 67873 26608 27877 70131*
70171* 70064* 70132* 70133* 70110*
70123* 70122* 70121* 70120* 70125*
70106* 70093* 70088* 70087* 70047*
70028* 70096* 70088* 70087* 70004*
70072* 69956* 69955* 70073* 70063*
70016* 70060* 70061* 69983* 69982*
69967* 69954* 69945* 70100* 70004*
69982* 70078* 70130*
- Condition Reports generated during the inspection
A1-4 Attachment
DRAWINGS
NUMBER TITLE REVISION
E-13PA12 Startup Source 13.8kV Bus PA01 Feeder Brkr 5
252PA0110
E-13PA12 Startup Source 13.8kV Bus PA01 Feeder Brkr 5
252PA0110
M-13EF01 Piping Isometric Essential Service Water System 26
Control Bldg. A & B Train
M-13EF02 Piping Isometric Essential Service Water System Aux. 10
Bldg. A & B Train
M-13EF03 Piping Isometric Essential Service Water System Aux. 21
Bldg. A Train
M-13EF04 Piping Isometric Essential Service Water System Aux. 13
Bldg. B Train
M-13EF05 Piping Isometric Essential Service Water System Aux. 13
Bldg. B Train Return
M-13EF06 Piping Isometric Essential Service Water System Aux. 16
Bldg. A & B Train Supply & Return
M-13EF07 Piping Isometric Essential Service Wtr. Sys. Control 3
Bldg. D.G. Cooler (A&B) Train Supply & Rtn.
M-13EF14 Piping Iso./Essential Service Wtr. Sys. Class 1E 6
Switchgear A/C Condenser Control Bldg. A Train
M-13EF15 Piping Isometric Essential Service Water System Class 5
1E Switchgear A/C Condenser Control Building B
Train
M-13GN01 Piping Isometric Containment cooling System Reactor 4
Building Train A
M-13GN02 Piping Isometric Containment cooling System Reactor 5
Building Train B
M-KC0111 ESWS Pumphouse Piping Plan 25
LERs
NUMBER TITLE DATE
2013-003-00 Movement of Irradiated Fuel Progressed After April 15, 2013
Non-Conservative Decision Making Resulted in
Removal of One Source Range Monitor from Service
A1-5 Attachment
WORK ORDERS
12-351611-014 12-351847-000 12-351850-000 12-351851-000 12-351852-000
11-342808-006 11-342821-014 11-342432-026 11-342-808-002 10-333110-026
10-333111-145 12-361103-198 12-361103-199
PURCHASE ORDERS
765347 765193 742810 750883 755955
757508 764579
SURVEILLANCES
QS 2012-0313 QS 2012-0242 QS 2012-0422 QS 2013-0512
MISCELLANEOUS
NUMBER TITLE REVISION /
DATE
Quality Division Fundamental Behaviors June 18,
2012
Engineering Department Fundamental Behaviors June 18,
2012
Operations Division Fundamental Behaviors June 4, 2012
Maintenance Division Fundamental Behaviors April 10,
2012
Health Physics Division Fundamental Behaviors May 18, 2012
Wolf Creek Engineering Technical Rigor Expectations May 2013
TIN# HU Pre-Outage Dynamic Learning Activity - The Film
HU1445501 Festival
Prompt Operability Determination Challenge Checklist
Maintenance Procedure Improvement Project - #500408
List and Status of Priority One Maintenance Procedures June 6, 2013
Recovery team H2C Closure Package Status May 31, 2013
Summary of Open PRCs by Priority June 6, 2013
Closure Review Board Package for 25062-02-01 Quality May 15, 2013
Review Team Procedure
A1-6 Attachment
MISCELLANEOUS
NUMBER TITLE REVISION /
DATE
Closure Review Board Package for 25062-02-02 Quality May 15, 2013
Review Team Procedure
Condition Reports for Daily SRT Meeting June 5, 2013
Grading Criteria for CR Immediate Operability
Determination (IOD) and Functionality Assessment (FA)
Performance Indicator
P.1(c) and P.1(d) SCCI Performance Monitoring Metrics April 2013
AIF 28A-018-01 CARB Grading Standard for RCA 0
AIF 28A-018-02 CARB Grading Standard for ACE 0
Corrective Action Review Board Agenda June 5, 2013
Nuclear Safety Culture Monitoring Senior Leadership Team May 16, 2013
Minutes
Nuclear Safety Culture Monitoring Senior Leadership Team May 22, 2013
Minutes
Nuclear Safety Culture Monitoring Senior Leadership Team May 31, 2013
Minutes
P.1(c) and P.1(d) SCCI Performance Monitoring Metrics March 2013
P.1(c) and P.1(d) SCCI Performance Monitoring Metrics April 2013
Training Materials: Wolf Creek Generating Station Cause
Evaluation Techniques
Training Materials: Wolf Creek Generating Station
Corrective Action Review Board
Training Materials: Wolf Creek Generating Station Human
Performance
Training Materials: Wolf Creek Generating Station
Interviewing
Training Materials: Wolf Creek Generating Station
Introduction to Cause Evaluations
AIF 28A-018-01 CARB Grading Standard for RCA 0
AIF 28A-018-02 CARB Grading Standard for ACE 0
GT1245001 Lesson Plan: Site Access Training Site Specific 26
TG1645500 Lesson Plan: Safety Culture - Whats at Stake? 0
A1-7 Attachment
MISCELLANEOUS
NUMBER TITLE REVISION /
DATE
Plant Health Committee Meeting Agenda June 3, 2012
2012 System Health Report - Component Cooling Water May 22, 2013
2012 System Health Report - Control Building HVAC May 22, 2013
2012 System Health Report - Emergency Diesel May 22, 2013
Generators
2012 System Health Report - Low Voltage Non-Class 1E May 22, 2013
2012 System Health Report - Essential Service Water May 22, 2013
Closure Review Board for 34886-02-02, 09, 10 Leadership May 15, 2013
Model
Closure Review Board for 34886-02-02, 13 Fundamental May 15, 2013
Behaviors
PMO Status Report January 2013 January 2013
PMO Status Report May 2013 May 2013
PMO Project Report 4, 7
Single Point Vulnerability (SPV) Review Phase V Report June 2012
PMO Phase 1 Assets List
QH 1921 Quick Hit Detail Report September
30, 2010
QH 1942 Quick Hit Detail Report October 7,
2010
QH 2011-0021 Quick Hit Detail Report October 6,
2011
QH 2035 Quick Hit Detail Report April 5, 2011
CSM 3386 Computer Software Management Freeform May 16, 2012
PMC Backlog April 2013
P-WCNOC- PMO-Current Transformer Templates
000400
P-WCNOC- PMO-Panel Templates
000404
P-WCNOC- PMO Current Transformer Templates
000401
A1-8 Attachment
MISCELLANEOUS
NUMBER TITLE REVISION /
DATE
CARB Meeting Minutes May 8, 2013
CARB Meeting Minutes May 15, 2013
CARB Meeting Minutes May 22, 2013
CARB Meeting Minutes May 29, 2013
Plant Health Committee Meeting Agenda June 3, 2013
Current WCNOC Maintenance Rule (a)(1) Issues May 22, 2013
IIT 10-01 Investigation into the material Condition of ESW Piping and
Events from CR 00026466 and CR 00028474
Corrective Action Backlog Reduction Initiative May 6, 2013
Essential Service Water Presentation June 3, 2013
P.1(c) and P.1(d) SCCI Performance Monitoring Metrics April 2013
ES1337401 Lesson Plan: Troubleshooting DLA 000
CN-RAM-13-010 Wolf Creek PSA Revision 6 Model-of-Record 0
A1-9 Attachment