IR 05000458/2015008

IR 05000458/2015008; on 06/08/2015 - 07/02/2015; River Bend Station; Problem Identification and Resolution (Biennial)

ML15229A163
Person / Time
Site:	River Bend
Issue date:	08/13/2015
From:	Thomas Farnholtz Region 4 Engineering Branch 1
To:	Olson E W Entergy Operations
Ruesch E A
References
IR 2015008
Download: ML15229A163 (36)

Text

UNITED STATES NUCLEAR REGULATORY COMMISSION REGION IV 1600 E. LAMAR BLVD. ARLINGTON, TX 76011-4511 August 13, 2015

Mr. Eric W. Olson, Site Vice President Entergy Operations, Inc. River Bend Station

5485 US Highway 61N St. Francisville, LA 70775

SUBJECT: RIVER BEND STATION - NRC PROBLEM IDENTIFICATION AND RESOLUTION INSPECTION REPORT 05000458/2015008

Dear Mr. Olson:

On July 2, 2015, the U.S. Nuclear Regulatory Commission (NRC) completed a problem identification and resolution biennial inspection at the River Bend Station and discussed the results of this inspection with you and members of your staff. The inspection team documented the results of this inspection in the enclosed inspection report.

Based on the inspection sample, the inspection team concluded that River Bend Station's corrective action program, and your staff's implementation of the corrective action program, were adequate to support nuclear safety.

In reviewing your corrective action program, t he team assessed how well your staff identified problems at a low threshold, your staff's implementation of the station's process for prioritizing and evaluating these problems, and the effectiveness of corrective actions taken by the station to resolve these problems. The team also evaluated other processes your staff used to identify issues for resolution. These included your use of audits and self-assessments to identify latent problems and your incorporation of lessons learned from industry operating experience into station programs, processes, and procedures. The team determined that your station's performance in each of these areas supported nuclear safety.

However, the team noted that the station did not consistently develop and implement effective corrective actions to address organizational and programmatic contributors to some identified problems. Additionally, the team noted several instances where your staff did not timely initiate condition reports or did not recognize circumstances in which a condition report was required.

Finally, the team did not identify any challenges to your station management's maintenance of a safety-conscious work environment in which your employees are willing to raise nuclear safety concerns through at least one of the several means available.

The NRC inspectors documented four findings of very low safety significance (Green) in this report. Two of these findings involved violations of NRC requirements, both of which are documented as non-cited violations (NCVs) in accordance with Section 2.3.2.a of the NRC Enforcement Policy. If you contest the violations or significance of these NCVs, you should provide a response within 30 days of the date of this inspection report, with the basis for your denial, to the U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555-0001; with copies to the Regional Administrator, Region IV; the Director, Office of Enforcement, U.S. Nuclear Regulatory Commission, Washington, DC 20555-0001; and the NRC resident inspector at the River Bend Station. If you disagree with a cross-cutting aspect assignment or a finding not associated with a regulatory requirement in this report, you should provide a response within 30 days of the date of this inspection report, with the basis for your

disagreement, to the Regional Administrator, Region IV, and the NRC resident inspector at the River Bend Station.

In accordance with Title 10 of the Code of Federal Regulations (10 CFR) 2.390, "Public Inspections, Exemptions, Requests for Withholding," a copy of this letter, its enclosure, and your response (if any) will be available electronicall y for public inspection in the NRC's Public Document Room or from the Publicly Available Records (PARS) component of the NRC's Agencywide Documents Access and Management System (ADAMS). ADAMS is accessible from the NRC Web site at http://www.nrc.gov/reading-rm/adams.html (the Public Electronic Reading Room).

Sincerely,/RA/ Thomas R. Farnholtz, Chief Engineering Branch 1 Division of Reactor Safety

Docket No. 50-458 License No. NPF-47

Enclosure:

Inspection Report 05000458/2015008

w/Attachment:

Supplemental Information

cc w/encl: Electronic Distribution Enclosure U.S. NUCLEAR REGULATORY COMMISSION REGION IV Docket(s): 05000458 License: NPF-47

Report: 05000458/2015008 Licensee: Entergy Operations, Inc.

Facility: River Bend Station Location: 5485 U.S. Highway 61N St. Francisville, LA 70775 Dates: June 8 - July 2, 2015 Inspectors:

E. Ruesch, J.D., Team Lead (Acting) (Lead Inspector)

C. Alldredge, Project Engineer B. Baca, Project Engineer A. Barrett, Resident Inspector S. Makor, Reactor Inspector Approved By: Thomas R. Farnholtz Chief, Engineering Branch 1

Division of Reactor Safety

SUMMARY

IR 05000458/2015008; 06/08/2015 - 07/02/2015; RIVER BEND STATION; Problem Identification and Resolution (Biennial)

The inspection activities described in this report were performed between June 8 and July 2, 2015, by four inspectors from the NRC's Region IV office and the resident inspector at River Bend Station. The report documents four findings of very low safety significance (Green). Two of these findings involved violations of NRC requirements. The significance of inspection findings is indicated by their color (Green, White, Yellow, or Red), which is determined using Inspection Manual Chapter 0609, "Significance Determination Process." Their cross-cutting aspects are determined using Inspection Manual Chapter 0310, "Aspects Within the Cross-Cutting Areas." Violations of NRC requirement s are dispositioned in accordance with the NRC Enforcement Policy. The NRC's program for overseeing the safe operation of commercial nuclear power reactors is described in NUREG-1649, "Reactor Oversight Process."

Assessment of Problem Identification and Resolution Based on its inspection sample, the team concluded that the licensee maintained a corrective action program in which individuals generally identified issues at an appropriately low threshold. Once entered into the corrective action program, the licensee generally evaluated and addressed these issues appropriately and timely, commensurate with their safety significance.

The licensee's corrective actions were generally effective, addressing the causes and extents of condition of problems.

However, the team noted that the station did not consistently develop and implement effective corrective actions to address organizational and programmatic contributors to some identified problems. Additionally, the team noted several instances where licensee personnel did not timely initiate condition reports or did not recognize circumstances in which a condition report was required.

The licensee appropriately evaluated industry operating experience for relevance to the facility and entered applicable items in the corrective action program. The licensee incorporated industry and internal operating experience in its root cause and apparent cause evaluations.

The licensee performed effective and self-critical nuclear oversight audits and self-assessments. The licensee maintained an effective process to ensure significant findings from these audits and self-assessments were addressed.

The licensee maintained a safety-conscious work environment in which personnel were willing to raise nuclear safety concerns without fear of retaliation.

Cornerstone: Initiating Events

Green.

The team identified a Green non-cited violation of 10 CFR Part 50 Appendix B Criterion XVI, "Corrective Action," for the licensee's failure to preclude repetition of consequential gaps in operator performance. In August 2013, the licensee identified that gaps in operator fundamentals, a significant condition adverse to quality, had caused or contributed to plant transients earlier that year. The licensee's corrective actions were inadequate to prevent gaps in operator fundamentals from again causing or contributing to plant transients in late 2014.

The failure to correct and preclude repetition of consequential gaps in operator fundamentals, a significant condition adverse to quality, as required by 10 CFR Part 50 Appendix B Criterion XVI, was a performance deficiency. This performance deficiency was more than minor because it affected the human performance attribute of the initiating events cornerstone objective to limit the likelihood of events that upset plant stability and challenge critical safety function. Using Inspection Manual Chapter 0609 Appendix A, the team determined that this finding was of very low safety significance (Green) because it did not involve the loss of mitigation equipment or a support system. This finding has a field presence cross-cutting aspect in the human performance cross-cutting area (H.2) because leaders failed to provide oversight of work activities and to promptly correct deviations from standards and expectations. (Section 4OA2.5.c)

Green.

The team identified a Green non-cited violation of 10 CFR Part 50 Appendix B Criterion XVI, "Corrective Action," for the failure to identify and correct a condition adverse to quality. Specifically, the licensee failed to identify an adverse trend in the performance of post maintenance testing on high critical components. The licensee did not identify a trend or evaluate whether multiple equipment or component failures that in some instances complicated and challenged operators response to a scram was related to maintenance work performed, and if there was an opportunity to identify the issues through post maintenance testing prior to returning equipment to service.

The licensee's failure to promptly identify and correct a condition adverse to quality, as required by 10 CFR Part 50 Appendix B Criterion XVI, was a performance deficiency. The licensee failed to identify an adverse trend in the performance of post-maintenance testing on high-critical components. The performance deficiency was more than minor, and therefore a finding, because it was associated with the equipment performance attribute of the initiating event cornerstone and adversely affected the cornerstone objective to limit the likelihood of events that upset plant stability and challenge critical safety functions during shutdown as well as power operations. Specifically, the failure to identify a programmatic trend that reduced the reliability of multiple high-critical components whose failure could result in a significant impact to safe and reliable plant operation. Using Inspection Manual Chapter 0609, Appendix A, the team determined that this finding was of very low safety significance (Green) because it did not involve the loss of mitigation equipment or a support system. The finding has a human performance cross-cutting aspect associated with resources, in that the licensee leaders failed to ensure that personnel, equipment, procedures, and resources are available and adequate to support nuclear safety (H.1).

Specifically, the licensee failed to evaluate a trend in degraded critical component conditions or malfunctions for multiple high critical components. (Section 4OA2.5.d)

Cornerstone: Mitigating Systems

Green.

The team identified a Green finding for multiple examples of failures to timely document adverse conditions, as defined by corrective action program procedures, in condition reports. The team determined that these multiple failures, which were spread across multiple departments and programs, represented a programmatic deficiency in training of personnel and communication of expectations for compliance with corrective action program requirements.

The licensee's failure to promptly document multiple adverse conditions in condition reports as required by Procedure EN-LI-102 was a performance deficiency. This performance deficiency was more than minor because if left uncorrected in could lead to a more significant safety or security concern. Specifically, it could result in the licensee failing to promptly correct an adverse condition, which could lead to more significant consequences. This finding was associated with multiple cornerstones; the team determined that the mitigating systems cornerstone was the most appropriate for screening. Using Inspection Manual Chapter 0609 Appendix A, the team determined that this finding was of very low safety significance (Green) because it did not cause the loss of operability or function of any system or train and did not affect external event mitigation. This finding has a training cross-cutting aspect in the human performance cross-cutting area (H.9) because the licensee failed to ensure that individuals were adequately trained to ensure an understanding of standards. (Section 4OA2.5.b)

Cornerstone: Occupational Radiation Safety

Green.

The team identified a Green finding for a failure to document adverse conditions associated with radiological housekeeping or contamination controls in the corrective action program as required by procedure. The licensee's procedures did not adequately provide examples of deficient radiological practices as adverse conditions.

The licensee's failure to document adverse conditions in the corrective actions program as required by procedure was a performance deficiency. This constituted a programmatic weakness in the licensee's corrective action program to document adverse conditions associated with inadequate radiological practices. This performance deficiency is more than minor because it is associated with the program and process attribute (contamination control) of the Occupational Radiation Safety cornerstone and adversely affected the cornerstone objective to ensure adequate protection of the worker health and safety from exposure to radiation from radioactive material during routine civilian nuclear reactor operation. Using IMC 0609, Appendix C, "Occupational Radiation Safety Significance Determination Process," dated August 19, 2008, the inspectors determined the finding to be of very low safety significance because it was not an as low as reasonably achievable (ALARA) issue, there was no overexposure or substantial potential for overexposure, and the licensee's ability to assess dose was not compromised. This finding has a cross-cutting aspect in resources component of the human performance area because the licensee's corrective action procedures were not adequate to include deficient radiological practices as an adverse condition (H.1). (Section 4OA2.5.a)

REPORT DETAILS

4OA2 Problem Identification and Resolution

The team based the following conclusions on a sample of corrective action documents that were open during the assessment period, which ranged from July 12, 2013, to the end of the on-site portion of this inspection on July 2, 2015.

.1 Assessment of the Corrective Action Program Effectiveness

a. Inspection Scope

The team reviewed approximately 275 condition reports (CRs), including associated root cause analyses and apparent cause evaluations, from approximately 14,500 that the licensee had initiated or closed between July 12, 2013, and July 2, 2015. The majority of these (approximately 12,000) were lower-level condition reports that did not require cause evaluations. The inspection sample focused on higher-significance condition reports for which the licensee evaluated and took actions to address the cause of the condition. In performing its review, the team evaluated whether the licensee had properly identified, characterized, and entered issues into the corrective action program, and whether the licensee had appropriately evaluated and resolved the issues in accordance with established programs, processes, and procedures. The team also reviewed these programs, processes, and procedures to determine if any issues existed that may impair their effectiveness.

The team reviewed a sample of performance metrics, system health reports, operability determinations, self-assessments, trending reports and metrics, and various other documents related to the licensee's corrective action program. The team evaluated the licensee's efforts in determining the scope of problems by reviewing selected logs, work orders, self-assessment results, audits, system health reports, recovery plans, and results from surveillance tests and preventive maintenance tasks. The team reviewed daily CRs and attended the licensee's condition review group (CRG), corrective action review board (CARB), and operations focus meetings to assess the reporting threshold and prioritization efforts, and to observe the corrective action program's interfaces with the operability assessment and work control processes. The team's review included an evaluation of whether the licensee considered the full extent of cause and extent of condition for problems, and a review of how the licensee assessed generic implications and previous occurrences of issues. The team assessed the timeliness and effectiveness of corrective actions, completed or planned, and looked for additional examples of problems similar to those the licensee had previously addressed. The team conducted interviews with plant personnel to identify other processes that may exist where problems may be identified and addressed outside the corrective action program.

The team reviewed corrective action doc uments that addressed past NRC-identified violations to evaluate whether corrective actions addressed the issues described in the inspection reports. The team reviewed a sample of corrective actions closed to other corrective action documents to ensure that the ultimate corrective actions remained appropriate and timely. The team reviewed a sample of condition reports where the licensee had changed the significance level after initial classification to determine whether the level changes were in accordance with station procedure and that the conditions were appropriately addressed.

The team considered risk insights from both the NRC's and River Bend Station's risk models to focus the sample selection and plant tours on risk-significant systems and components. The team focused a portion of its sample on the residual heat removal systems, which the team selected for a fi ve-year in-depth review. The team conducted walk-downs of this system and other plant areas to assess whether licensee personnel identified problems at a low threshold and entered them into the corrective action program.

b. Assessments

1. Effectiveness of Problem Identification

During the 25-month inspection period, licensee staff generated approximately 14,500 condition reports. The team determined that most conditions that required generation of a condition report by Procedure EN-LI-102, "Corrective Action Program," had been appropriately entered into the corrective action program.

In September 2014, the licensee implemented a major change to its corrective action program. This change provided for the segregation of condition reports documenting "adverse conditions" from those documenting "non-adverse conditions." Adverse conditions include conditions adverse to quality and conditions related to other regulations or regulatory oversight processes. Though both adverse and non-adverse condition reports are handled within the licensee's paperless condition reporting system (PCRS) software, non-adverse condition reports are considered to be outside the corrective action program. Identification of an adverse condition requires prompt initiation of a condition report; condition reports are optional for non-adverse conditions. The team noted several cases where the licensee failed to properly identify and document adverse conditions. These included the failure to recognize conditions involving deficient radiological contamination controls as adverse conditions, and undue delay in documenting adverse conditions related to

program implementation. These two exam ples are discussed in two Green findings in Sections 4OA2.5.a and 4OA2.5.b below.

The team also identified incorrect information in Emergency Operating Procedure EOP-0001, "Reactor Pressure Vessel Control," which had not been identified by licensee staff during revisions of the procedure. Specifically, the team found that the procedure listed incorrect pump flow rates in a table that showed capacity for each pump at listed pressures. The emergency core cooling system line fill pumps, high pressure core spray line fill pump and reactor core isolation cooling fill pump flow rates did not account for the specific system operating curves, and had the potential to mislead operators. Title 10 CFR 50 Appendix B, Criterion V, states in part that, "Activities affecting quality shall be prescribed by documented instructions, procedures, or drawings, of a type appropriate to the circumstances and shall be accomplished in accordance with these instructions, procedures, or drawings." Contrary to this, the emergency operating procedure included operator information that was not appropriate. Failure to use correct pump flow rate information for operators use during an emergency is a performance deficiency. The performance deficiency is minor because it did not impact the station's ability to declare or upgrade an emergency class. The failure to comply with 10 CFR50 Appendix B, Criterion V, constitutes a minor violation that is not subject to enforcement action in accordance with the NRC's Enforcement Policy. The licensee documented this deficiency in condition report CR-RBS-2015-04730.

Most of the personnel interviewed by the team understood the requirements for condition report initiation; most expressed a willingness to enter newly identified issues into the corrective action program at a very low threshold. However, approximately 29 percent of interviewees expressed negative views when asked how effective the station's corrective action program is at identifying and addressing problems. Several interviewees stated that the corrective action program appeared marginally effective or ineffective at correcting problems unless those problems were either (1) major problems impacting plant operation or (2) very minor problems that could be fixed using minimal resources. As a result, several (approximately 10 percent) expressed reluctance to continue to initiate condition reports for conditions that did not fall into one of these two categories based on a lack of confidence that the problem would be resolved.

Overall, the team concluded that the licensee generally maintained a low threshold for the formal identification of problems and entry into the corrective action program for evaluation. Licensee personnel initiated an average of approximately 600 CRs

per month during the inspection period. Most of the personnel interviewed by the team understood the requirements for condition report initiation; most expressed a willingness to enter newly identified issues into the corrective action program at a very low threshold.

2. Effectiveness of Prioritization and Evaluation of Issues The sample of CRs reviewed by the team focused primarily on issues screened by the licensee as having higher-level significance, including those that received cause evaluations, those classified as significant conditions adverse to quality, and those that required engineering evaluations. The team also reviewed a number of condition reports that included or should have included immediate operability determinations to assess the quality, timeliness, and prioritization of these

determinations.

The team reviewed the licensee's evaluation of organizational and programmatic (O&P) causes in 15 root cause evaluations and 20 apparent cause evaluations. In five of the root cause evaluations (33 percent) and seven of the apparent cause evaluations (35 percent), the licensee evaluators determined that managers and other leaders were either not effectively communicating standards or not enforcing compliance with those standards. Three of the root cause evaluations noted an inadequate field presence of supervisors. In each of these instances, corrective actions such as training, increased management observation requirements, or procedure changes were developed. While these corrective actions appeared adequate to correct the issue in each case individually, the licensee failed to develop comprehensive corrective actions to address the trend of leadership-related organizational and programmatic causes.

Additionally, three of the four findings the team documented during this inspection were assigned leadership-related cross-cutting aspects due to licensee management's failure to provide adequate oversight of some station activities. One of these findings documents a failure to preclude repetition of a significant condition adverse to quality, which recurred-at least in part-due to failures to correct gaps in leadership engagement after these gaps were identified during a September 2013 root cause evaluation. This finding is discussed in Section 4OA2.5.c, below.

The team also identified a deficiency in the licensee's handling of NRC-documented issues. After the September 2014 change to the corrective action program, Procedure EN-LI-102, "Corrective Action Program," required that all findings and violations documented in NRC inspection reports be classified as Category B or higher, requiring at least an apparent cause evaluation. Prior to the September 2014 change, there was only a single very narrow exception allowing such CRs to be classified at a lower level. In reviewing the licensee's follow-up actions to a sample of NRC-documented issues, the team noted that in 10 of 17 cases, the licensee had not performed an apparent cause evaluation. The team noted that the licensee's failure to perform a cause evaluation in these cases resulted in a missed opportunity for the licensee to determine why licensee personnel were not self-identifying issues before they were identified by the NRC. The team determined that this was a minor performance deficiency because it did not adversely affect a cornerstone objective and it was unlikely to lead to a more significant safety concern if uncorrected. The licensee had evaluated all of the mischaracterized issues-albeit at a lower level than required by procedure-prior to the team identifying this issue. The licensee entered this minor performance deficiency into the corrective action program as CR-RBS-2015-04790.

Overall, the team determined that the licensee's process for screening and prioritizing issues that had been entered into the corrective action program supported nuclear safety. The licensee's operability determinations were generally consistent, accurately documented, and completed in accordance with procedures.

3. Effectiveness of Corrective Actions

In general, the corrective actions identified by the licensee to address adverse conditions were effective when the adverse conditions were equipment related.

However, the team noted that the licensee did not always develop and implement effective corrective actions for organizational and programmatic issues.

As discussed in the Prioritization and Evaluation section above, the licensee often identified organizational and programmatic causes during root and apparent cause evaluations. However, the licensee did not develop and implement comprehensive corrective actions for these programmatic causes, especially when the causes were related to leadership behaviors.

Further, the team identified that the licensee had repeatedly identified gaps in operator performance related to operator fundamentals. These gaps resulted in plant transients such as run-backs and scrams, loss of configuration control events such as component mispositionings, and errors associated with clearance tags. Corrective actions developed and implemented after these adverse trends were identified repeatedly failed to provide sustainable improvement to prevent future events due to the same or similar causes. This performance deficiency is further discussed as a finding in section 4OA2.5.c below.

Overall, despite these gaps, the team concluded that the licensee generally identified effective corrective actions for the problems evaluated in the corrective action program. The licensee generally implemented these corrective actions in a timely manner, commensurate with their safety significance, and reviewed the effectiveness of the corrective actions appropriately.

.2 Assessment of the Use of Operating Experience

a. Inspection Scope

The team examined the licensee's program for reviewing industry operating experience, including reviewing the governing procedures. The team reviewed a sample of 25 industry operating experience communications and the associated site evaluations to assess whether the licensee had appropriately assessed the communications for relevance to the facility. The team reviewed assigned actions to address these communications to determine whether they were appropriate. The inspectors also reviewed a sample of ten fleet corrective actions for assessment and communication to

site workers.

b. Assessment Overall, the team determined that the licensee appropriately evaluated industry operating experience for its relevance to the facility. Operating experience information was incorporated into plant procedures and processes as appropriate. The team determined that the licensee appropriately evaluated industry operating experience when performing root cause analyses and apparent cause evaluations.

The licensee incorporated both internal and external operating experience into lessons learned for training and pre-job briefs. However, the inspectors identified a weakness in which only significant operating experience was reviewed during work planning and problem resolution while lower-level operating experience was reviewed during root cause analysis and apparent cause evaluations. This weakness lead to an untimely assessment of an adverse trend with post-ma intenance testing of critical components, as documented in Section 4OA2.5.d below.

Procedure EN-OE-100, "Operating Experience Program," provides a process by which industry operating experience is evaluated and disseminated at the facility. The licensee receives industry operating experience data packages with selected information flagged as "significant." The significant operating events are evaluated, addressed, and placed into the corrective action program. The less significant events are reviewed and, if not elevated for additional evaluation, are entered into PCRS for future data mining. The team determined that the licensee was not effectively evaluating and incorporating potential lessons learned using the lower-level operating experience trends to prevent events at River Bend. The team noted multiple examples where, following an event or the identification of a condition requiring a cause evaluation, the licensee's cause

evaluators identified a several similar events or events with similar causes at other Entergy facilities. Had the licensee proactively identified these similar events through its operating experience program or while incorporating lessons learned into work packages, the station may have been able to develop improvements to programs, processes, or procedures that may have precluded the event from occurring at River Bend.

.3 Assessment of Self-Assessments and Audits

a. Inspection Scope

The team reviewed a sample of licensee self-assessments and audits to assess whether the licensee was regularly identifying performance trends and effectively addressing them. The team also reviewed audit reports to assess the effectiveness of assessments in specific areas. The specific self-assessment documents and audits reviewed are listed in Attachment 1.

b. Assessment Overall, the team concluded that the licensee had an effective self-assessment and audit process. The team determined that self-assessments were self-critical and thorough enough to identify deficiencies.

.4 Assessment of Safety-Conscious Work Environment

a. Inspection Scope

The team interviewed 39 individuals in five focus groups. The purpose of these

interviews was (1) to evaluate the willingness of licensee staff to raise nuclear safety issues, either by initiating a condition report or by another method, (2) to evaluate the perceived effectiveness of the corrective action program at resolving identified problems, and (3) to evaluate the licensee's safety-conscious work environment (SCWE). The focus group participants included personnel from security, radiation protection, chemistry, engineering (design and systems), operations, production, and maintenance. At the team's request, the licensee's regulatory affairs staff selected the participants blindly from these work groups, based partially on availability. To supplement these focus group discussions, the team interviewed the employee concerns program coordinator to assess her perception of the site employees' willingness to raise nuclear safety concerns. The team reviewed the employee concerns program case log and select case files. The team also reviewed the minutes from the licensee's most recent safety culture monitoring panel meetings.

b. Assessment 1. Willingness to Raise Nuclear Safety Issues All individuals interviewed indicated that they would raise nuclear safety concerns. All felt that their management was receptive to nuclear safety concerns and was willing to address them promptly. All of the interviewees further stated that if they were not satisfied with the response from their immediate supervisor, they had the ability to escalate the concern to a higher organizational level. Most expressed positive experiences after raising issues to their supervisors. All expressed positive experiences documenting most issues in condition reports.

2. Employee Concerns Program

All interviewees were aware of the employee concerns program. Most explained that they had heard about the program through various means, such as posters and training. With the exception of one group, all interviewees stated that they would use employee concerns if they felt it was necessary. All except for that same group expressed confidence that their confidentiality would be maintained if they brought issues to employee concerns.

3. Preventing or Mitigating Perceptions of Retaliation When asked if there have been any instances where individuals experienced retaliation or other negative reaction for raising issues, all individuals interviewed stated that they had neither experienced nor heard of an instance of retaliation, harassment, intimidation or discrimination at the site.

.5 Findings

a. Failure to recognize violations of co ntamination control requirements as adverse conditions

Introduction.

The team identified a Green finding for a failure to document adverse conditions associated with radiological housekeeping or contamination controls in the corrective action program as required by procedure. The licensee's procedures did not adequately provide examples of deficient radiological practices as adverse conditions.

Description.

On multiple inspector facility tours from May 27 through June 11, 2015, the inspectors identified poor radiological housekeeping practices in which contaminated materials were not appropriately controlled within contaminated areas. For example, contaminated material was observed spilling out of a radiological trash bag over grated flooring, miscellaneous tools were observed crossing posted contaminated areas, and unsecured ropes and hoses were noted crossing the posted boundaries.

In Procedure EN-LI-102 Attachment 9.2, the licensee identifies as adverse conditions items which are "violations of procedures or regulations that are intended to satisfy 10CFR19, 10CFR20, or other applicable federal regulation." Radiological housekeeping deficiencies are violations of procedures intended to satisfy 10 CFR Part 20, which are also required by Technical Specification 5.4.1(a).

Technical Specification 5.4.1(a) requires the implementation of procedures listed in Appendix A to Regulatory Guide 1.33, Revision 2. These include radiation protection procedures for contamination control. The licensee implements this requirement with Procedure EN-RP-100, "Radiation Worker Expectations." Sections 5.6[1](l, n, and o) of Revision 9 of this procedure require radiation workers to keep work areas neat and orderly during work, to ensure work areas are cleaned up after job completion, to contact

Radiation Protection prior to placing anything across a contamination area boundary, and to secure all cords, hoses, wires, etc. that cross contamination area boundaries. Further, Section 5.6[2](o) requires employees to "Maintain neat and orderly work areas to prevent contamination spread within Contamination Areas and across Contamination Area boundaries." The team determined that because the radiological housekeeping deficiencies constituted violations of procedures both required by the station's license and intended to implement requirements of 10 CFR Part 20, these were adverse conditions which required initiation of a condition report.

During discussions of the licensee's procedural definition of adverse conditions, the inspectors identified that either the corrective action program did not provide adequate guidance regarding deficient radiological practices, or station personnel did not understand the guidance provided. The adverse conditions were subsequently documented in the corrective action program as CR-RBS-2015-03877, -04265, and -04298. While each individual violation of EN-RP-100 was a minor performance deficiency in itself, the programmatic failure to recognize and document these violations as adverse conditions was a separate and more significant performance deficiency.

Analysis.

The licensee's failure to document adverse conditions in the corrective actions program as required by procedure was a performance deficiency. This constituted a programmatic weakness in the licensee's corrective action program to document adverse conditions associated with inadequate radiological practices. This performance deficiency is more than minor because it is associated with the program and process attribute (contamination control) of the occupational radiation safety cornerstone and adversely affected the cornerstone objective to ensure adequate protection of the worker health and safety from exposure to radiation from radioactive material during routine civilian nuclear reactor operation. Using IMC 0609, Appendix C, "Occupational Radiation Safety Significance Determination Process," dated August 19, 2008, the inspectors determined the finding to be of very low safety significance because it was not an as low as reasonably achievable (ALARA) issue, there was no overexposure or substantial potential for overexposure, and the licensee's ability to assess dose was not compromised. This finding has a cross-cutting aspect in resources component of the human performance area because the licensee's corrective action procedures were not adequate to include deficient radiological practices as an adverse condition (H.1).

Enforcement.

This finding does not involve enforcement action because no violation of a regulatory requirement was identified. The licensee documented the finding in the corrective action program as CR-2015-04791. Because the finding does not involve a violation and is of very low safety significance (Green), it is being characterized as a finding: FIN 05000485/2015008-01, "Failure to Recognize Violations of Contamination Control Requirements as Adverse Conditions."

b. Failure to promptly document adverse conditions in the corrective action program

Introduction.

The team identified a Green finding for multiple examples of failures to timely document adverse conditions, as defined by its corrective action program procedures, in condition reports. The team determined that these multiple failures, which were spread across multiple departments and programs, represented a programmatic deficiency in training of personnel and communication of expectations for compliance with corrective action program requirements.

Description.

The licensee's corrective action program is described in Procedure EN-LI-102, "Corrective Action Program." This procedure defines an adverse condition as:

A general term which [sic] includes Conditions Adverse to Quality plus conditions related to the following: . . . (a) De sign basis (b) Licensing basis (c) NRC regulations and commitments (d) State and federal regulations other than NRC . . . (e) Key elements of reactor oversight process (ROP) (f) Equipment required to support safety related equipment as defined by the functionality assessment process.

Section 5.2[1](b) requires all employees and contractors to initiate condition reports for adverse conditions, and encourages them to initiate CRs for other issues that do not meet the definition of adverse condition. Section 5.2[1](d) requires any individual discovering an adverse condition "to ensure . . . The condition is promptly documented in a Condition Report."

The team identified multiple examples in which licensee personnel failed to promptly initiate a condition report following discovery of an adverse condition:

• On June 10, 2015, during a discussion with the team, a licensee manager stated that an adverse trend in housekeeping, including radiological housekeeping, had been identified on June 4. After the team requested the condition report documenting the adverse trend, the manager generated the condition report on June 11.

• Condition report CR-RBS-2015-04071 was generated following a failed effectiveness review of a corrective action to preclude repetition of gaps in operator fundamentals (CR-RBS-2014-05022; see discussion in Section 4OA2.5.c below). The licensee's condition review group (CRG) processed this condition report on June 9, 2015, assigning category D and closing it to actions being taken under another condition report; however, this

other condition report did not address the causes of the failed effectiveness review. After identification by the team on June 12, CR-RBS-2015-04071 was upgraded to category C at CRG on June 22. No new condition report was initiated to document the inappropriate initial screening.

• On June 30, 2015, NRC inspectors performing another inspection activity identified an adverse condition related to cybersecurity. Licensee security personnel immediately corrected the condition, but failed to initiate a condition report until prompted by the NRC senior resident inspector the following morning.

• While performing reviews of corrective actions for a degrading emergency core cooling system line fill pump, the inspectors identified incorrect flow rates used by operators to estimate coolant flow to the reactor core during accident conditions.

The emergency operating procedure did not list pump flow rates using the specific system operating curves, which may have misled operators during an event. The inspectors brought these concerns to the plant staff during the first week of the inspection (June 8-12, 2015), however no condition report was written until questioned by the inspectors three weeks later on July 1.

Analysis.

The licensee's failure to promptly document multiple adverse conditions in condition reports as required by Procedure EN-LI-102 was a performance deficiency. This performance deficiency was more than minor because if left uncorrected in could lead to a more significant safety or security concern. Specifically, it could result in the licensee failing to promptly correct an adverse condition, which could lead to more significant consequences. This finding was associated with multiple cornerstones; the team determined that the mitigating systems cornerstone was the most appropriate for screening. Using Inspection Manual Chapter 0609 Appendix A, the team determined that this finding was of very low safety significance (Green) because it did not cause the loss of operability or function of any system or train and did not affect external event mitigation. This finding has a training cross-cutting aspect in the human performance cross-cutting area (H.9) because the licensee failed to ensure that individuals were adequately trained to ensure an understanding of standards.

Enforcement.

This finding does not involve enforcement action because no violation of a regulatory requirement was identified. Because this finding does not involve a violation and is of very low safety significance, it is identified as FIN 05000458/2015008-02, "Failure to Promptly Document Adverse Conditions in the Corrective Action Program."

c. Failure to preclude repetition of consequential gaps in operator performance

Introduction.

The team identified a Green non-cited violation of 10 CFR Part 50 Appendix B Criterion XVI for the licensee's failure to preclude repetition of consequential gaps in operator performance. In August 2013, the licensee identified that gaps in operator fundamentals, a significant condition adverse to quality, had caused or contributed to plant transients earlier that year. The licensee's corrective actions were inadequate to prevent gaps in operator fundamentals from again causing or contributing to plant transients in late 2014.

Description.

On August 1, 2013, the licensee initiated condition report CR-RBS-2013-05180 "to document areas of declining performance within the Operations Department." One of the areas identified in which performance declining was "operator fundamentals." The condition report noted that "weaknesses in application" of operator fundamentals had resulted in several operational events including a flow-control valve runback and component mispositionings. The licensee evaluated this as a significant condition adverse to quality and initiated a root cause evaluation.

The licensee's root cause evaluators determined that root cause of the decline in operator performance was that "operations department workers and leaders do not consistently demonstrate high standards in all activities." The root cause evaluators recommended two corrective actions to preclude repetition of this significant condition

adverse to quality by eliminating the root cause. First, develop and implement guidance to provide for additional shift manager oversight in the control room during high activity periods; and second, develop and implement guidance to require that one field observation per shift be observed and critiqued against the operator fundamentals. After incorporating comments made by the corrective action review board-the station's leadership oversight of the corrective action process for significant issues-the root cause was changed to state, "Crew performance monitoring following the departmental realignments after RF-17 was insufficient in identifying gaps in operator fundamentals." The corrective action to preclude repetition of this condition was revised as follows:

Develop and implement a protocol to cause additional monitoring of crew performance. This protocol will include event and condition based triggers to prompt the additional monitoring and guidance on how the monitoring will be documented. . . . Include this material in OSP-0222, "Operations General

Administrative Guidelines."

To implement this corrective action, rather than revising the controlled OSP-0222 procedure as directed by the CARB, operations staff instead added guidance to the Operations Standards and Expectations. The Operations Standards and Expectations is an uncontrolled "guideline"; it had been revised 34 times in the 18-month period between September 2013 and March 2015. This change to the corrective action to preclude repetition (CAPR) was approved by the operations manager with no oversight by the CARB, contrary to the direction of Procedure EN-LI-102, revision 21, steps 4.0[9](f)and 5.7[8], which required CARB review and approval for the replacement of CAPRs.

Also contrary to the requirements of Procedure EN-LI-102, 1 there is no indication that these added guidelines, currently contained on page 78 of the 103-page document, are intended to implement a CAPR. Additionally, EN-LI-118, "Root Cause Evaluation Process," includes guidance that neither "training" nor "reinforcing or clarifying expectations" are appropriate actions for CAPRs "unless done systematically."

2 The same section of EN-LI-118 required that CAPRs be "sustainable" actions that would "clearly result in long-term correction." The actions implemented by the licensee failed to meet these corrective action program requirements.

The licensee's root cause evaluators also determined that one of the contributing causes of declining performance was that "operations leaders failed to detect and correct low level behavioral issues." The root caus e evaluators recommended seven corrective actions to address this contributing cause. These included the addition of specific requirements for shift managers to perform formal observations of crew performance and report observations to the leadership team, the addition of specific requirements for other management observation of crew performance, and several actions to formalize the reporting process of these observations. Following review of the root cause evaluation by the CARB, this contributing cause was removed and all of these corrective actions were deleted. The team noted that several of these canceled actions would have enhanced monitoring by leadership and would have met the procedural requirements for CAPRs.

In April 2014, the licensee performed an effectiveness review of the CAPR under LO-RLO-2013-00107, which determined that the CAPR had been effective. The effectiveness review documented that the guidance had been added to the Operations 1 Step 5.9[1](d) of revisions 21 and 22, which were in effect when the CAPR was initiated (9/13/13) and implemented (11/18/13), states, "For CAPRs that are credited as being implemented by procedure actions or requirements the applicable steps in the associated procedure should be annotated or flagged as commitments in accordance with EN-AD-101 and applicable site procedures." Revision 24, which was in effect at the time of the inspection, contains the same requirem ent at step 5.6[1](c).

2 This guidance was in Attachment 9.9 § A.3 of revision 18, which was in effect when the CAPR was initiated, and step 5.12[10](e) of revision 19, which was in effect when the CAPR was implemented and when the effectiveness review was performed.

Standards and Expectations rather than OSP-0022, but did not document this as a deficiency. The team noted that after an assistant operations manager had initially changed the CAPR without CARB approval, this change had been reviewed by the operations manager to approve completion of the action, the corrective action program manager to approve closure of the condition report, and again by the operations department during its effectiveness review. None of these reviews identified that the CAPR had been inappropriately changed.

In October 2014, the licensee's operations department documented in CR-RBS-2014-05022 an adverse trend in operations department performance, which included several errors "tied to operator fundamentals." The licensee determined that one of the apparent causes for this decline in performance was "a deficiency in the Operations Fundamental of Control." Corrective actions for this apparent cause again involved several revisions to the Operations Standards and Expectations. In the apparent cause evaluation, the licensee identified that the effectiveness measures used to evaluate the CAPR from the August 2013 root cause evaluation had been inappropriate: "Absence of events does not equate to better performance." The apparent cause evaluators documented that for the August 2013 root cause, "More appropriate actions may have been to require managers to perform a certain number of observations on fundamentals, structure the observations so that they are critical, development of [sic] a matrix to track those observations, analysis of [sic] the data to identify weaknesses, then to adjust as necessary going forward so that the observation program is being effectively used." The inspectors noted that these actions suggested by the apparent cause evaluators were very similar to the proposed actions that the CARB had rejected. The corrective actions for the apparent cause evaluation included the implementation of several of these "more appropriate actions."

In January 2015, the licensee's performance improvement department initiated CR-RBS-2015-00153, which again documented an adverse trend in operations performance. This condition report identified the adverse trend as a result of several station events that occurred in the third quarter of 2014, including two reactor scrams and a reactor recirculation flow-control valve run-back. The licensee performed an apparent cause evaluation and a common cause analysis to evaluate this adverse trend. The cause evaluators identified four apparent causes for this adverse trend. Among these were (1) leaders and managers were not reinforcing standards or holding themselves accountable to those standards, and (2) leaders, managers, and workers were not rigorously applying sound fundamentals to everyday work preparation and execution. To correct the adverse trend and its apparent causes, the licensee developed and began implementing a comprehensive station recovery plan, which was issued on May 6, 2015, and is being implemented in accordance with Fleet Procedure EN-FAP-OM-020, "Comprehensive Recovery Plans."

The team noted that the licensee now appears to have identified appropriate causes for the continued challenges to operations performance. The licensee's recovery plan contains actions to correct these causes that appear to be comprehensive, with success criteria that appear measurable and appropriate. However, this finding is NRC identified because the licensee failed to address the repeated unsuccessful corrective actions, the failures to follow corrective action program procedures, or the evidence of potential inappropriate CARB direction regarding determination of causes and development of corrective actions following initial identification of the issue.

Analysis.

The failure to correct and preclude repetition of consequential gaps in operator fundamentals, a significant condition adverse to quality, as required by 10 CFR 50 Appendix B Criterion XVI, was a performance deficiency. This performance deficiency was more than minor because it affected the human performance attribute of the initiating events cornerstone objective to limit the likelihood of events that upset plant stability and challenge critical safety function. Using Inspection Manual Chapter 0609 Appendix A, the team determined that this finding was of very low safety significance (Green) because it did not involve the loss of mitigation equipment or a support system. This finding has a field presence cross-cutting aspect in the human performance cross-cutting area (H.2) because leaders failed to provide oversight of work activities and to promptly correct deviations from standards and expectations.

Enforcement.

Title 10 of the Code of Federal Regulations, Part 50, Appendix B, Criterion XVI requires that for significant conditions adverse to quality, the licensee establish measures that assure that the cause of the condition is determined and corrective action taken to preclude repetition. Contrary to this requirement, from August 2013 through January 2015, the licensee failed to establish measures that assured that the cause of a significant condition adverse to quality was determined and that corrective actions were taken to preclude repetition. Specifically, in August 2013, the licensee identified that gaps in operator fundamentals had led to plant transients, which was a significant condition adverse to quality. The licensee's corrective actions did not ensure that these gaps did not recur; in January 2015, the licensee identified that the recurrence of these gaps had led to additional plant transients in late 2014. At the conclusion of this inspection, the licensee was developing and im plementing actions to provide oversight from station leadership that would communicate and reinforce operations standards and expectations; the licensee intends to establish measures to ensure improvements resulting from these actions are sustainable. Because this violation was of very low safety significance and was entered into the licensee's corrective action program as CR-RBS-2015-04794, it is being treated as a non-cited violation in accordance with Section 2.3.2 of the NRC Enforcement Policy: NCV 05000458/2015008-03, Failure to Preclude Repetition of Consequential Gaps in Operator Performance.

d. Failure to identify an adverse trend in the performance of post-maintenance testing

Introduction.

The team identified a Green non-cited violation of 10 CFR Part 50 Appendix B Criterion XVI, "Corrective Action," for the licensee's failure to identify and correct a condition adverse to quality. Specifically, the licensee failed to identify an adverse trend in the performance of post maintenance testing on high-critical components. The licensee did not identify a trend or evaluate whether multiple equipment or component failures that in some instances complicated and challenged operators response to a scram were related to maintenance, or if there had been an opportunity to identify the issues through post-maintenance testing prior to returning equipment to service.

Description.

During the problem identification and resolution inspection, the team identified five examples of high-critical components that failed to meet their function following maintenance, and in some cases complicated recovery following a scram. The licensee had failed to identify these multiple failures as an adverse trend:

• In May and June 2014, EC50035 implemented a chiller heater control circuit modification, and three chiller ECs (50103, 50104, and 50105) that modified the oil heater for HVK-CH21A, B, and C by disabling its operation while chiller is running. Following this design change, A and B oil heater logic contained an error that prevented the chiller oil heater from energizing while the chiller was in standby. The licensee determined that the post-modification plan had been inadequate because when B was returned to service, all required functions of the chiller and oil heater had not been verified to be functioning properly.

(CR-RCS-2015-02660)

• From December 12-31, 2014, reactor feedwater pumps failed to start on five different occasions due to their breakers failing to close. The licensee experienced ten failures to close when required in the last five years, with eight of these failures being associated with the supply breaker (NPS-SWG1B-ACB28)for reactor feedwater pump 1B (FWS-P1B). This also contributed to complicating the December 25, 2014, scram recovery. The licensee modified maintenance procedures to correct this condition. The licensee documented this issue

in CR-RBS-2015-06696.

• On January 9, 2013, the main control room received two alarms after the relay calibration of C33A-K10, which was part of the low-level setpoint setdown circuitry, due to inadequate post-maintenance testing. The licensee documented this condition CR-RBS-2013-07482.

• On December 6, 2014, the Division 2 reactor protection system (RPS) bus de-energized unexpectedly. This event involved the loss of RPS B bus voltage due to a loss of the B RPS motor-generator set when the Electrical Protection Assembly (EPA) breakers 3B/3D and the generator output breaker for RPS B were found tripped. The event occurred approximately 25 hours2.893519e-4 days <br />0.00694 hours <br />4.133598e-5 weeks <br />9.5125e-6 months <br /> after the Division 2 RPS motor-generator had been aligned to the bus following voltage regulator replacement. The loss of RPS Bus B caused a Division 2 scram. The licensee addressed this issue in CR-RBS-2014-06233.

• In October 2014, the license replaced the startup feed regulating valve controller, but failed to perform adequate post-maintenance. As a result, an unidentified latent condition caused a failure of the controller, which resulted in complicating operators' recovery from a plant scram on December 25, 2014. In CR-RBS-2015-02812, the licensee identified that work order WO 52571888 had been issued to replace the valve during refueling outage RF-18, but had not been completed. Specifically, a task within the work order to perform online tuning had not been performed and the tuning following the card replacement could not be verified.

The team found that the failure to identify a programmatic trend reduced the reliability of multiple high-critical components whose failure could result in a significant impact to safe and reliable plant operation.

Analysis.

The licensee's failure to promptly identify and correct a condition adverse to quality, as required by 10 CFR Part 50 Appendix B Criterion XVI, was a performance deficiency. The licensee failed to identify an adverse trend in the performance of post maintenance testing on high-critical components. The performance deficiency was more than minor, and therefore a finding, because it was associated with the equipment performance attribute of the initiating event cornerstone and adversely affected the cornerstone objective to limit the likelihood of events that upset plant stability and challenge critical safety functions during shutdown as well as power operations.

Specifically, the failure to identify a programmatic trend that reduced the reliability of multiple high-critical components whose failure could result in a significant impact to safe and reliable plant operation. Using Inspection Manual Chapter 0609, Appendix A, the team determined that this finding was of very low safety significance (Green) because it did not involve the loss of mitigation equipment or a support system. The finding has a human performance cross-cutting aspect associated with resources, in that the licensee leaders failed to ensure that personnel, equipment, procedures, and resources are available and adequate to support nuclear safety (H.1). Specifically, the licensee failed to evaluate a trend in degraded critical component conditions or malfunctions for multiple high critical components.

Enforcement.

Title 10 CFR Part 50, Appendix B, Criterion XVI, "Corrective Action," states, in part, that measures shall be established to assure that conditions adverse to quality are promptly identified and corrected. Contrary to the above, the licensee failed to establish measures to assure that a condition adverse to quality was promptly identified and corrected. Specifically, the licensee failed to identify and correct an adverse trend in the performance of post-maintenance testing on high-critical components. The licensee addressed this deficiency by entering this condition into this corrective action program. Because this violation is of very low significance (Green) and was entered into the licensee's corrective action program as CR-RBS-2015-04795, this violation is being treated as a non-cited violation (NCV), consistent with Section 2.3.2 of the Enforcement Policy: NCV 05000458/2015008-04, "Failure to Identify an Adverse Trend in the Performance of Post Maintenance Testing on High Critical Components."

.6 Review of Open Items

(Closed) Licensee Event Report (LER) 05000458/2014-006-00, Automatic Reactor Scram and Primary Containment Isolation Due to Loss of Power on the Division II Reactor Protection System with a Concurrent Division I Half-Scram

The licensee event report described a reactor scram that occurred on December 25, 2014, while the plant was operating at approximately 85 percent power. This event resulted from the loss of power on the Division II reactor protection system bus in conjunction with a pre-existing half scram on Division I. Four minutes after the scram, reactor water level increased to the Level 8 setpoint, causing the running main feedwater pump to trip. Operators attempted to re-start main feedwater pump C, but its supply breaker failed to close. The station started main feedwater pump A. The startup feedwater regulating valve should have opened to establish control, but the valve failed to open, and reactor pressure vessel level decreased slightly below the level 3 setpoint, resulting in a second scram signal. The station placed C feedwater regulating valve in service, and restored feed, and raised reactor pressure vessel water level above the Level 3 setpoint, and maintained vessel level in a normal shutdown band.

The resident inspectors responded to the site, interviewed plant personnel, and reviewed plant parameters and conditions. One of two special inspection teams was chartered to investigate the particulars of this scram and began inspection activities onsite on January 26, 2015. The site performed an apparent cause evaluation (CR-RBS-2014-06602) that was rejected by the CARB based on the quality and facts associated with the investigation, which did not fully address the condition identified during the reactor scram (CR-RBS-2015-01615). Condition Report CR-RBS-2015-02812 documents that Work Order WO 52571888 to replace the Start-up Feedwater Regulating Valve, which was performed in refueling outage RF-18, was closed, but had not been completed. Task 03 to perform online tuning had not been performed, and the tuning following the card replacement could not be verified. The problem identification and resolution team reviewed the licensee's design control, post-maintenance testing, and the overall replacement of the controller for the startup feed regulating valve. The performance deficiencies and other significance and enforcement aspects of the issues related to this event are discussed in Special Inspection Report 05000458/2015008 and in Section 4OA2.5.d above. [Licensee Even Report (LER)05000458/2014-006-00 is closed.]

4OA6 Meetings, Including Exit

Exit Meeting Summary

On July 2, 2015, the inspectors presented the inspection results to Mr. Eric Olson, Site Vice President, and other members of the licensee staff. The licensee acknowledged the issues presented. The licensee confirmed that any proprietary information reviewed by the inspectors had been returned or destroyed.

ATTACHMENTS: 1. Supplemental Information 2. Information Request A1-

SUPPLEMENTAL INFORMATION

KEY POINTS OF CONTACT

Licensee Personnel

C. Blankenship, Sr. HP/Chemistry Specialist

T. Brumfield, Director, Regulatory and Performance Improvement

P. Chapman, ILD Power, Inc.

L. Creekbaum, ECP Coordinator

K. Crissman, Sr. Manager, Maintenance

M. Freeman, Sr. CAA Specialist

R. Horn, Radiation Protection Technician

K. Huffstatler, Sr. Licensing Specialist

K. Klamert, Sr. Engineer

R. Leasure, Manager (Acting), Radiation Protection

P. Lucky, Manager, Performance Improvement

R. Mayeux, ILD Power, Inc.

J. Reynolds, Sr. Manager, Operations

E. Roan, Sr. Staff Engineer

G. Wascom, Sr. CAA Specialist

NRC Personnel

J. Sowa, Senior Resident Inspector, River Bend Station

LIST OF ITEMS OPENED, CLOSED, AND DISCUSSED

Opened and Closed

05000485/2015008-01 FIN Failure to Recognize Violations of Contamination Control Requirements as Adverse Conditions (Section 4OA2.5.a)

05000458/2015008-02 FIN Failure to Promptly Document Adverse Conditions in the Corrective Action Program (Section 4OA2.5.b)

05000458/2015008-03 NCV Failure to Preclude Repetition of Consequential Gaps in Operator Performance (Section 4OA2.5.c)

05000458/2015008-04 NCV Failure to Identify an Adverse Trend in the Performance of Post Maintenance Testing on High Critical Components

(Section 4OA2.5d)

Closed

05000458/LER-2014-006-00 LER Automatic Reactor Scram and Primary Containment Isolation

Due to Loss of Power on the Division II Reactor Protection System with a Concurrent Division I Half-Scram

(Section 4OA2.6.b)

Discussed

05000458/2013007-01 VIO Failure to Resolve Noncompliance Associated with Multiple Spurious Operations in a Timely Manner (Section 4OA2.6.a)

LIST OF DOCUMENTS REVIEWED

Procedures

Number Title Revision

EIP-2-001 Classification of Emergencies 25

EN-DC-117 Post Modification Testing and Special Instructions 7

EN-DC-203 Maintenance Rule Program 3

EN-DC-204 Maintenance Rule Scope and Basis 3

EN-DC-205 Maintenance Rule Monitoring 5

EN-DC-206 Maintenance Rule (a)(1) Process 3

EN-DC-345 Critical Component Failure Determination 3

EN-FAP-LI-001 Condition Review Group (CRG) 5

EN-FAP-LI-003 Corrective Action Review Board (CARB) Process 16

EN-FAP-LR-007 Evaluation of Aging Management Programs 6

EN-FAP-OP-006 Operator Aggregate Impact Index Performance Indicator 2

EN-FAP-WM-011 Work Planning Standard 3

EN-HU-101 Human Performance Program 15

EN-HU-102 Human Performance Traps and Tools 13

EN-HU-105 Human Performance - Managed Defenses 15

EN-LI-102 Corrective Action Program 21-24

EN-LI-102-02 CR Closeout Review 9

EN-LI-104 Self-Assessment and Benchmark Process 11

EN-LI-118 Cause Evaluation Process 18-21

EN-LI-118-03 Barrier Analysis 1

EN-LI-118-11 Why Staircase 0

EN-OE-100 Operating Experience Program 23

EN-OE-100-01 IER Level 1 and Level Evaluations and Effectiveness Reviews 1

EN-OE-100-02 Operating Experience Evaluations 1

EN-OP-115 Conduct of Operations 15

EN-RP-100 Radiation Worker Expectations 9

EN-RP-102 Radiological Controls 4

EN-RP-108 Radiation Protection Posting 15

Procedures

Number Title Revision

EN-RP-121 Radioactive Material Control 10

EN-WM-100 Work Request (WR) Generation, Screening and Classification

EN-WM-102 Work Implementation and Closeout 9

EN-WM-105 Planning 15

EN-WM-107 Post Maintenance Testing 4

EOP-0001 Emergency Operating Procedure - RPV Control 026

OSP-0022 Operations General Administrative Guidelines 77, 78, 82

RBNP-097 Control and Use Of Temporary Hoses 8

RPP-0005 Radiological Postings 29

RSP-0008 Offsite Dose Calculation Manual (ODCM) 14

STP-000-6606 Section XI Safety and Relief Valve Testing 025

STP-204-6301 DIV I LPCI (RHR) Pump and Valve Operability Test 026

STP-204-6302 DIV II LPCI (RHR) Pump and Valve Operability Test 029

STP-204-6303 DIV I RHR Quarterly Valve Operability Test 021

STP-204-6304 DIV II RHR Quarterly Valve Operability Test 022

STP-204-6501 DIV I ECCS Check Valve Operability Test 002

STP-204-6502 DIV II ECCS Check Valve Operability Test 002

STP-204-6603 RHR System Refuel Pressure Isolation Valve Test 006

STP-204-6604 RHR System Refuel Valve Operability Test 301

STP-204-6801 DIV I ECCS Cold Shutdown Valve Operability Test 012

STP-204-6802 DIV II ECCS Cold Shutdown Valve Operability Test 010

TSP-0018 Loop C RHR System Leak Test 5B

Training Documents Number Title Revision

RLP-STM-0204 Operations Training - Residual Heat Removal (RHR)

System 2

RPPT-STM-0204-ILO RHR System 0

Training Documents Number Title Revision

RPPT-STM-0204-LOR Residual Heat Removal 0

RSMS-OPS-314 Simulator Training - Saboteur Loss of Inventory with SDC in Service

RSMS-OPS-0321 Simulator Training - RPV Head Off - Refueling - LOP - Fuel Bundle in IFTS - Loss of SDC

Other Documents

Number Title Revision/Date Entergy Quality Assurance Program Manual 29

On-Line Operations Aggregate Index (OAI) April 30, 2015

On-Line Operations Aggregate Index (OAI) May 31, 2015

On-Line Operations Aggregate Index (OAI) June 30, 2014

On-Line Operations Aggregate Index (OAI) August 27, 2014

On-Line Operations Aggregate Index (OAI) September 30, 2014 On-Line Operations Aggregate Index (OAI) October 31, 2014

On-Line Operations Aggregate Index (OAI) November 30, 2014

On-Line Operations Aggregate Index (OAI) November 30,2014

On-Line Operations Aggregate Index (OAI) December 3, 2014

River Bend Recovery Plan 00

River Bend Station Operations Standards and Expectations

53, 87

System 410 and 200 (a)(1) History Summary July 1, 2015

Total Operations Aggregate Index (OAI)

July 31, 2015

Total Operations Aggregate Index (OAI) February 28, 2015

Total Operations Aggregate Index (OAI) March 31, 2015

Total Operations Aggregate Index (OAI) July 31, 2014

Total Operations Aggregate Index (OAI) July 29, 2014

Total Operations Aggregate Index (OAI) August 31, 2014

Total Operations Aggregate Index (OAI) September 24, 2014

Total Operations Aggregate Index (OAI) December 31, 2014

Total Operations Aggregate Index (OAI) August 20, 2014

Other Documents

Number Title Revision/Date Total Operations Aggregate Index (OAI) September 17, 2014 Total Operations Aggregate Index (OAI) December 10, 2014

00108828 Procurement Engineering Evaluation for Manual Control Unit Feedwater System (C33-R602-2/Manual)

July 16, 2012

00108829 Procurement Engineering Evaluation for Unit, Logic (C33-R602-3/Logic)

July 16, 2012

00108834 Procurement Engineering Evaluation for Control Unit (C33-R602-1/Auto)

July 16, 2012 G13.18.2.6*183 Subsystem Fill Pumps Calculation of TDH, NPSH, and Heat Dissipation Capabilities

LO-RLO-2013-

00104 Operating Experience Program Assessment January 17, 2014 LO-RLO-2014-

00103 Radioactive Shipping Documentation April 15, 2015 WTRBS-2015-

213 Radiation Protection Recover Plan May 6, 2015

Operating Experience

Documents Number Title

CR-ANO-C-2013-3001 2013 INPO Evaluation Area for Improvement (OP.1-1) During simulated events, operators and supervisors are not proficient in the implementation of some Emergency Operating Procedure (EOP) strategies

CR-ANO-C-2014-0022 INPO AFI on Operation's Errors During Plant Configuration Changes

CR-CNS-2014-03926 Operator knowledge gaps

CR-IP2-2014-02351 INPO 2103 E&A Performance Deficiency:

RP

CR-JAF-2014-1990 2014 WANO AFI (LF.1-2):

In a few cases, managers and supervisors are not reinforcing standards and expectations to improve behaviors necessary to accelerate station improvement

CR-PNP-2014-1080 Unexpected Voltage in Fuse Block Holder

EPRI-21-TIN-2014-01 Performance Predictive Methodology (PPM) Motor Operated Valve (MOV) Software (versions 1.0 through 3.5)

GE-TIL-1920 Recommendations for NDT and Evaluation of Generator Fields Number Title

ICES-305245-20130928-(6)

ANO-1 Generator Stator Temporary Lifts Assembly Collapse While Removing the Original Stator from the Turbine Building Causing a Fatality and Extensive Damage to Turbine Building and Non Vital Electrical Distribution System

ICES-305633-20130817-(4) Unusual Event - Inability to Confirm Fire in Protected Area

ICES-306442-20130803-(3) Leakage Through Turbine/Condenser Expansion Joint (Dogbone) Results in Plant Shutdown

ICES-310444-20140503-(1) Common Cause Evaluation

NRC 95-002 White Finding Events

ICES-313638-20141122-(1) Reactor Makeup Water Tank Contamination Caused By Internals Coating

INPO-IER-L2-14-26 Temporary Lift Assembly Failure Results in a Fatality, Loss of Off-site Power, Scram and Equipment Damage

INPO-IER-L3-13-30 Automatic Reactor Scram Following a 500-kV Insulator Flashover

INPO-IER-L3-13-33 Automatic Scram Following Closure of a Main Steam Isolation Valve

INPO-IER-L3-13-38 Reactor Scram Caused by Debris in Feedwater Regulator Control Valve

INPO-IER-L3-13-44 Manual Reactor Scram Resulting From Loss of Feedwater Control

INPO-IER-L3-13-51 Long-Standing Equipment Problems Complicate Scram Response

INPO-IER-L3-14-1 Improper Setpoints Lead to Generator Trip and Reactor Scram

INPO-IER-L3-14-11 Inadequate Communications Resulted in Cable Support Structure Damage

INPO-IER-L3-14-16 Delayed Dose Survey Led to Unplanned Worker Dose

NRC-21-EVENT-49370 Part 21 Issue On Rosemount Model 710DU Trip Units

NRC-21-EVENT-49809 Part 21 Interim Reporting Regarding Tricentric Triple Offset Butterfly Valves

NRC-21-SC-13-13 Rosemount 710 Trip Unit Radiological Qualification Concern

NRC-IN-2013-13 Deficiencies with Effluent Radiation Monitoring System Instrumentation

NRC-IN-2013-14 Potential Design Deficiency in Motor-Operated Valve Control Circuitry Number Title

NRC-IN-2013-15 Willful Misconduct/Record Falsification and Nuclear Safety Culture

NRC-IN-2013-18 Refueling Water Storage Tank Degradation

NRC-IN-2014-15 Inadequate Controls of Respiratory Protection Accessibility, Training, and Maintenance

NRC-RIS-2012-08-REV1 Developing Inserv ice Testing And Inservice Inspection Programs Under 10 CFR Part 52

Condition Reports

(CRs) (CR-RBS-)

2008-02376

2008-05615

2009-02377

2010-00790

2010-02481 2010-03311

2010-03361

2010-03404

2010-03499

2010-03648

2010-03936

2010-04538

2010-05979

2010-06834

2011-00331 2011-00363 2011-00834

2011-01197

2011-01285

2011-01540 2011-01863 2011-01902

2011-02933

2011-03117

2011-03531

2011-03813 2011-04665 2011-05642

2011-05801

2011-06147

2011-07674 2011-09030 2011-09171

2011-09173

2012-00183

2012-01541

2012-01652 2012-02211

2012-02213

2012-02340

2012-02347

2012-02480

2012-03192

2012-03252

2012-03307

2012-03310

2012-03351

2012-03395

2012-03658

2012-03685

2012-03742

2012-04058

2012-04063

2012-05869

2012-06329

2012-06472

2012-07040

2012-07077

2013-00515

2013-00971

2013-01326

2013-01389

2013-01475

2013-01691

2013-01742

2013-01806

2013-01836

2013-01987

2013-02096

2013-02345

2013-02427

2013-02442

2013-03098

2013-03118

2013-03273

2013-03465

2013-03630

2013-03661

2013-04049

2013-04083

2013-04191

2013-04228

2013-04291

2013-04295

2013-04369

2013-04402

2013-04419

2013-04428

2013-04431

2013-04780

2013-05180

2013-05649

2013-06073

2013-06309

2013-06358

2013-06471

2013-06729

2013-06743

2013-06744

2013-06750

2013-06755

2013-06789

2013-06824

2013-06855

2013-06860

2013-06877

2013-07105

2013-07133

2013-07222

2013-07265

2013-07316

2013-07368

2013-07414

2013-07417

2013-07482

2013-07690

2014-00072

2014-00106

2014-00119

2014-00186

2014-00237

2014-00413

2014-00541

2014-00627

2014-00720

2014-00832

2014-00926

2014-00951

2014-00966

2014-01029

2014-01030 2014-01168

2014-01218

2014-01220

2014-01221

2014-01307

2014-01309

2014-01390

2014-01394

2014-01465

2014-01475

2014-01500

2014-01540

2014-01678

2014-01681

2014-01746

2014-01763

2014-01764

2014-01834

2014-01863

2014-01865

2014-01952

2014-01955

2014-02040

2014-02085

2014-02115

2014-02200

2014-02454

2014-02456

2014-02480

2014-02489

2014-02513

2014-02559

2014-02803

2014-02815

2014-02849

2014-02850

2014-02940

2014-03006

2014-03057

2014-03212

2014-03408

2014-03409

2014-03543

2014-03545

2014-03576

2014-03641

2014-03778

2014-03977

2014-04049

2014-04084

2014-04086

2014-04104

2014-04106

2014-04108

2014-04212

2014-04277

2014-04306

2014-04307

2014-04332

2014-04467

2014-04585

2014-04596

2014-04624

2014-04637

2014-04802

2014-05022

2014-05074

2014-05098

2014-05162

2014-05209

2014-05253

2014-05254

2014-05314

2014-05466

2014-05894

2014-05974

2014-06135

2014-06218

2014-06233

2014-06350

2014-06357

2014-06601

2014-06605

2014-06649

2014-06653

2014-06685

2014-06691

2014-06696

2015-00038

2015-00112

2015-00153

2015-00182

2015-00213

2015-00272

2015-00280

2015-00287

2015-00450

2015-00484

2015-00626

2015-00667

2015-01096 2015-01134 2015-01160

2015-01216

2015-01260

2015-01370

2015-01379

2015-01474

2015-01476

2015-01487

2015-01494

2015-01495

2015-01595

2015-01605

2015-01615

2015-01698

2015-01714

2015-01772

2015-01783

2015-01824

2015-02123

2015-02245

2015-02260

2015-02264

2015-02322

2015-02335

2015-02354

2015-02496

2015-02635

2015-02660

2015-02810

2015-02812

2015-02949

2015-02953

2015-03019

2015-03024

2015-03197

2015-03428

2015-03532

2015-03696

2015-03951

2015-04071

Work Orders

257122

00304959

00323679

00327687

00360451

00398658

50688170

50986092

51038080

51514125

52251008

52331679

52341561

52428117

2456572

Self-Assessments

LO-RLO-2013-00107

LO-RLO-2013-0028

Conduct of Operations

LO-RLO-2013-0063

SE EPRI Diesel Generator Reliability Tech Advisory Meeting

LO-RLO-2014-00145,

RBS Pre-Nuclear Industry Evaluation Program (NIEP), October 8, 2014

LO-RLO-2014-00175

LO-RLO-2014-0026

Snubber Program Compliance with 10CFR503.55a

LO-RLO-2014-0078

Control of Supplemental Personnel BM

LO-RLO-2014-0098

Troubleshooting

LO-RLO-2014-0103

Radwaste Shipping

LO-RLO-2014-0104

Foreign Material Exclusion Snapshot Assessment

LO-RLO-2015-0010

Snapshot Assessment of NERC Standard

PRC-005 Program

LO-RLO-2015-0012

Operator Aggregate Assessment of Plant Deficiencies

LO-RLO-2015-0059

Annual Snapshot Assessment of Selected Elements of

EN-NS-2014

LO-RLO-2015-0104

Maintenance Fundamentals Incorporation in Training

LO-RLO-2015-0115

Loss of Shutdown Cooling

LO-RLO-2015-0121

Loss of Control Building Ventilation

RF-18

OE-NOE-2014-00020

QS-2013-RBS-015

QS-2013-RBS-016

QS-2013-RBS-018

QS-2013-RBS-019

QS-2013-RBS-020

QS-2013-RBS-021

QS-2013-RBS-022

QS-2013-RBS-024

QS-2013-RBS-026

QS-2013-RBS-028

QS-2013-RBS-029

QS-2013-RBS-030

QS-2013-RBS-031

QS-2013-RBS-032

QS-2013-RBS-033

QS-2013-RBS-034

QS-2013-RBS-035

QS-2013-RBS-036

QS-2013-RBS-037

QS-2013-RBS-038

Attachment 2

ML15229A163

SUNSI Review by:

EAR ADAMS:

Yes

No

Non-Sensitive

Sensitive

Publicly Available

Non-Publicly Available Keyword:

NRC-002 OFFICE PE/DRS PE/DRS RI/DRP RI/DRS C:/DRP/PBC SRI/DRS C:EB1

NAME CAlldredge:DCH BBaca ABarrett SMakor GWarnick ERuesch TFarnholtz SIGNATURE /RA/ /RA/-email /RA/-email /RA/ /RA/ /RA/ /RA/ DATE 8/6/15 8/7/15 8/11/15

8/6/15 8/10/15 8/12/15 8/13/15

Letter to Eric W. Olson from Thomas R. Farnholtz, dated August 13, 2015

SUBJECT: RIVER BEND STATION - NRC PROBLEM IDENTIFICATION AND RESOLUTION

INSPECTION REPORT 05000458/2015008

Distribution Regional Administrator (Marc.Dapas@nrc.gov)

Deputy Regional Administrator (Kriss.Kennedy@nrc.gov)

DRP Director (Troy.Pruett@nrc.gov) DRP Deputy Director (Ryan.Lantz@nrc.gov) DRS Director (Anton.Vegel@nrc.gov)

DRS Deputy Director (Jeff.Clark@nrc.gov)

Senior Resident Inspector (Jeffrey.Sowa@nrc.gov)

Senior Resident Inspector (Nick.Hernandez@nrc.gov)

Resident Inspector (Brian.Parks@nrc.gov) RBS Administrative Assistant (Lisa.Day@nrc.gov)

Branch Chief, DRP/C (Greg.Warnick@nrc.gov)

Senior Project Engineer (Ray.Azua@nrc.gov)

Public Affairs Officer (Victor.Dricks@nrc.gov) Public Affairs Officer (Lara.Uselding@nrc.gov)

Project Manager (Alan.Wang@nrc.gov)

Acting Team Leader, DRS/TSS (Eric.Ruesch@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 Congressional Affairs Officer (Angel.Moreno@nrc.gov)

RIV/ETA: OEDO (Cindy.Rosales-Cooper@nrc.gov)