IR 05000313/2018013
ML18165A206 | |
Person / Time | |
---|---|
Site: | Arkansas Nuclear |
Issue date: | 06/18/2018 |
From: | Kennedy K Region 4 Administrator |
To: | Richard Anderson Entergy Operations |
O'Keefe C | |
References | |
EA-14-008, EA-14-088, EA-16-124, ML16169A193, ML18078B153, ML18092A005 IR 2018013 | |
Download: ML18165A206 (60) | |
Text
une 18, 2018
SUBJECT:
ARKANSAS NUCLEAR ONE - NRC CONFIRMATORY ACTION LETTER (EA-16-124) FOLLOW-UP INSPECTION REPORT 05000313/2018013 AND 05000368/2018013 AND ASSESSMENT FOLLOW-UP LETTER
Dear Mr. Anderson:
On May 31, 2018, the U.S. Nuclear Regulatory Commission (NRC) completed an inspection at your Arkansas Nuclear One (ANO) facility, Units 1 and 2. The team discussed the results of this inspection with you and other members of your staff. The results of this inspection are documented in the enclosed report.
During this inspection, the inspection team reviewed the last of the specific actions from the ANO Comprehensive Recovery Plan to which you committed via a Confirmatory Action Letter (CAL) dated June 17, 2016, (Agencywide Documents Access and Management System (ADAMS) Accession No. ML16169A193) (EA-16-124). This letter presents the results of that inspection, closes the CAL, and updates the NRCs assessment of performance at ANO, Units 1 and 2.
The NRC team did not identify any findings or violations of more than minor significance.
On March 2, 2015, ANO, Units 1 and 2, were placed into the Multiple/Repetitive Degraded Cornerstone Column (Column 4) of the NRCs Reactor Oversight Process (ROP) Action Matrix.
This action was based on having one Yellow finding in the Initiating Events Cornerstone and one Yellow finding in the Mitigating Systems Cornerstone in each unit.
Between August 2016 and May 2018, the NRC conducted eight CAL follow-up inspections to review Entergys progress in completing 161 CAL actions to address performance issues at ANO. You reported completing the CAL inspection focus areas in letters dated February 6, 2018, (ADAMS Accession No. ML18040A918) and March 19, 2018, (ADAMS Accession No. ML18078B153). The NRC closed the Significant Performance Deficiencies and the Identification, Assessment, and Correction of Performance Deficiencies areas in Inspection Report 05000313/2018012 and 05000368/2018012 (ADAMS Accession No. ML18092A005).
During this inspection, the NRC completed the final closeout review of your CAL actions. Specifically, this report closes the CAL areas for Human Performance, Equipment Reliability and Engineering Programs, Safety Culture, and Service Water System Self-Assessment. The NRC has determined that all of Entergys committed actions to improve the safety performance at ANO have been completed and should sustain performance improvement. Therefore, the ANO CAL is closed.
As a result of closing the Yellow findings and the CAL, the NRC has updated its assessment of ANO, Units 1 and 2. Based on a review of current performance indicators and inspection results, the NRC determined the performance at ANO, Units 1 and 2 to be in the Licensee Response Column (Column 1) of the Reactor Oversight Process Action Matrix as of the date of this letter.
This letter, its enclosure, and your response (if any) will be made available for public inspection and copying at http://www.nrc.gov/reading-rm/adams.html and at the NRC Public Document Room in accordance with 10 CFR 2.390, Public Inspections, Exemptions, Requests for Withholding.
Sincerely,
/RA/
Kriss M. Kennedy Regional Administrator Docket Nos. 50-313; 50-368 License Nos. DPR-51; NPF-6 Enclosure:
Inspection Report 05000313/2018013 and 05000368/2018013 w/ Attachments:
1. List of Confirmatory Action Letter Items Closed and Discussed 2. List of Documents Reviewed 3. Confirmatory Action Letter Item Status
U.S. NUCLEAR REGULATORY COMMISSION
Inspection Report
Docket Number(s): 05000313, 05000368 License Number(s): DPR-51, NPF-6 Report Number(s): 05000313/2018013, 05000368/2018013 Enterprise Identifier: I-2018-013-0003 Licensee: Entergy Operations, Inc.
Facility: Arkansas Nuclear One, Units 1 and 2 Location: Russellville, Arkansas Inspection Dates: April 2, 2018 to May 31, 2018 Inspectors: J. Dixon, Senior Project Engineer, (Team Leader)
E. Duncan, Region III, Branch Chief M. Keefe-Forsyth, Office of Nuclear Reactor Regulation, Safety Culture Specialist M. Tobin, Resident Inspector D. Willis, Office of Enforcement, Allegation Team Leader Approved By: N. OKeefe Branch Chief Division of Reactor Projects Enclosure
SUMMARY
IR 05000313/2018013; 05000368/2018013; 4/2/2018 - 5/31/2018; Arkansas Nuclear One,
Units 1 and 2; Confirmatory Action Letter (CAL) Follow-up Inspection (IP 92702).
The inspection activities described in this report were performed between April 2 and May 31, 2018, by a team from the NRCs Region III and IV offices, the Office of Nuclear Reactor Regulation, the Office of Enforcement, and a resident inspector at Arkansas Nuclear One. The NRCs program for overseeing the safe operation of commercial nuclear power reactors is described in NUREG-1649, Reactor Oversight Process, dated July 2016.
On June 17, 2016, the NRC issued a Confirmatory Action Letter (CAL) (ADAMS Accession No. ML16169A193) (EA-16-124) confirming actions that Entergy committed to take in the Arkansas Nuclear One (ANO) Comprehensive Recovery Plan (CRP).
On March 19, 2018, the licensee notified the NRC that actions to improve performance in the four remaining inspection focus areas from the CAL were complete and effective, and requested an inspection of these areas for possible closure (ADAMS Accession No. ML18078B153).
During this inspection, the team reviewed and closed the last four specific actions from the CAL, and also reviewed the Human Performance, Equipment Reliability and Engineering Programs,
Safety Culture, and Service Water System inspection focus areas. The team concluded that, individually and collectively, the licensees actions were effective in achieving the CRP objectives. Therefore, all actions and inspection focus areas from the ANO CAL are closed.
Below is a summary of the NRCs basis for closing each of the inspection focus areas in the CAL.
Improvements to Address Significant Performance Deficiencies To address the root and contributing causes for the Yellow findings for the stator drop and the flooding events, including plant deficiencies and problems with vendor oversight, change management, conservative decision-making, and risk management, Entergy implemented 39 actions in addition to those already completed at the time the CAL was issued. With respect to the Yellow inspection finding associated with the drop of the Unit 1 main generator stator on March 31, 2013, the NRC concluded that the corrective actions improved the licensees implementation of the oversight of contractors and vendors. Decision-making, risk recognition, and the ability to manage risk were also improved, as well as increasing the technical rigor used to assess vendor work products. Many of these corrective actions were demonstrated to be effective during the replacement of both shutdown cooling heat exchangers in Unit 2 in 2017.
This project involved many of the complex challenges that were present during the stator replacement project, including special lifts, and our inspections noted significantly improved planning, oversight, technical rigor, testing, and risk management actions.
Actions taken to address the Yellow flood protection inspection finding to reconstitute and document the design basis for plant features intended to protect vital plant equipment from the damage caused by flooding, tornado missiles, and other external events were effective in identifying and correcting deficiencies and establishing appropriate configuration control mechanisms. Preventive maintenance and testing strategies were also improved to verify effective flood sealing.
On March 29, 2018, the NRC determined that all Significant Performance Deficiency actions were complete and effective, and concluded that ANOs actions met the objectives of Inspection Procedure 95002 and the associated objectives stated in the ANO CRP. Therefore, the Yellow finding involving the failure to approve the design and to load test a temporary lift assembly (EA-14-008), the Yellow finding involving the failure to maintain required flood mitigation design features (EA-14-088), and the Significant Performance Deficiency inspection focus area of the CAL were closed in NRC Inspection Report 05000313/2018012 and 05000368/2018012.
Improvements to Corrective Action Program To address improvement in the implementation and oversight of the corrective action program, self-assessment, performance monitoring, quality of problem evaluations, and use of operating experience, Entergy implemented 34 actions. The NRC determined that actions to improve training, defining roles and responsibilities, and management oversight of corrective action program functions resulted in improved identification, evaluation, and corrective actions for performance deficiencies. Problems are evaluated and assumptions are validated prior to making decisions. ANO reduced its reliance on compensatory measures and engineering evaluations for degraded conditions by correcting problems and restoring plant safety margins.
Corrective actions are timely and backlogs have been reduced. Improved self-assessment and performance monitoring practices have identified and addressed declining performance trends.
Operating experience issues are being identified and addressed at a low threshold.
On March 29, 2018, the NRC determined that all corrective action program actions were complete and effective in achieving the stated objectives. Therefore, the Identification,
Assessment, and Correction of Performance Deficiencies inspection focus area of the CAL was closed in NRC Inspection Report 05000313/2018012 and 05000368/2018012 (ADAMS Accession No. ML18092A005).
Improvements in Human Performance To improve human performance, leadership behaviors, organizational capacity, procedure quality, standards, and accountability, Entergy implemented 40 actions. The ability to complete work across all site departments improved, in part, through hiring and training efforts. ANO implemented a new process to anticipate and address organizational capacity challenges in staffing, training, and expertise that closed existing gaps. Additionally, ANO implemented actions to reduce reliance on vendors and the training department increased its capacity and facilities in order to support departmental training needs.
The NRC noted that there were changes in the station leadership team composition and capabilities. Leadership assessments, individual development plans, and training and coaching enhanced leader behaviors in the areas that caused the safety culture at ANO to degrade.
Station leaders improved their ability to observe and assess performance and address shortfalls. Decision-making has been proactive, strategic, conservative, and includes seeking input from workers. Increased field presence for leaders improved their understanding of work conditions. This has facilitated recognizing and addressing problems with work processes, work instruction quality, teamwork, standards, and accountability. Procedure writers and work planners were trained to implement industry procedure quality standards, and station procedures and work instructions are being upgraded to improve technical content, clarity, and human factoring that are appropriate for the existing experience levels of the users.
The human error rate was reduced by reinforcing procedure use and adherence standards and improving procedure quality. Operator performance was improved and challenges during events were reduced by removing distractions and fixing degraded equipment, as well as by raising teamwork, standards, and accountability through high-impact training and increased oversight.
The NRC determined that all Human Performance improvement actions were complete and effective in achieving the associated objectives stated in the ANO CRP. Therefore, the Human Performance inspection focus area of the CAL is closed.
Improvements to Equipment Reliability and Engineering Programs To improve implementation of processes and programs that ensure key plant equipment remains available, reliable, and capable of meeting the plant design and licensing bases, including resolving specific equipment conditions, Entergy implemented 25 actions. ANO improved the organizational capacity in engineering through targeted hiring, training, and development plans for engineers. This included staffing all engineering programs with trained and qualified program owners and backups. The quality of engineering programs and plant systems are being effectively monitored through the Program Health and Plant Health processes. Industry best practices for system health were implemented, including using a multidiscipline Plant Health Committee to review performance trends and develop improvement plans, including those that address equipment aging and obsolescence issues, as well as procurement of strategic spare components.
The NRC reviewed the results of numerous equipment reliability improvement projects and noted that each project was effective in improving the reliability of key plant equipment or restoring lost safety margins. ANO reevaluated the equipment classification of the components and systems most important to safety and stable plant operation, increasing many of the importance rankings using the latest industry standards. ANO implemented a process for reviewing preventive maintenance strategies and vendor recommendations during the work planning process, using plant operating and maintenance experience to make timely adjustments to the scope and frequency of the work. A new Component Maintenance Optimization group was also created to place maintenance support engineers and predictive maintenance personnel within the Maintenance department to provide technical expertise to support work in progress and preventive maintenance planning.
The NRC determined that all Equipment Reliability and Engineering Program improvement actions were complete and effective in achieving the associated objectives stated in the ANO CRP. Therefore, the Equipment Reliability and Engineering Program inspection focus area of the CAL is closed.
Improvements in Safety Culture To improve nuclear safety culture values and behaviors to ensure commitment by leaders and individuals to emphasize safety over competing goals, Entergy implemented 22 actions.
Entergy increased the staffing and funding resources available to ANO to support the workload and improve the safety culture at the station. Efforts to build trust and demonstrate conservative decision-making, improve equipment reliability, reduce work backlogs, and raise standards demonstrated leaderships commitment to improving safety and performance at ANO. Union leadership and individual contributors have become engaged, taking ownership of organizational challenges through committees and working groups to identify and address process and teamwork issues. Workers have been trained on plant risk and how their job tasks relate to plant safety; allowing workers across the station to identify and report challenges that could affect safety. Training on the corrective action program, including roles and responsibilities, have improved worker understanding of the processes available to correct problems, leading to better problem reporting and suggestions to improve processes.
Safety culture surveys conducted throughout the time that ANO was in Column 4 have demonstrated an improving trend. The NRC performed safety culture focus group discussions in August 2017, and during this current inspection, and noted more positive responses.
Performance indicators also demonstrated improved outcomes in areas supported by positive safety culture behaviors.
The NRC determined that all Safety Culture improvement actions were complete and effective in achieving the associated objectives stated in the ANO CRP. Therefore, the Safety Culture inspection focus area of the CAL is closed.
Actions to Assess the Service Water System To ensure conditions adverse to quality are identified and resolved, Entergy committed to conduct a focused self-assessment of the Units 1 and 2 service water systems in accordance with station procedures and NRC Inspection Procedure 93810, Service Water System Operational Performance Inspection. The NRC concluded that ANO performed a thorough assessment of the condition of the service water system on both units. The resulting project plan to fund improvements to the technology used to monitor corrosion and pitting in system components, improve water chemistry control to minimize corrosion, and the replacement of piping and large components has restored system operating margins and addressed aging issues.
The NRC determined that the service water system self-assessment and the resulting project plan to address system problems were complete and effective in achieving the associated objectives stated in the ANO CRP. Therefore, the Service Water System Self-Assessment inspection focus area of the CAL is closed.
No findings were identified.
REPORT DETAILS
OTHER ACTIVITIES
4OA5 Other Activities
.1 Confirmatory Action Letter (CAL) Inspection Focus Area Closures (IP 92702)
Background On March 4, 2015, ANO Units 1 and 2 transitioned to the Multiple/Repetitive Degraded Cornerstone Column (Column 4) of the NRCs Reactor Oversight Process Action Matrix as a result of having two Yellow findings for each unit. In response, the NRC performed IP 95003, concluding the onsite portion of the inspection on February 26, 2016, and provided insights on ANOs performance weaknesses, their causes, and related safety culture issues. The 95003 team reviewed proposed corrective actions and identified the need for additional corrective actions to create prompt and sustained improvement. In a letter dated May 17, 2016, ANO Comprehensive Recovery Plan (ADAMS Accession No. ML16139A059), Entergy notified the NRC staff of its plan to perform specific actions to resolve the causes for declining performance at ANO, and provided a summary of that plan.
The NRC reviewed Entergys CRP and concluded that Entergys planned corrective actions should correct significant performance deficiencies and result in sustained performance improvement at ANO. The CRP is comprised of 14 Area Action Plans that contain key improvement actions and scheduled completion dates. The NRC grouped the CRP actions into six inspection focus areas to support future inspection activities based on ANO performance concerns documented in NRC Inspection Report 05000313/2016007 and 05000368/2016007 (ADAMS Accession No. ML16161B279). The NRC issued the CAL on June 17, 2016 (ADAMS Accession No. ML16169A193) to confirm commitments made by Entergy concerning ANO, Units 1 and 2, in each of the six inspection focus areas.
a. Closure of CAL Inspection Focus Area: Human Performance Background In performing their root cause evaluations for the stator drop and flood protection issues, ANO identified multiple areas where human performance did not meet industry standards, such as procedural use and adherence, caused by poor leadership behaviors. In response, ANO implemented prompt actions to improve operator performance, but Entergys CRP included limited actions to address improving worker behaviors or increasing field presence of managers to set and enforce expectations.
The Third Party Nuclear Safety Culture Assessment in 2015 identified that ANO personnel tolerated, and at times normalized, degraded conditions. In addition to using analyses to accept degraded conditions and reduced safety margins, ANO management adopted long-term or permanent compensatory measures. These compensatory actions distracted operators from their normal duties and challenged response actions during events. The true number of degraded conditions and compensatory measures was not apparent because they were dispersed in a variety of tracking processes or the actions were made permanent through analyses, or proceduralized actions.
The 95003 inspection team concluded from observations in the control room, plant, and simulator that operator performance improvement actions were effective, and that actions to improve the quality and effectiveness of supervisory field observations appeared to be successful at the first- and second-line supervisor level. However, both ANO and the NRC identified concerns with procedure adherence as ANO had not evaluated the causes for problems in this area beyond determining that the quality of site-specific procedures and work instructions were below current industry standards and were not adequately human factored. The NRC team identified that workers attempted to informally resolve unclear guidance in procedures rather than stopping and notifying supervisors.
Scope of Review Since August 29, 2016, the NRC has performed quarterly CAL inspections of individual action items and found the items to be complete and effective. The complete list of individual action items along with descriptions and relevant inspection reports is provided in Attachment 3. To ensure the licensee adequately addressed the inspection focus area, the NRC team reviewed the key desired behaviors and outcomes (DB&Os) to verify that the licensee achieved sustained improvement. Specifically, the following DB&Os where reviewed:
- Corrective Action Program (CA) DB&O-2: Workers identify conditions adverse to quality promptly and in accordance with station procedure and expectations.
Workers apply a low threshold for reporting problems. (Key Actions CA-1, CA-4)
- Decision Making and Risk Management (DM) DB&O-2: Senior leaders demonstrate accountability and a bias for action to correct deficiencies and challenges to safe and reliable operation for the long term. Responsible managers present accurate information and thorough solutions that minimize threats to plant performance and safety. (Key Action DM-2)
- Leadership Fundamentals (LF) DB&O-1: Leaders communicate and build trust in the organization. (Key Actions LF-1, LF-3, LF-4, LF-5, LF-6, LF-7, and LF-9)
- LF DB&O-4: ANO leaders are identifying and addressing individual and organizational performance issues. (Key Actions LF-1, LF-3, LF-5, LF-9, and LF-13)
- Nuclear Fundamentals (NF) DB&O-5: Workers apply a questioning attitude and stop when unsure. Individuals challenge assumptions and offer opposing views when they think something is not correct. Concerns are fully satisfied before work continues. (Key Actions NF-1, NF-6, NF-7, and NF-9)
- NF DB&O-7: Workers and leaders are observant of conditions in the plant and ensure that issues, problems, degraded conditions, and near misses are promptly reported and documented in the corrective action program at a low threshold. (Key Actions NF-1, NF-6, NF-7, and NF-9)
- NF DB&O-8: Workers understand what it means to be thinking and engaged and practice the foundational behaviors (criteria) defined by the industry for the Nuclear Professional. (Key Actions NF-1, NF-2, NF-6, NF-7, NF-8, and NF-9)
- NF DB&O-10: Application of fundamental behaviors is reflected in low rates of human performance errors and rework. (Key Actions NF-1, NF-3, NF-5, NF-7, NF-8, NF-9, and NF-10)
- Organizational Capacity (OC) DB&O-1: Leaders ensure nuclear safety is the top consideration in making decisions on workforce resources. Leaders use appropriate information to make strategic decisions regarding workforce needs.
The information includes data supporting organization capability, e.g., knowledge gaps, attrition projections and demographic makeup (age and years of service -
proficiency). This information is incorporated into an Integrated Strategic Workforce Plan (ISWP) that leaders use to ensure the organization has the necessary capacity and skills for safe and reliable plant operation. (Key Actions OC-1, OC-2, OC-3, and OC-4)
- Plant Health (PH) DB&O-2: Plant Health Working Group and Plant Health Committee members make conservative decisions on plant health issues with a primary emphasis on nuclear safety risk. The Plant Health Process supports nuclear safety by minimizing long-standing equipment issues. Equipment problems and vulnerabilities are addressed using well thought out, permanent solutions. (Key Actions PH-1, PH-5, PH-6, PH-9, PH-11, PH-12, PH-13, and PH-14)
- Procedure and Work Instruction Quality (PQ) DB&O-1: Station procedures and work instructions are technically accurate, complete, and contain consistent human factoring and clarity to support predictable, repeatable, and successful work performance. (Key Actions PQ-1, PQ-2, PQ-3, PQ-5, PQ-6, PQ-7, PQ-8, PQ-9, and PQ-10)
- PQ DB&O-4: Procedure Improvement and Work Order Feedback backlogs are minimized to ensure quality, up-to-date work documents are available. (Key Action PQ-11, supporting actions include PM-07 and PM-09: monitored by metrics)
- Safety Culture (SC) DB&O-2: Leaders model correct behaviors, especially when resolving apparent conflicts between nuclear safety and production. (Key Actions SC-1, SC-4, SC-8, SC-9, and SC-14)
To evaluate the licensees corrective action effectiveness, the team reviewed:
- Confirmatory Action Letter and Area Action Plan Actions Effectiveness (LO-ALO-2018-00014)
- Human Performance Closure Readiness Evaluation
- Leadership Fundamentals Area Action Plan Closure Report
- Nuclear Fundamentals Area Action Plan Closure Report
- Procedure and Work Instruction Quality Area Action Plan Closure Report
- Station and CRP metrics
- Interviewed a cross section of station managers, employees, and contractors The team evaluated the corrective actions and effectiveness criteria established by the licensee in aggregate for the reviewed DB&Os. The team noted that the licensee took multiple actions to address human performance not meeting industry standards in areas such as: procedural use and adherence; improving worker behaviors; increasing field presence of supervisors and managers; setting and enforcing expectations; personnel tolerating, and at times normalizing, degraded conditions; and management adopting long-term or permanent compensatory measures.
As a result of the teams review of the corrective actions and discussions with station employees and contractors, the team concluded the licensee has steadily improved human performance at the station. The team determined that the licensees actions to address procedural use and adherence, create a procedure writers guide, and improve the quality of procedures and work orders to the new standard has reduced the number of procedure errors. The team also determined that the licensees paired observation and behavior based safety observation programs have been accepted by the work force as a positive tool to hold each other accountable, maintain a questioning attitude, and stop and seek clarification when they encounter unclear guidance. The team was able to confirm this improving trend by discussions with station employees and contractors, and reviewing specific metrics such as, Online Risk (Actual vs Planned), Consequential Error Rate, Open Preventive Maintenance Change Requests, Open Craft Feedback Requests, Rework, and Procedure and Work Instruction Backlog.
The team determined that the licensees actions to address improving worker behavior by establishing a paired observation program, implementing a behavior based safety program, implementing weekly leadership alignment meetings for supervisors and above to reinforce the expected actions and behaviors, and implementing a Connection to the Core campaign, as examples, has resulted in a more engaged work force. The team also determined that the licensees behavior based safety observation program and the Connection to the Core campaign have been accepted by the work force as a way for workers to hold each other and management accountable for maintaining a low reporting threshold and understanding how their specific work activity can affect plant safety. The team was able to confirm this improving trend by discussions with station employees and contractors, and reviewing specific metrics such as, Consequential Error Rate, Observation Program Health Index, Recordable Injury Rate, Nuclear Safety Culture Monitoring Index, Technical Conscience Index, and Rework.
The team determined that the licensees actions to improve field presence of supervisors and managers and use this as a mechanism to set and enforce expectations has resulted in improved communications and trust between workers and the leadership team. The licensee established a field presence initiative that promotes and measures leader field presence, 1X1 meetings (pronounced as one by one meeting, where a manager coaches a supervisor) that promote alignment and reinforce leader behaviors, and benchmarking an external organization to identify and adopt best practices in the Leadership Fundamentals area. The team determined that the licensee improved communications through implementation of a new Nuclear Excellence Model that reinforced trust and teamwork, adding new field presence performance indicators for supervisors and managers to monitor results, and establishing an Employee Communication Advisory Team. The Employee Communication Advisory Team consists of management and individual contributors from cross-functional groups that make recommendations to improve the effectiveness of site/fleet communications. The team was able to confirm this improving trend through discussions with station employees and contractors, reviewing specific metrics such as, 1X1 Meeting Effectiveness, Observation Program Health Index, Field Presence, and validating that the weekly protected time meetings are being implemented to share the messages from the Leadership and Alignment meetings with their workers.
The team determined that the licensees actions to address tolerating/normalizing degraded conditions and adopting long-term or permanent compensatory measures have resulted in station employees having a lower threshold for reporting problems. The licensee achieved these results by providing training on the Corrective Action Program, implementing a Comprehensive Site Plan for Equipment Reliability, resolving long-standing equipment issues, assigning mentors from outside of the Entergy Fleet to each shift manager, and improving the Site Integrated Planning Database process for equipment related entries. The team determined that the licensees actions resulted in workers focusing on procedure use and adherence, challenging assumptions and decision making, and improving risk recognition. The team was able to confirm these outcomes through discussions with station employees and contractors, and by reviewing specific metrics such as, Equipment Reliability Index, Deficiency Induced Fire Impairments, Age of Red and Yellow Systems, Operator Aggregate Index Non-Outage, Engineering Program Health, Critical Equipment Failures, Rework - Nuclear Fundamentals, Condition Report Backlog, Maintenance Backlog, and CAP Line Ownership and Engagement Index.
The team also determined that the licensees actions to increase the number of employees, improve mentoring and training availability, improve industry participation, and availability of training from vendors have had a positive impact on communications, trust, and culture among large sections of the work force. The team also determined that the licensees actions to address risk have been effective by observing risk recognition, prioritization, mitigation, and discussion at all levels of the organization during observations of work.
The team concluded that there has been a steady improvement in human performance at the station. Examples include a declining number of consequential errors, a lower threshold for reporting problems, an increase in the number of equipment-related Site Integrated Planning Database entries (reflecting a higher confidence in the effectiveness of the process), and a more inclusive work force. Based on the actions taken by the licensee, data evaluated by the team, and observations performed on site, the team concluded that the actions taken to address Human Performance inspection focus area were effective. Therefore, the Human Performance inspection focus area of the CAL is closed.
b. Closure of CAL Inspection Focus Area: Equipment Reliability and Engineering Programs Background In 2007, Entergy implemented an alignment initiative across their fleet, which resulted in reduced staffing levels at ANO. The reduced resources available to do work at ANO created a number of challenges that slowly began to impact equipment reliability by reducing the amount of preventive maintenance performed and extending the time between maintenance activities. The loss of experienced staff made on-time completion of maintenance activities difficult, and the lack of effective action to maintain equipment reliability in an aging plant caused an increase in emergent work that disrupted scheduled maintenance. A cumbersome and poorly understood process for approving and funding equipment upgrades resulted in only the highest priority work being approved, and rescheduling or cancellation of lower priority work. ANO did not identify problems in the Site Integrated Planning Database process for approving and funding major projects. The 95003 inspection team noted that the CRP was updated to address this gap.
Scope of Review Since August 29, 2016, the NRC has performed quarterly CAL inspections of individual action items and found the items to be complete and effective. The complete list of individual action items along with descriptions and relevant inspection reports is provided in Attachment 3. To ensure the licensee adequately addressed the inspection focus area, the NRC team reviewed the key DB&Os to verify that the licensee achieved and sustained improvement. Specifically, the following DB&Os were reviewed:
- Design and Licensing Basis (DB) DB&O-2: Engineering staffing levels are adequate to sustain improved plant operations, maintain high levels of equipment performance, and support excellence in Engineering Program implementation.
Changes to staffing levels, workload, skills, proficiency, or knowledge level will be addressed with nuclear safety as the overriding priority. Engineering backlogs are maintained such that latent risks are minimized. (Key Actions DB-4, DB-5, and DB-6)
- DM DB&O-2: Senior leaders demonstrate accountability and a bias for action to correct deficiencies and challenges to safe and reliable operation for the long term. Responsible managers present accurate information and thorough solutions that minimize threats to plant performance and safety. (Key Action DM-2)
- PH DB&O-2: Plant Health Working Group and Plant Health Committee members make conservative decisions on plant health issues with a primary emphasis on nuclear safety risk. The Plant Health Process supports nuclear safety by minimizing long-standing equipment issues. Equipment problems and vulnerabilities are addressed using well thought out, permanent solutions.
(Key Actions PH-5, PH-6, PH-9, PH-11, PH-12, PH-13, and PH-14)
- Preventive Maintenance (PM) DB&O-6: The standards for PM Work Order quality result in high quality PM Work Orders. PM Work Order Feedback from Craft personnel is incorporated in a timely manner. (Key Actions PM-7, PM-9, PM-19, and supporting action PQ-9)
- PM DB&O-7: Weaknesses in PM strategies are consistently identified and resolved prior to PM implementation. (Key Actions PM-13, PM-19, and supporting actions PM-4 and PM-15)
- PM DB&O-8: Operating experience, vendor recommendations, internal technical expertise, and craftsmanship are applied through the PM program to minimize consequential equipment failures. (Key Actions PM-2, PM-4, PM-6, PM-13, and supporting action PQ-09)
To evaluate the licensees corrective action effectiveness, the team reviewed:
- Confirmatory Action Letter and Area Action Plan Actions Effectiveness (LO-ALO-2018-00014)
- Decision Making and Risk Management Area Action Plan Closure Report
- Design and Licensing Basis Area Action Plan Closure Report
- Equipment Reliability and Engineering Programs Closure Readiness Evaluation
- Plant Health Area Action Plan Closure Report
- Preventive Maintenance Program Area Action Plan Closure Report
- Station and CRP metrics, as well as other relevant performance monitoring data
- Interviewed a cross section of station managers, employees, and contractors The team evaluated the corrective actions and effectiveness criteria established by the licensee in aggregate for the reviewed DB&Os. The team noted that the licensee took multiple actions to address equipment reliability and engineering programs. The team reviewed corrective actions to address longstanding equipment performance trends, classification, and inclusion of plant components in key programs, loss of engineering experience, understaffing for engineering programs, and training and qualification for engineers to ensure deficiencies identified during the IP 95003 inspection were appropriately addressed.
The team performed a detailed review of the following key actions:
- Key Action DB-4: Determine the appropriate level of staffing for safe and reliable operation of ANO given experience, training needs, knowledge management needs, projected attrition, and the workload of the current level of staffing.
(CR-ANO-C-2015-02833, CA-47)
- Key Action DB-5: Implement a staffing plan developed in response to staffing issues. Include baseline organizational changes and staffing for Recovery efforts. (CR-ANO-C-2015-02831, CA-41)
- Key Action DB-6: Implement a workforce planning process to include a long-term ANO Integrated Strategic Workforce Plan (ISWP) that will provide the necessary level of detail to ensure a sustained staffing plan that accounts for talent needs, knowledge management, and training. (CR-ANO-C-2015-02833, CA-48)
The team reviewed People Health Committee meeting minutes that documented actual and projected hiring and attrition data, in both a monthly and cumulative manner, with a particular focus on the People Health Committee meeting results for February 15, 2018, that focused on engineering department staffing. The team also reviewed current organization charts to determine whether any staffing vacancies existed and, if so, whether plans were in place to fill those vacancies.
The team also reviewed performance indicators and metric data associated with engineering. In particular, engineering backlogs such as design and system engineering and programs condition report backlogs, configuration management workload backlogs, engineering change backlogs, paid and nonpaid overtime, and staffing were reviewed.
The results of these reviews reflected an increase in staffing levels that supported the current workload without the need for frequent overtime. For the areas reviewed, where engineering-related performance did not meet station goals, such as Engineering Change Delivery, the team verified that the licensee was implementing an action plan to improve performance.
The team identified one area that was assessed as an opportunity for further enhancement associated with Key Action DM-2: Establish a decision making Nuclear Safety Culture Observation form to include the top Leader Behaviors to be demonstrated and reinforced at ANO meetings. The form should include decision-making practices that emphasize prudent choices over those that are simply allowable. The team reviewed approximately 100 recent Nuclear Safety Culture Observation forms to assess whether top behaviors by leaders, including those related to decision-making, were being demonstrated. The team identified that the forms have wide variability in the level of detail provided, which limited the overall usefulness of the data. However, the team determined through interviews that the Nuclear Safety Culture Observer function was being implemented as an effective improvement tool. The licensee entered the need to provide instruction on transferring data from the observation form into the observation database into their corrective action program as Condition Report CR-ANO-C-2018-01500.
A bias for action in addressing equipment reliability issues was evidenced in the performance indicators and metric data that was reviewed by the team. In particular, performance improvement metrics in areas affected by decision-making with a bias to action, such as equipment reliability, the length of time that systems are not performing at optimum levels, and critical equipment failures demonstrated improvement and met or exceeded licensee goals in most cases. In cases where the performance had not yet achieved the goal, the performance trend was observed by the team to be in a positive direction as a result of the licensee implementing an action plan.
The team also reviewed performance indicators and metric data associated with Plant Health. In particular, the team reviewed critical equipment failures, equipment reliability index, and the length of time that systems were not performing at optimum levels. The team also reviewed the most recent System Health IQ report, which assessed the overall health of all of the safety-related and nonsafety-related systems that supported plant operation. The team determined that the health of the systems had improved, system health fully supported safe plant operation, and that performance was sustainable based on the consistency in performance over time.
The team also reviewed performance indicators and metric data associated with preventive maintenance. In particular, the team reviewed procedure and work instruction backlogs, procedure and work instruction workoff curves, maintenance backlogs, open craft feedback requests, and open preventive maintenance change requests. The team determined that the preventive maintenance indicators continued to improve to performance levels that exceeded licensee performance goals.
The results of the teams interviews reflected very positive worker opinions regarding the changes implemented at ANO. In particular, the interviews identified that a bias for action to address problems had developed in the organization at both the site and corporate level. Decisions to perform new work identified during refueling outages that caused those outages to be extended beyond their original completion dates were frequently identified as evidence of this new bias for action and to make decisions focused on long-term plant reliability.
The interviews also consistently reflected an increase in the staffing levels in the engineering department with an associated decrease in workload, despite the additional engineering work required to support plant recovery activities. The hiring of both experienced personnel and recent college graduates was viewed positively by the organization, and the hiring of a dedicated recruiter to help identify prospective candidates to fill vacancies at the site improved the process.
The team noted that the process for incorporating feedback into work orders lacked a clear mechanism for making prompt changes. In particular, there was no formal process to make high priority work order changes. This type of process exists for changes to procedures. Procedure EN-WM-105, Planning, step 5.9, Planning Feedback, Substep [3] only required that preventive maintenance work order feedback be monitored and incorporated within 90 days or that the feedback be evaluated and the preventive maintenance model work order be placed in a plan status within 90 days with a hold pending incorporation of the feedback. The licensee entered the lack of procedural clarity to incorporating feedback to work orders prior to field implementation into their corrective action program as Condition Report CR-ANO-C-2018-01552.
Based on the actions taken by the licensee, data evaluated by the team, and observations performed on site, the team concluded that the actions taken to address the Equipment Reliability and Engineering Programs inspection focus area were effective in meeting the DB&Os. Therefore, the Equipment Reliability and Engineering Programs inspection focus area of the CAL is closed.
c. Closure of CAL Inspection Focus Area: Safety Culture Background ANO determined that the most significant causes for declining performance were ineffective change management with respect to resource reductions, and leadership behaviors that were not commensurate with a strong safety culture. When implementing resource reductions across its fleet in 2007 and 2013, Entergy did not consider the unique staffing needs for ANO created by having two units with different technologies.
ANO management did not reduce workloads through efficiencies or the elimination of unnecessary work, as was intended as part of the resource reduction initiatives.
Leaders attempted to prioritize work with the available resources, but were unable to address expanding work backlogs. An unexpected increase in attrition between 2012 and 2014 caused a loss in experienced personnel, a reduced capacity to accomplish work, and an increase in the need for training and supervision. While the 95003 inspection team determined that workers were willing to raise safety concerns, the workers were not confident that management would address more routine problems.
ANO leaders missed an opportunity to engage the workforce early in the recovery process to help identify, assess, and develop corrective actions for declining performance. As a result, the NRC teams independent safety culture evaluation noted limited improvement in safety culture since the completion of ANOs independent Third Party Nuclear Safety Culture Assessment in 2015.
ANO had not initially assessed the training function, even though safety culture assessments identified training as a problem area. Workers reported that training did not have sufficient priority, impacting their ability to perform their current roles and the ability to achieve higher level qualifications. In response, ANO conducted an evaluation and identified that training needed to be used as a tool to correct problems and improve performance and created a Training to Improve Organizational Performance Area Action Plan.
ANO had not created a specific improvement plan to address the findings of the safety culture assessments, choosing to address selected safety culture attributes that were associated with root cause evaluations rather than treating the findings in the context of a separate problem area. By not performing a cause evaluation for safety culture, ANO management missed the opportunity to address the full scope of safety culture weaknesses. To address this issue, ANO performed two cause evaluations, developed the Safety Culture Area Action Plan, and assigned a full-time Safety Culture Manager.
Scope of Review Since August 29, 2016, the NRC has performed quarterly CAL inspections of individual action items and found the items to be complete and effective. The complete list of individual action items along with descriptions and relevant inspection reports is provided in Attachment 3. To ensure the licensee adequately addressed the inspection focus area, the NRC team reviewed the focus area for key DB&Os to verify that the licensee showed sustained improvement. Specifically, the following DB&Os where reviewed:
- Corporate and Independent Oversight (CO) DB&O-1: Specific information is provided on ANO Safety Culture and regulatory perspective to the Entergy Operations senior management review board (Oversight Analysis Meeting and Oversight Review Board). This information is used for performance monitoring and comprehensive oversight decisions. (Key Actions CO-1, CO-2, and CO-4)
- CO DB&O-4: Controls are established for the Entergy change management processes including planning, execution, and effectiveness review. These controls are used to prevent unintended consequences during high-risk changes.
(Key Action CO-5)
- CO DB&O-6: Specific information is provided on ANO Safety Culture and regulatory perspective to the Entergy Operations senior management review board (Oversight Analysis Meeting (OAM) and Oversight Review Board (ORB)).
This information is used for performance monitoring and comprehensive oversight decisions. This action is designated DBO-1. (Key Actions CO-1, CO-2)
- DM DB&O-3: Senior leaders create an environment that encourages the raising of concerns and questions, and is conducive to robust interaction and problem resolution. (Key Actions DM-2 and DM-3)
- LF DB&O-1: Leaders communicate and build trust in the organization. (Key Actions LF-1, LF-3, LF-4, LF-5, LF-6, LF-7, and LF-9)
- LF DB&O-4: ANO leaders are identifying and addressing individual and organizational performance issues. (Key Actions LF-1, LF-3, LF-5, LF-9, and LF-13)
- LF DB&O-5: ANO leaders drive excellence in processes and procedures through the Department Performance Improvement Meetings (DPRMs) and Aggregate Performance Improvement Meetings (APRMs). (Key Actions: LF-8, LF-11, LF-12 and LF-14)
- NF DB&O-8: Workers understand what it means to be thinking and engaged and practice the foundational behaviors (criteria) defined by the industry for the Nuclear Professional. (Key actions NF-1, NF-2, NF-6, NF-7, NF-8, and NF-9)
- NF DB&O-10: Application of fundamental behaviors is reflected in low rates of human performance errors and rework. (Key actions NF-1, NF-2, NF-3, NF-5, NF-6, NF-7, NF-9, and NF-11)
- OC DB&O-1: Leaders ensure nuclear safety is the top consideration in making decisions on workforce resources. Leaders use appropriate information to make strategic decisions regarding workforce needs. The information includes data supporting organization capability, e.g., knowledge gaps, attrition projections and demographic makeup (age and years of service - proficiency). This information is incorporated into an Integrated Strategic Workforce Plan (ISWP) that leaders use to ensure the organization has the necessary capacity and skills for safe and reliable plant operation. (Key Actions OC-1, OC-2, OC-3, and OC-4)
- Safety Culture (SC) DB&O-1: All individuals take personal responsibility and are accountable for displaying core values and behaviors that support a healthy Nuclear Safety Culture at ANO. (Key Actions SC-5, SC-6, SC-7, SC-10, and SC-19)
- SC DB&O-3: Leaders create an environment where upward communication/feedback is sought out, valued, and rewarded. Leaders create communication opportunities, encourage the free flow of information, and respond to individuals in an open, honest, and no-defensive manner. Trust, respect and a sense of teamwork permeate the ANO organization. (Key Actions SC-7, SC-8, SC-9, and SC-11)
- SC DB&O-8: Nuclear safety is constantly scrutinized through a variety of monitoring tools, including effective use of the Nuclear Safety Culture Monitoring Panel and Corporate Oversight. (Key Actions SC-1, SC-2, SC-3, SC-14 and SC-15)
- Training to Improve Organizational Performance (TR) DB&O-3: Resources in key departments, including the training department, are sufficient to support training for organizational performance improvement. (Key Action TR-5)
To evaluate the licensees corrective action effectiveness, the team reviewed:
- Confirmatory Action Letter and Area Action Plan Actions Effectiveness (LO-ALO-2018-00014)
- Nuclear Safety Culture Area Action Plan Closure Report
- Nuclear Safety Culture Monitoring Panel Meeting Minutes
- Nuclear Safety Culture Closure Readiness Evaluation
- Station and CRP metrics, as well as other relevant performance monitoring data
- Synergy and Organizational Health Index (OHI) Survey Results and Data
- Interviewed a cross section of station management and employees To evaluate the licensees corrective action effectiveness, the team conducted seven focus group discussions with ANO personnel, including maintenance, operations, planning, and engineering. Focus group discussions and interviews were conducted using questions related to the areas of leadership, personal accountability, questioning attitude, problem identification and resolution, change management, decision making, effective communications, and continual learning. Additional insights were gathered by reviewing documents related to ANOs safety culture, including safety culture assessment reports, the Nuclear Safety Closure Readiness Evaluation, OHI survey results and corrective actions associated with the most recent OHI survey, and Nuclear Safety Culture Monitoring Panel meeting minutes. The team evaluated the Nuclear Safety Culture Monitoring Panel to verify their effectiveness in continuously monitoring the safety culture at ANO. In addition, the team evaluated the corrective actions and effectiveness criteria established by the licensee in aggregate for the reviewed DB&Os.
Based on focus group discussions, the team determined that most personnel believed that ANO management places an appropriate level of emphasis on safety. In addition, personnel stated that they are free to stop work and resolve issues concerning safety with management support. Most personnel feel that safety standards have been raised to an appropriate level at the site. The team determined that because the work management process was not identified to be a significant contributor to declining safety performance during the NRCs 95003 inspection, certain isolated organizations within the work management process received less attention in the area of safety culture improvement than other work groups. This has resulted in challenges with interdepartmental coordination.
Most personnel interviewed in the focus groups agreed that staffing levels had increased; however, some individuals felt that more personnel are still needed in some work groups. Those individuals stated that ANO had communicated to them that they would continue to hire more personnel. The team determined that ANO had increased staffing at the site using the Nuclear Strategic Plan. The Nuclear Strategic Plan for ANO indicated that ANO would hire additional staff in the future to meet the needs of the organization. In addition, most personnel interviewed stated that they were receiving the necessary amount of training in order to qualify and perform their jobs safely. Most personnel stated that the use of mentors was a positive mechanism to transfer knowledge from the senior personnel to the junior personnel.
Most personnel interviewed stated that the Behavior Based Safety program (peer-to-peer coaching) was an effective method to help each other maintain high safety standards. The team determined that this process was effective in supporting leaders in reinforcing fundamental behaviors and fostering worker ownership and engagement in licensee performance.
Through a review of the licensees 2017 OHI survey combined with the results of the teams focus group discussions and interviews, the team identified that ANO did not identify a potential priority group following the most recent safety culture survey. A priority group is a work group whose safety culture survey results were sufficiently more negative than the general population to warrant additional evaluation and possible development of an action plan to address the underlying causes for those negative responses. While reviewing Safety Culture DB&O-8, which states, Nuclear safety is constantly scrutinized through a variety of monitoring tools, the team reviewed the process that Entergy used to evaluate the safety culture of the station, which had changed to use the OHI Survey. The team identified that Entergy had previously relied upon multiple external monitoring tools to identify potential priority groups and provide information and possible causes from the survey results. Previous monitoring tools appropriately included qualitative assessment tools, such as interviews and focus groups, to identify causal factors for significant negative response trends. However, the Entergy change management process did not identify that the OHI survey did not include qualitative evaluation tools. The team concluded that the Entergy program had adequate steps to address priority groups when they are recognized, but did not have steps to make a determination whether any work groups should be classified as a priority group. The team noted that the ANO Safety Culture Monitoring Panel reviewed the OHI survey results and had been developing an action plan, but did not specifically consider whether any work groups should be considered for treatment as priority groups.
The team concluded that this was because the Entergy program did not require a qualitative evaluation be performed for significant negative response trends. In response to this concern, ANO wrote Condition Reports CR-ANO-C-2018-01736 and CR-HQN-2018-00803 and Learning Organization Report LO-ALO-2018-00029 (Corrective Action 28). Entergy stated that they would take the following actions and provide the results to the NRC for review. Changes to this plan may not be made without a review by the Nuclear Safety Culture Monitoring Panel.
- (1) Revise the Entergy program to address identifying potential priority groups and if safety culture concerns are identified, conduct qualitative analysis of the survey results to determine appropriate actions to address those concerns. The results of the analysis and any planned actions will be tracked via Learning Organization Report actions and presented in an applicable management forum;
- (2) Perform interviews and focus group discussions with a representative sample of site personnel for significant results identified from the 2017 OHI survey and ensure appropriate corrective actions have been developed; and
- (3) Perform interviews and focus group discussions with a representative sample of site personnel, if necessary, after receiving the results of the upcoming 2018 OHI survey.
The team concluded that these actions were appropriate to establish an adequate understanding of the causes for negative responses to the OHI survey results, to ensure that priority groups would be appropriately identified, and to develop appropriate corrective actions.
Based on the actions taken by the licensee, data evaluated by the team, and observations performed on site, the team concluded that the actions taken to address the Safety Culture inspection focus area were effective. Therefore, the Safety Culture inspection focus area of the CAL is closed.
d. Closure of CAL Inspection Focus Area: Service Water System Self-Assessment Background On January 26, 1990, ANO committed to establishing a program to address biofouling in raw water cooling systems which included chlorination, inspection and cleaning, and periodic flow tests. This included conducting periodic flow tests of the safety-related heat exchangers cooled by the service water (SW) system and periodic flushes of normally stagnant SW system pipe sections. ANOs December 2015 assessment of their SW Program documented seven problems, and stated that the overall program health was good with respect to the primary goal of ensuring the systems ability to provide its required heat removal function. The report stated that the program had maintained flows above required limits, although problems were identified with improving low flow margins for some components, inadequate configuration control, inadequate alignment between governing documents, and implementation actions that need to be addressed. Specifically, the Unit 2 emergency diesel generator heat exchangers (2E-20/63/64A and B), shutdown cooling heat exchangers (2E-35A and B), and B control room chiller condenser (2VE-1B) had a longstanding trend of having low flow margins, although the flows have been maintained above the required flow.
The 95003 inspection team noted that the ANO SW Program assessment did not classify the long-term, low flow margin trends as problems because credit was given for the site processes to elevate awareness of the margin concern, the effectiveness of past actions to sustain acceptable flow, and the success of recently performed actions at improving flow margin. The NRC team concluded that ANO had been attempting to manage a problem that affected the entire SW system by reducing margins to keep the system within the minimum requirements. The team concluded that the assessment applied a systematic approach to review of the SW Program, but did not provide a realistic assessment of the effectiveness of the program in identifying and correcting longstanding degraded conditions. The NRC team concluded that ANO did not have an adequate assessment of system performance problems or a holistic plan to correct the problems and causes.
As part of the 95003 Inspection Report 05000313/2016007 and 05000368/2016007 (ADAMS Accession No. ML16161B279), the NRC issued ANO four Green, non-cited violations and documented one licensee-identified finding involving the service water system.
The licensees progress in implementing the Service Water System Self-Assessment, Action SW-1, was reviewed in NRC Inspection Report 05000313/2016008 and 05000368/2016008 (ADAMS Accession No. ML17059D000) to assess how the focused self-assessment was being performed while the assessment was in progress. The NRC closed SW-1 in NRC Inspection Report 05000313/2017011 and 05000368/2017011 (ADAMS Accession No. ML17195A478). During this inspection, the team reviewed the focused self-assessment report Service Water System Operational Performance Inspection, and NUENERGY Report NUI-EOI-ANO SWS SA 2016-01; the Service Water System Improvement Plan; Condition Reports; and the CRP Action Effectiveness Summary for SW-1. The team compared the recommendations and problems identified in the self-assessment to the actions in the Service Water System Improvement Plan to verify that the actions needed to address material condition challenges and equipment reliability were included in the plan and were scheduled for completion in an appropriate timeframe based on the current conditions and safety significance. The team also verified that issues were entered into the corrective action program for resolution.
The team concluded that the focused self-assessment was completed in a manner that was consistent with the guidance in NRC Inspection Procedure 93810. The team interviewed the Unit 1 and 2 service water system engineers, the service water system self-assessment team leader, the Microbiological-Influenced Corrosion Program engineer, the Inservice Inspection Program engineer, the heat exchanger engineer, and the Design and Programs Engineering manager to discuss the material history of the system, degradation mechanisms, and previous actions to address those challenges.
These discussions focused on the licensees understanding of pitting corrosion, piping occlusion, flow degradation, and component functionality. The team concluded that the licensee identified all issues of concern in the corrective action program and understood the degradation mechanisms for service water system piping and components, which involved a combination of microbiologically-influenced corrosion and galvanic corrosion.
Scope of Review Since August 29, 2016, the NRC has performed quarterly CAL inspections of individual action items and found the items to be complete and effective. The complete list of individual action items along with descriptions and relevant inspection reports is provided in Attachment 3. To ensure the licensee adequately addressed the CAL inspection focus area, the NRC team reviewed the focus area for the key DB&O to verify that the licensee showed sustained improvement. Specifically, the following DB&O was reviewed:
- Service Water DB&O: To ensure conditions adverse to quality are identified and resolved, ANO will conduct a focused self-assessment of Units 1 and 2 service water systems in accordance with station procedures and NRC Inspection Procedure 93810, Service Water System Operational Performance Inspection.
(Key Action SW-01)
To evaluate the licensees corrective action effectiveness, the team reviewed:
- Service Water System Closure Readiness Evaluation
- Comprehensive Recovery Plan Action Effectiveness for NRC closure for SW-01
- Comprehensive Recovery Plan Action Item Closure SW-01
- Service Water System Operational Performance Inspection Report (SWSOPI)
- NUENERGY Innovative Solutions, Inc., Support of ANO 2016 Service Water Self-Assessment Activities Report (NUI-EOI-ANO SWS SA 2016-01)
- Design and Licensing Basis Area Action Plan Closure Report
- Confirmatory Action Letter and Area Action Plan Actions Effectiveness (LO-ALO-2018-00014)
- Interviewed engineers, program owners, supervisors, and managers with a connection to service water The team evaluated the corrective actions and effectiveness criteria established by the licensee in aggregate for the reviewed DB&O. The team verified that the licensee was following the Service Water Improvement Plan to address the material condition challenges and equipment reliability in an appropriate timeframe based on the current conditions and safety significance. The team noted that the licensee replaced the chemical treatment system for both units and several hundred feet of service water piping in both units, and continues to replace piping and perform testing. In addition, the team noted that the licensee has become more proactive in finding, addressing, and evaluating pipe pitting. The licensee accomplished this by addressing all the currently existing through-wall leaks and adopting improved nondestructive testing methods and water treatment. The licensee also prioritized the nondestructive testing and the replacement of piping and major components based on the risk significance. In particular, the team noted strong ownership by all the engineers, program owners, supervisors, and managers interviewed.
Based on the actions taken by the licensee, data evaluated by the team, and observations performed on site, the team concluded that the actions taken to address Service Water Self-Assessment were effective. Therefore, the Service Water Self-Assessment inspection focus area of the CAL is closed.
.2 CAL Action Follow-up (IP 92702)
This section describes the scope, corrective action, and inspection of the remaining open CAL items.
Actions to Address Equipment Reliability and Engineering Program Deficiencies DB-11 Perform one benchmark or one self-assessment between March 1, 2016, and March 1, 2020, for each of 24 engineering programs. (CR-ANO-C-2015-02833 CA-28, and CR-ANO-C-2016-00614 CA-8 and CA-22)
During the 95003 supplemental inspection, the NRC team found that the ANO snapshot assessments of engineering programs were conducted in a systematic manner, some used industry experts, and identified program deficiencies.
However, the NRC team concluded that ANOs snapshot assessments were not fully effective in assessing whether some programs addressed longstanding equipment performance trends or whether plant components were appropriately included in programs. In response to the NRC teams observations, ANO initiated actions (CR-ANO-C-2016-00614) to conduct benchmarking of engineering programs and assign experienced mentors to program owners.
During the NRCs first review of DB-11 in Inspection Report 05000313/2018012 and 05000368/2018012 (ADAMS Accession No. ML18092A005), the team identified missing design bases calculations and licensing documents related to the High Energy Line Break (HELB/MELB) program. The licensee had failed to initiate condition reports or corrective actions for missing design bases calculations or licensing documents identified in CALC-ANOC-CS-16-00004, HELB Program Design Basis Consolidation Report, Table 9-1. The team concluded that DB-11 would be held open to review the licensees corrective action plan to locate or reconstitute the missing design information.
For this inspection, the team reviewed corrective actions associated with this concern to evaluate the licensee's corrective action effectiveness. As a result of the NRCs first review, the licensee re-evaluated the high energy line break program to determine the appropriate resolution of the design documents that could not be readily retrieved. The licensee developed a High Energy Line Break Design Basis Documents Project Plan, documented in Condition Report CR-ANO-C-2015-02833 (CA-27 and CA-28) with specific actions assigned to each of the 12 affected plant areas to either locate or create the required documentation (CAs 122-133). In addition, the Project Plan also required updating the design drawings for these areas to ensure that if modifications were performed before the required documentation was identified that additional actions were required to create the required calculations.
At the time of this inspection, the licensee believed they located the required documentation for at least three of the remaining 12 areas. The licensee is continuing to search for the documents, have discussions with the vendor, and has hired an investigator to assist in locating documents for the remaining areas.
The team reviewed the Project Plan, procedures, calculations, corrective action documents, and interviewed station personnel to determine that the High Energy Line Break Design Basis Documents Project Plan was adequate to ensure design basis reconciliation for high energy line break locations.
Based on the actions taken by the licensee, information evaluated by the team, and observations performed on site, the team concluded that the actions taken to address DB-11 were effective. Therefore, DB-11 is closed.
PH-12 The following list contains equipment reliability issues in systems or components necessary for the safe and reliable operation of the unit(s) that will be resolved over the next two unit operating cycles. The intent of this action is to demonstrate improved equipment reliability by resolving long-standing equipment issues. (CR-ANO-C-2014-00259 CA-130, CR-ANO-C-2015-02832 CA-33 through CA-35, CR-ANO-C-2015-03029 CA-13, CR-ANO-2-2013-02242 CA-50, and CR-ANO-2-2015-02879 CA-24)
- Unit 1 reactor building coatings margin improvement
- Unit 1 NI-501 detector replacement
- Unit 2 shutdown cooling heat exchanger replacement
- Unit 2 instrument air compressor replacement
- Fire suppression system reliability improvement
- Diesel fire pump engine overhaul
- Radiation monitor reliability improvement
- Unit 2 component cooling water (CCW) system performance improvements o 2P-33C CCW pump overhaul o 2P-33B CCW pump overhaul o 2E-28B CCW heat exchanger replacement
- Service water and circulating water chemical treatment system upgrade
- Unit 2 cooling tower crane replacement
- Unit 2 condensate pump 2P-2A rebuild
- Unit 1 letdown heat exchanger replacement
- Decay heat check valves DH-17 and DH-18 replacement
- Unit 1 reactor vessel head O-ring leakage resolution
- SU2 transformer inspections
- SU3 transformer inspections
- Complete design of Unit 1 integrated control system reverse engineered modules
- Implement single point vulnerability mitigation and elimination efforts The licensees Collective Evaluation identified weaknesses with the organizations ability to identify, prioritize, fund, and implement modifications and other capital improvements required to address equipment issues in a timely manner. Multiple aspects of this process were determined to have challenges.
The licensee committed to complete multiple actions to improve equipment reliability related to items in the Site Integrated Plant Database process. Actions PH-1 through PH-11 in the Plant Health Area Action Plan caused the licensee to identify the equipment reliability problems and improve the processes for prioritizing, planning and funding the projects, while PH-12 through PH-14 committed to implement specific improvement projects. CAL action PH-12 committed ANO to implement a list of specific equipment reliability improvements that had plans developed that were scheduled to be completed between early 2016 and late 2018. The NRC reviewed a sample of risk significant items from the above list to evaluate the effectiveness of the licensees corrective actions to the long-standing equipment issues. The NRC has reviewed items over the last 2 years and reviewed the final seven items of interest in this current inspection.
The team reviewed the licensees progress in resolving equipment reliability issues by evaluating the actions taken to address the following:
- Unit 2 shutdown cooling heat exchanger replacement The team reviewed the system health reports and work orders and interviewed plant personnel regarding the specific equipment reliability issues. The licensee has replaced this equipment, and the team noted that the equipment has been operating with no major issues since these replacements. This item is closed.
- Fire suppression system reliability improvement The team reviewed the system health reports and work orders and interviewed plant personnel regarding the specific equipment reliability issues. The licensee has improved the reliability of the fire suppression system, and the team noted that the equipment has been operating with no major issues since these improvements. The team noted that there was one work order that was cancelled inappropriately, but an extent of condition review conducted by the licensee revealed that there were no further work orders cancelled inappropriately. This item is closed.
- Service water and circulating water chemical treatment system upgrade The team reviewed the system health reports and work orders and interviewed plant personnel regarding the specific equipment reliability issues. The licensee has replaced this equipment in both units and added alternate injection points to ensure the chemical protection was available during outages. The team noted that the equipment has been operating with no major issues since these replacements. This item is closed.
- Decay heat check valves DH-17 and DH-18 replacement The team reviewed the system health reports and work orders and interviewed plant personnel regarding the specific equipment reliability issues. The licensee has replaced these check valves with valves of a different design intended to minimize back-leakage through the check valves.
The team reviewed the post-maintenance testing of the valves prior to being declared operable. This item is closed.
- Startup Transformer 2 inspections The team reviewed the system health reports and work orders and interviewed plant personnel regarding the specific equipment reliability issues. The licensee has inspected this equipment, and the team noted that the equipment has been operating with no major issues since these inspections. This item is closed.
- Complete design of Unit 1 integrated control system reverse engineered modules The team reviewed the system health reports and work orders and interviewed plant personnel regarding the specific equipment reliability issues. This item is intended to address an obsolescence issue before it becomes a reliability problem because the manufacture no longer supplies spare parts for the system. The licensee selected 13 of the 23 modules to be reverse-engineered and have new modules manufactured. Six of the remaining modules were partially reverse-engineered and had components replaced on existing boards. The remainder of the boards were not reverse engineered due to having a sufficient spare stock or because they had no components subject to time degradation. The components that were not reverse-engineered were scheduled to be refurbished to restore each module to the standards in SPEC-16-00001-MULTI, Electronic Assembly Refurbishment/Repair.
The licensee has replaced or has plans to refurbish this equipment, and the team noted that the equipment has been operating with no major issues.
This item is closed.
- Implement single point vulnerability (SPV) mitigation and elimination efforts The team reviewed the system health reports and work orders and interviewed plant personnel regarding the specific equipment reliability issues. This was a proactive action to identify components that have the potential to create plant transients if they fail while in service, and was not intended to correct existing reliability problems. The licensee has implemented these mitigation and elimination efforts. This item is closed.
The items documented above are the final items from PH-12 that the NRC planned to review. Based on the samples in this and previous inspections, the team concluded that the licensee is resolving the equipment reliability issues listed. Therefore, this item is closed.
PH-13 The following list contains equipment reliability issues that are being evaluated by the Plant Health Committee for resolution commensurate with the potential impact on safe and reliable operation of the units by December 20, 2018. For items not resolved by the due date, the Plant Health Committee will provide the safety basis for the extension. (CR-ANO-C-2015-02832 CA-38, and CR-ANO-C-2015-03029 CA-34)
CAL action PH-13 committed ANO to implement a list of specific equipment reliability improvements that did not have improvement plans that were fully developed or funded when the commitment was made. Since the CAL was written, ANO completed planning, scheduling, and budgeting activities for each of the actions listed below. The team reviewed the actions that were completed as samples to evaluate the effectiveness of the licensees corrective actions to the long-standing equipment issues.
- Resolution of Unit 1 emergency diesel generator exhaust stack thinning
- Resolution of Unit 2 emergency diesel generator exhaust stack thinning
- Unit 2 spent fuel pool cooling system performance improvement
- Service water piping replacement
- Correct back-leakage into the Unit 1 boric acid system
- Unit 2 emergency feedwater Terry turbine governor replacement
- Unit 2 spare service water motor issue resolution
- Unit 1 high pressure injection pump P-36B motor refurbishment
- Tornado/missile protection for emergency feedwater piping resolution
- Unit 1 reactor vessel head leak-off line replacement
- Unit 1 and Unit 2 super particulate iodine and noble gas monitor replacement During the 95003 supplemental inspection, the NRC team identified weaknesses in the selection of the right work in the normal work planning process and the backlog reduction process. ANO had defined right work as the grouping of work activities, which best met the equipment reliability needs of the station by balancing the priority to correct degraded conditions against the capability of the station to complete the activity. The mechanical, electrical, and instrumentation and control maintenance coordinators for the online maintenance disciplines and the backlog project manager for the backlog reduction team select the right work. The NRC team noted that the process did not seek input from operations and engineering to help identify the right work activities. For normal online work, ANOs implementation resulted in a poor work bundling, excessive equipment unavailability, and delays in addressing difficult or complex tasks.
The team reviewed the licensees progress in resolving equipment reliability issues by evaluating the actions taken to address the following:
- Unit 1 and Unit 2 Super Particulate Iodine and Noble Gaseous Monitor (SPINGS) replacement The team noted that the licensee has placed one of the SPINGS in service successfully in Unit 1, with the other three Unit 1 SPINGS planned to be fully operable by the end of May 2018. Unit 2 SPINGS are planned to be fully operable by the end of the 2018 fall refueling outage. The team noted that the installed SPING has been operating with no major issues since being replaced.
This item was the final item the NRC planned to review from PH-13. Therefore, this item is closed.
PH-14 Track and audit the completion of the following equipment reliability issues related to the White Finding and the potential for additional unplanned plant trips.
(CR-ANO-C-2015-02831 CA-31, CR-ANO-C-2015-02833 CA-44, and CR-ANO-C-2015-03029 CA-2, CA-3, CA-4, and CA-6)
Action PH-14 committed to complete corrective actions that were planned, scheduled, and funded at the time the commitment was made in order to address the causes and extent of condition/extent of cause from three scrams in Unit 2.
The team reviewed the licensees progress in resolving equipment reliability issues by evaluating the actions taken to address the following:
- Audit completion of repair of 161 kV Russellville East Transmission Line Lightning Protection System.
- Audit completion of Entergy Transmission inspection of static line grounds on Transmission lines that end in ANO switchyard and insure the acceptance criteria per Entergy Transmission Standards. Includes
- (1) Pleasant Hill (500 kV),
- (2) Fort Smith (500 kV),
- (3) Mabelvale (500 kV), and
- (4) Pleasant Hill (161 kV).
- Replace damaged Unit 2 Unit Auxiliary Transformer 6900 V and 4160 V buses and ducting.
- Audit completion of Startup Transformer 3 non-segmented bus inspections, to include visual confirmation of filler material under taped, bolted connections.
- Verify that all medium voltage connections have adequate fill and air gap.
o Issue work requests to inspect all ANO-1 and ANO-2 medium voltage connections for the existence of corona effects o Issue work requests to re-tape all ANO-1 and ANO-2 medium voltage connections in accordance with OP-6030.110, and ensure adequate fill is installed.
o Either track completions of the resulting work orders listed above or close this corrective action to the associated work orders with concurrence by the Condition Review Group and/or Corrective Action Review Board, as required.
The team reviewed the system health reports and work orders and interviewed plant personnel regarding the specific equipment reliability issues. The licensee has inspected and repaired this equipment as needed, and the team noted that the equipment has been operating with no major issues since these improvements.
The items documented above are the final items in PH-14. These actions have been reviewed, and inspectors have verified that the licensee has resolved the equipment reliability issues listed. Therefore, this item is closed.
4OA6 Meetings, Including Exit
Exit Meeting Summary
On May 31, 2018, the team presented the inspection results to Mr. R. Anderson, Site Vice President, and other members of the licensee staff at a public meeting. The licensee acknowledged the issues presented. The inspectors verified no proprietary information was retained or documented in this report.
LIST OF CONFIRMATORY ACTION LETTER ITEMS CLOSED AND DISCUSSED Closed Equipment Reliability and Engineering Program Deficiencies DB-11 (Section 4OA5.2)
PH-12 (Section 4OA5.2)
PH-13 (Section 4OA5.2)
PH-14 (Section 4OA5.2)
LIST OF
DOCUMENTS REVIEWED
Audits/Self Assessments
Number Title Revision/Date
Corporate & Independent Oversight Area Action Plan March 2018
Closure Report
Decision Making and Risk Management Area Action Plan March 2018
Closure Report
Design and Licensing Basis Area Action Plan Closure March 2018
Report
Human Performance Closure Readiness Evaluation 0
Leadership Fundamentals Area Action Plan Closure March 2018
Report
Nuclear Fundamentals Area Action Plan Closure Report March 2018
Nuclear Safety Culture Area Action Plan Closure Report March 2018
Nuclear Safety Culture Closure Readiness Evaluation 0
Organizational Capacity Area Action Plan Closure Report March 2018
Plant Health Area Action Plan Closure Report March 2018
Preventive Maintenance Program Area Action Plan March 2018
Closure Report
Procedure and Work Instruction Quality Area Action Plan March 2018
Closure Report
Service Water System Closure Readiness Evaluation 0
LO-ALO-2016- Confirmatory Action Letter Key Improvement Action 6: December
00078 Service Water System Operational Performance 2016
Inspection (SWSOPI)
LO-ALO-2018- Confirmatory Action Letter (CAL) and Area Action Plan February
00014 (AAP) Actions Effectiveness 2018
LO-ALO-2018- Comprehensive Recovery Plan Procedure Reconciliation March 2018
00040
NUI-EOI-ANO Support of ANO 2016 Service Water System Self December
SWS SA 2016-01 Assessment Activities 2016
Condition Reports (CR-ANO-)
C-2015-02829 C-2015-02833 C-2015-04876 C-2016-00435 C-2016-00524
C-2016-00546 C-2016-00614 C-2016-01736 C-2017-00926 C-2017-02836
C-2018-00554 C-2018-01118 C-2018-01189 C-2018-01500 C-2018-01502
C-2018-01552 C-2018-01554 C-2018-01555 C-2018-01556 C-2018-01558
C-2018-01560 C-2018-01736 1-2015-02032 1-2016-04138 1-2016-04924
1-2016-05076 1-2016-05100 1-2016-05107 1-2018-00541 1-2018-01178
2-2016-00361 2-2016-00421 2-2016-00672 2-2016-00674 2-2016-03882
2-2016-04014 2-2016-04175 2-2018-00724
CR-HQN-2018- CR-HQN-2018- CR-HQN-2018- CR-HQN-2018-
00024 00298 00786 00803
Procedures
Number Title Revision
COPD-024 Risk Assessment Guidelines 65
EN-DC-115 Engineering Change Process 23
EN-DC-134 Design Verification 7
EN-DC-329 Engineering Programs Control and Oversight 6
EN-FAP-OM-016 Performance Management Process and Practices 8
EN-LI-121 Trending and Performance Review Process 24
EN-OM-126 Management and Oversight of Supplemental Personnel 6
EN-QV-136 Nuclear Safety Culture Monitoring 12
EN-WM-100 Work Request (WR) Generation, Screening, and 13
Classification
EN-WM-104 On Line Risk Assessment 16
EN-WM-105 Planning 20
PI-001 Paired Observation Program 4
SEP-EPCO- ANO Engineering Programs Control and Oversight 3
ANO-001
Miscellaneous
Number Title Revision/Date
1R27 Outage Meeting & Communication Schedule
Action Plan to Address Unit 1 Scope and Selection Stability
Red Performance Indicator
ANO Employee Handbook
ANO People Health Committee - Engineering Minutes February 15,
2018
ANO Integrated Strategic Workforce Plan (ISWP)
Miscellaneous
Number Title Revision/Date
Average Functional Area Scores and Weighted Fleet Index
Comprehensive Recovery Plan Metrics January -
February
2018
Critical Preventive Maintenance Index - ANO Unit 1 and February
Unit 2 2018
Equipment Reliability Index - ANO Unit 1 and Unit 2 February
2018
High Energy Line Break (HELB) Design Basis Documents 0
Project Plan
Main Control Room Deficiencies - ANO Unit 1 and Unit 2 March 2018
Nuclear Safety Culture Monitoring Panel Meeting Minutes Various
Nuclear Safety Culture Observation Forms February 1,
2018 - March
30, 2018
OHI Survey Results 2016, 2017
Red Comprehensive Recovery Plan Indicators and
Associated Action Plans
Site Scorecard - ANO Unit 1 and Unit 2
Synergy Survey Results 2016
Tracking Spreadsheet and Work Curves for Procedure
Changes
Weighted Functional Area Index
CALC-ANOC- Arkansas Nuclear One Units 1 & 2 High Energy Line Break 1
CS-16-0004 (HELB) Program Revalidation (HELB Program Design Basis
Consolidation Report)
Drawing A-7003 High Energy Line Break (HELB) various
Sheets 1-16
WO-ANO- CV-3811 PM IAW OP-1412.001
2550018
WT-WTHQN- Perform Effectiveness Review of Fleet Implementation of
CONFIRMATORY ACTION LETTER ITEM STATUS
Significant Performance Deficiencies
Area
Inspection Inspection Report
Action Description Status
Dates Number(s)
Plan
CO-5 Develop and issue an Entergy 8/28/17 - 05000313/2017012, Closed
OC-5 change management procedure 9/1/17 05000368/2017012
for planning, execution, and follow
up of high risk changes. The
procedure will include specific
expectations for reviewing the
effectiveness of high risk
changes. Perform a snapshot
benchmarking to check the
approach for change
management against industry
practices.
DB-1 Establish metrics to monitor 8/28/17 - 05000313/2017012, Closed
performance that would indicate 9/1/17 05000368/2017012
that leadership focus on
minimizing risk and nuclear safety
results in improvement to the
health of maintenance rule
systems.
DB-2 Facilitate behavior change by 8/28/17 - 05000313/2017012, Closed
rewarding performance that 9/1/17 05000368/2017012
indicates leadership behaviors are
focused on minimizing risk and
nuclear safety by incorporating
maintenance rule monitoring
goals into the supervisor and
above incentive plan.
DB-3 Provide training to Engineering, 10/31/16 - 05000313/2016008, Closed
Operations, and Planners to 12/2/16 05000368/2016008
increase the knowledge and skills
regarding passive barriers and
other Design Basis Features.
DM-1 Establish a decision making tool 11/27/17 - 05000313/2017013, Closed
for station personnel that includes 12/1/17 05000368/2017013
expectations for use at ANO. The
intent of this action is to establish
a minimum risk option behavior
that drives the decision maker to
develop multiple solutions and
drive the decision that has the
least risk.
Area
Inspection Inspection Report
Action Description Status
Dates Number(s)
Plan
DM-6 Deliver risk recognition training 11/27/17 - 05000313/2017013, Closed
and develop curriculum for all site 12/1/17 05000368/2017013
personnel with unescorted
access.
DM-7 Develop and implement training 8/28/17 - 05000313/2017012, Closed
on procedures governing risk 9/1/17 05000368/2017012
assessment for work
management SROs, work week
managers, shift managers, and
unit coordinators.
DM-8 Develop and implement a 8/28/17 - 05000313/2017012, Closed
familiarization (FAM) guide for the 9/1/17 05000368/2017012
function of work management
SRO that will ensure clear
understanding of job functions.
DM-10 Revise procedure EN-WM-104, 5/22/17 - 05000313/2017011, Closed
On-Line Risk Assessment, to 5/26/17 05000368/2017011
include guidance for classifying as
high risk those work activities
involving a credible risk concern
with unacceptable consequences
and first-of-a-kind or first-in-a-
while activities.
DM-11 Revise project management 11/27/17 - 05000313/2017013, Closed
VO-19 procedures to ensure high 12/1/17 05000368/2017013
consequence risks are properly
identified and eliminated/mitigated
through a structured risk
management process.
FP-1 Develop external flooding design 10/31/16 - 05000313/2016008, Closed
basis documentation so 12/2/16 05000368/2016008
configuration control is defined
and maintained. Develop an
engineering report and flood
protection drawings similar to fire
protection drawings to clearly
document the flooding design
basis and credited flood
protection features (credited
external flood protection features
and credited operator actions),
and assign unique equipment ID
to each flood protection feature
and boundary.
Area
Inspection Inspection Report
Action Description Status
Dates Number(s)
Plan
FP-2 Develop internal flooding design 10/31/16 - 05000313/2016008, Discussed,
basis documentation so 12/2/16 05000368/2016008 awaiting
configuration control is defined licensee
and maintained. Develop an action
engineering report and flood
protection drawings similar to the
fire protection drawings to clearly
document the flooding design
5/22/17 - 05000313/2017011, Closed
basis and credited flood
5/26/17 05000368/2017011
protection features (credited
internal flood protection features
and credited operator actions).
Update the Flooding Upper Level
Document (ULD). Assign unique
equipment identification to each
flood protection feature and
boundary.
FP-3 Label external flood barriers in the 10/31/16 - 05000313/2016008, Closed
plant to provide in-field awareness 12/2/16 05000368/2016008
of flood protection features.
FP-4 Establish an Engineering Barrier 8/28/17 - 05000313/2017012, Closed
Program to include external and 9/1/17 05000368/2017012
internal flood protection in
accordance with the requirements
of procedure EN-DC-329,
Engineering Programs Control
and Oversight. Assign program
owner and backup. Establish
PMs for external and internal
flood protection features including
scope, frequency, testing criteria,
and acceptance criteria.
FP-5 Revise procedure EN-DC-329, 2/27/17 - 05000313/2017010, Closed
Engineering Programs Control 3/3/17 05000368/2017010
and Oversight, to include
external and internal flood
protection in the Engineering
Program List. Revise the flooding
programmatic aspects of
procedure EN-DC-150, Condition
Monitoring of Maintenance Rule
Structures. Revise EN-DC-136,
incorporate external flood
considerations.
Area
Inspection Inspection Report
Action Description Status
Dates Number(s)
Plan
FP-6 Validate that all external flood 10/31/16 - 05000313/2016008, Closed
gaps identified from the review of 12/2/16 05000368/2016008
documentation for credible flood
paths and the follow-up walk
downs have been resolved.
FP-7 Perform walk downs of all 10/31/16 - 05000313/2016008, Discussed,
credited internal flood protection 12/2/16 05000368/2016008 awaiting
features and document the results licensee
in an engineering report. action
5/22/17 - 05000313/2017011, Closed
5/26/17 05000368/2017011
FP-8 11/27/17 - 05000313/2017013, Discussed,
Validate that all internal flood 12/1/17 05000368/2017013 awaiting
gaps identified from the review of licensee
documentation for credible flood action
paths and the follow-up walk 2/12/18 - 05000313/2018012, Closed
downs have been resolved. 2/16/18 05000368/2018012
FP-9 Establish the Program Notebook 5/22/17 - 05000313/2017011, Closed
and initial Program Health Report 5/26/17 05000368/2017011
for flood protection in accordance
with procedure EN-DC-143,
Engineering Health Reports, to
identify, communicate, prioritize
and drive resolution of issues that
challenge an effective flood
protection strategy including
performance indicators, initial
color rating (Red or Yellow), and
action plan.
FP-13 Develop and conduct initial and 10/31/16 - 05000313/2016008, Closed
continuing training essential to 12/2/16 05000368/2016008
understanding and maintaining
the license basis for flood barrier
features. Address Operations,
Engineering, and Work Planning
groups.
VO-1 Designate a Subject Matter 8/29/16 - 05000313/2016010, Closed
Expert (SME) to oversee 9/16/16 05000368/2016010
implementation of the procedure
for Management and Oversight of
Supplemental Personnel and
contractor oversight for AN
- O.
VO-4 Establish a Vendor Oversight 8/29/16 - 05000313/2016010, Closed
Team to drive continuous 9/16/16 05000368/2016010
improvement in Vendor Oversight.
Area
Inspection Inspection Report
Action Description Status
Dates Number(s)
Plan
VO-5 Develop and implement a process 5/22/17 - 05000313/2017011, Closed
for monitoring of supplemental 5/26/17 05000368/2017011
oversight plan compliance.
VO-6 Establish specific 5/22/17 - 05000313/2017011, Closed
templates/guidance/examples to 5/26/17 05000368/2017011
support consistent development
of supplemental oversight plans.
VO-7 Develop and implement initial and 8/28/17 - 05000313/2017012, Discussed,
continuing training on the 9/1/17 05000368/2017012 awaiting
procedure for management and licensee
oversight of supplemental action
personnel. Training is for site 2/12/18 - 05000313/2018012, Closed
contract managers and project 2/16/18 05000368/2018012
managers.
VO-8 Develop and implement a contract 11/27/17 - 05000313/2017013, Closed
management familiarization guide 12/1/17 05000368/2017013
to include determination and
documentation of work scope, risk
assessment, incentives and
penalties, and performance
monitoring. Include review of
operating experience, such as the
contractual aspects of the stator
lift rig failure and other related
industry events in the
familiarization guide.
VO-9 Perform an organizational 8/28/17 - 05000313/2017012, Closed
capacity assessment for vendor 9/1/17 05000368/2017012
oversight, including contract
management and administration,
critical procurements, and
department-specific resource
impacts.
VO-10 Evaluate span of control with 2/27/17 - 05000313/2017010, Closed
regard to responsible oversight of 3/3/17 05000368/2017010
vendors, and place actions to
address identified weaknesses in
the Corrective Action Program.
VO-11 Revise the Supplemental 5/22/17 - 05000313/2017011, Closed
Personnel Expectations Brief 5/26/17 05000368/2017011
Checklist to include supplemental
personnel receiving a site
employee handbook and a
discussion by responsible
management on the site
employee handbook and
expectations for use.
Area
Inspection Inspection Report
Action Description Status
Dates Number(s)
Plan
VO-14 Establish a fleet charter team or 2/27/17 - 05000313/2017010, Closed
ANO team to address 3/3/17 05000368/2017010
weaknesses in the procedures for
contractor oversight. Specifically,
identify gaps in the procedures to
align with industry guide AP-930,
Supplemental Personnel Process
Description. Assign additional
actions as warranted to address
any gaps identified.
VO-15 Review current processes in 10/31/16 - 05000313/2016008, Closed
Engineering related to Vendor 12/2/16 05000368/2016008
Oversight Fundamental Problem.
Determine if additional actions are
required to address less formal
interfaces with suppliers of
contract services. Assign
additional actions as warranted to
address any gaps identified.
VO-18 Revise Project Management 8/29/16 - 05000313/2016010, Discussed,
procedures to ensure projects are 9/16/16 05000368/2016010 awaiting
organized and managed with (1) licensee
effective support by subject action
experts and (2) effective vendor 11/27/17 - 05000313/2017013, Closed
and technical oversight. 12/1/17 05000368/2017013
VO-20 Issue a procedure for 2/27/17 - 05000313/2017010, Discussed,
management and oversight of 3/3/17 05000368/2017010 awaiting
supplemental personnel including licensee
improvements to (1) defined action
responsibilities, (2) assessment of 8/28/17 - 05000313/2017012, Closed
risk, and (3) vendor oversight 9/1/17 05000368/2017012
plans.
VO-21 Develop and implement recurring 5/22/17 - 05000313/2017011, Closed
DM-9 training for project management 5/26/17 05000368/2017011
personnel on risk recognition and
conservative decision-making.
Area
Inspection Inspection Report
Action Description Status
Dates Number(s)
Plan
VO-23 Revise EN-DC-114, Project 10/31/16 - 05000313/2016008, Closed
Management, to provide guidance 12/2/16 05000368/2016008
in specifying contract language
which will ensure detailed
engineering calculations, quality
requirements and standards are
provided for internal and third
party review, in accordance with
revised EN-MA-119, Material
Handling Program, when specially
designed temporary lift assembles
are to be used.
VO-24 Revise EN-MA-119, to require a 10/31/16 - 05000313/2016008, Closed
documented engineering 12/2/16 05000368/2016008
response to evaluation critical lifts
if using any specially designed
temporary lifting device, any lifting
device that cannot be load tested 2/27/17 - 05000313/2017010, Additional
per EN-MA-119 criteria, or any 3/3/17 05000368/2017010 information
lifting device without a certified added
load rating nameplate rating
affixed to it.
Identifying, Assessing and Correcting Performance Deficiencies
Area
Inspection Inspection Report
Action Description Status
Dates Number
Plan
CA-1 Establish Corrective Action 5/22/17 - 05000313/2017011, Closed
Program (CAP) content in the ANO 5/26/17 05000368/2017011
Employee Handbook to include
behaviors for prompt identification
of conditions into CA
- P.
CA-3 Conduct an organizational capacity 11/27/17 - 05000313/2017013, Closed
study to determine and correct 12/1/17 05000368/2017013
staffing and proficiency needs,
including needs to support CAP
implementation. Establish a
People Health Committee (APHC)
to support ongoing monitoring and
adjustments.
Area
Inspection Inspection Report
Action Description Status
Dates Number
Plan
CA-4 Develop and implement initial and 5/22/17 - 05000313/2017011, Closed
continuing CAP training for station 5/26/17 05000368/2017011
employees, ACE/RCE evaluators,
responsible managers (including
specialists and points of contact,
and performance improvement
personnel.
CA-5 Train investigators, managers and 8/29/16 - 05000313/2016010, Closed
Performance Improvement (PI) 9/16/16 05000368/2016010
Staff on proper causal techniques,
manager oversight expectations
and engagement, and conducting
quality reviews of completed cause
evaluations and corrective actions.
Establish initial and refresher
training requirements in these
areas.
CA-6 Implement training, benchmarking, 5/22/17 - 05000313/2017011, Discussed,
- SII* process improvements, and 5/26/17 05000368/2017011 awaiting
monitoring/feedback to improve licensee
the rigor, attention to detail, and action
overall quality of operability 8/28/17 - 05000313/2017012, Closed
determinations and functionality 9/1/17 05000368/2017012
assessments.
CA-7 Establish/refine key corrective 8/29/16 - 05000313/2016010, Discussed,
action program station and group- 9/16/16 05000368/2016010 awaiting
level performance indicators. licensee
action
11/27/17 - 05000313/2017013, Closed
2/1/17 05000368/2017013
CA-9 Revise the CARB process to 8/29/16 - 05000313/2016010, Discussed,
require the Performance 9/16/16 05000368/2016010 awaiting
Improvement Manager to present CA-7
the status of the condition closure
reporting process using and further
established metrics to the CARB. inspection
11/27/17 - 05000313/2017013, Closed
2/1/17 05000368/2017013
CA-10 Improve the periodic performance 11/27/17 - 05000313/2017013, Closed
reviews and oversight of corrective 12/1/17 05000368/2017013
action program and operating
experience performance in
Department Performance Review
Meetings and Aggregate
Performance Review Meetings.
Area
Inspection Inspection Report
Action Description Status
Dates Number
Plan
CA-11 Revise EN-LI-102 Corrective 8/29/16 - 05000313/2016010, Closed
Action Program to require a 9/16/16 05000368/2016010
focused self-assessment every 2
years focused primarily on whether
staffing levels support effective
corrective action program
implementation and oversight.
CA-12 Develop metrics to evaluate and 8/29/16 - 05000313/2016010, Closed
monitor the health of the operating 9/16/16 05000368/2016010
experience program.
CA-13 Establish an Operating Experience 5/22/17 - 05000313/2017011, Closed
(OE) mentor to review OE 5/26/17 05000368/2017011
responses and provide critical
feedback.
CA-14 For a period of one year, establish 8/28/17 - 05000313/2017012, Closed
Corrective Action Review Board 9/1/17 05000368/2017012
(CARB) oversight of selected
operating experience (OE)
responses to verify program
implementation meets CARB
standards.
CA-15 Revise the Operating Experience 2/27/17 - 05000313/2017010, Closed
(OE) actions for selected 3/3/17 05000368/2017010
responses to require a pre-job brief
from the OE specialist. This brief
should include examples of missed
opportunities from past OE
responses and a review of the
procedure requirements for a
satisfactory OE written response.
CA-16 Train each Operating Experience 2/27/17 - 05000313/2017010, Discussed,
(OE) point of contact on their 3/3/17 05000368/2017010 awaiting
responsibilities and skills needed licensee
to recognize the applicability of action
OE, elevate OE, and use search 8/28/17 - 05000313/2017012, Closed
tools to locate OE for evaluation. 9/1/17 05000368/2017012
CA-17 Revise Operating Experience (OE) 2/27/17 - 05000313/2017010, Closed
Program procedure to include an 3/3/17 05000368/2017010
annual review of the list of vendors
providing safety-related
products/services to ensure new
suppliers are added.
Area
Inspection Inspection Report
Action Description Status
Dates Number
Plan
CO-2 Revise procedure EN-FAP-OM- 5/22/17 - 05000313/2017011, Closed
2, Management Review 5/26/17 05000368/2017011
Meetings, to prioritize review of
Nuclear Safety Culture status and
regulatory performance to the
operational excellence
management review meeting
agenda.
CO-3 Align ANO and fleet key 8/29/16 - 05000313/2016010, Closed
performance indicators with the 9/16/16 05000368/2016010
industry and establish goals that
are challenging and consistent with
industry practices.
DM-5 Benchmark a nuclear facility 2/27/17 - 05000313/2017010, Closed
outside the Entergy fleet for its 3/3/17 05000368/2017010
ability to recognize risk.
Incorporate the learnings and
develop a risk recognition training
plan to be delivered at AN
- O.
DM-12 Conduct benchmarking of a high 2/12/18 - 05000313/2018012, Closed
performing station in the area of 2/16/18 05000368/2018012
operations focus with a plan based
on Principles for Effective
Operational Decision Making.
DM-15 Perform a benchmark on a high 2/12/18 - 05000313/2018012, Closed
performing station outside the 2/16/18 05000368/2018012
Entergy Fleet on Operational
Decision Making Instruction
(ODMI) development,
implementation and effectiveness
reviews, and develop improvement
actions based upon the results.
DM-22 Benchmark outside the Entergy 11/27/17 - 05000313/2017013, Closed
fleet to identify best practices in 12/1/17 05000368/2017013
the work management process.
DM-23 Have a group from another plant 2/27/17 - 05000313/2017010, Discussed,
perform a peer assist visit in work 3/3/17 05000368/2017010 awaiting
management. licensee
action
11/27/17 - 05000313/2017013, Closed
2/1/17 05000368/2017013
LF-11 Create trending and issue 11/27/17 - 05000313/2017013, Closed
performance review metrics to 12/1/17 05000368/2017013
improve the review of leader
behaviors and performance
results.
Area
Inspection Inspection Report
Action Description Status
Dates Number
Plan
OC-6 Create a simple tool to analyze 8/29/16 - 05000313/2016010, Discussed,
LF-14 externally identified performance 9/16/16 05000368/2016010 awaiting
issues both individually and in further
aggregate to present actionable inspection
data to the Aggregate 11/27/17 - 05000313/2017013, Closed
Performance Review Meeting 12/1/17 05000368/2017013
(APRM).
PH-9 Conduct a benchmark of the Plant 2/27/17 - 05000313/2017010, Closed
Health Committee and Plant 3/3/17 05000368/2017010
Health Working Group at a
recognized industry leader in
identifying and addressing
equipment reliability issues. The
intent of this action is to validate
the action plan for improving our
Plant Health Committee and
establishing a Plant Health
Working Group.
PM-6 The Event Report Review Board 8/28/17 - 05000313/2017012, Closed
will review all formal operating 9/1/17 05000368/2017012
experience (OE) evaluations for 12
months and initiate corrective
action for any that do not meet
management standards for quality.
PM-9 Develop metrics for the number of 2/27/17 - 05000313/2017010, Closed
open craft work order feedback 3/3/17 05000368/2017010
requests.
PM-10 Reestablish the Preventive 5/22/17 - 05000313/2017011, Closed
Maintenance (PM) Program health 5/26/17 05000368/2017011
report for a period of at least 12
months.
TR-2 Define and incorporate guidance in 8/28/17 - 05000313/2017012, Closed
the condition report (CR) screening 9/1/17 05000368/2017012
and review process to prompt
discussion and/or action for
conditions potentially warranting a
training solution.
TR-3 Define and incorporate practical 8/29/16 - 05000313/2016010, Closed
guidance in Procedure EN-LI-121, 9/16/16 05000368/2016010
Trending and Performance
Review, to support consideration
of training as a potential solution
for organizational performance
issues.
Area
Inspection Inspection Report
Action Description Status
Dates Number
Plan
TR-4 Training Manager provide 11/27/17 - 05000313/2017013, Closed
presentation(s) to managers and 12/1/17 05000368/2017013
Department Performance
Improvement Coordinators on the
use of training to support
organizational performance
improvement.
TR-5 Factor training needs into 11/27/17 - 05000313/2017013, Closed
resources for key departments, 12/1/17 05000368/2017013
including the training department,
to ensure that resources support
training for organizational
performance improvement. This
action refers to staffing to support
training beyond that necessary for
accredited programs.
VO-16 Benchmark an industry leader 8/28/17 - 05000313/2017012, Closed
outside the Entergy fleet to capture 9/1/17 05000368/2017012
best practices in vendor oversight.
Human Performance
Area
Inspection Inspection Report
Action Description Status
Dates Number
Plan
DB-9 Experienced mentors will be 11/27/17 - 05000313/2017013, Closed
assigned to the component and 12/1/17 05000368/2017013
programs areas from July 1, 2016,
through July 1, 2017. This
mentoring effort will focus on
behaviors, qualification, and
standards of the ANO component
and programs areas to ensure full
compliance and to build the
knowledge and proficiency in these
areas.
Area
Inspection Inspection Report
Action Description Status
Dates Number
Plan
DB-17 An engineering standard will be 2/12/18 - 05000313/2018012, Closed
produced to provide sustainable, 2/16/18 05000368/2018012
consistent guidance to station
engineers in the performance of
their duties. This standard will
incorporate best practices for
developing engineering products
beyond simple procedural
compliance and ensure that
standards and expectations for
performance of engineering duties
are clearly articulated to the
workforce.
DB-18 Re-baseline expectations for 5/22/17 - 05000313/2017011, Closed
supporting information for NRC 5/26/17 05000368/2017011
license amendment requests or
relief requests based on past
requests for additional information.
DB-19 Provide Regulatory Assurance 5/22/17 - 05000313/2017011, Closed
departmental training on 5/26/17 05000368/2017011
development of NRC license
amendment requests.
DM-13 Assign a mentor from outside the 11/27/17 - 05000313/2017013, Closed
Entergy fleet to coach and mentor 12/1/17 05000368/2017013
each shift manager, emphasizing
the aspect of leadership in
operational focus.
DM-14 Assign a mentor to review all 2/12/18 - 05000313/2018012, Closed
Operational Decision Making 2/16/18 05000368/2018012
Instructions until proficiency is
demonstrated.
DM-16 Develop and implement training for 2/12/18 - 05000313/2018012, Closed
key personnel on ODMI 2/16/18 05000368/2018012
development, implementation, and
effectiveness reviews.
DM-17 Develop roles and responsibilities 8/28/17 - 05000313/2017012, Closed
for the quorum line participants in 9/1/17 05000368/2017012
the work management process.
LF-1 Conduct leadership assessments 2/27/17 - 05000313/2017010, Closed
for the senior leadership team, 3/3/17 05000368/2017010
managers and superintendents
and establish individual
development plans to support
closing identified gaps in leader
behaviors.
Area
Inspection Inspection Report
Action Description Status
Dates Number
Plan
LF-2 Establish and roll out an ANO 11/27/17 - 05000313/2017013, Closed
employee handbook with attributes 12/1/17 05000368/2017013
and behaviors supporting nuclear
safety and long term strategic
improvement. The purpose of the
handbook is to communicate and
reinforce key values and
behaviors.
LF-3 Provide supervisory training on 2/12/18 - 05000313/2018012, Closed
constructive conversation skills. 2/16/18 05000368/2018012
LF-4 As an interim action, establish 8/29/16 - 05000313/2016010, Closed
weekly leadership alignment 9/16/16 05000368/2016010
meetings for supervisors and
above to reinforce actions and
behaviors needed to achieve
recovery objectives.
LF-6 Benchmark an external 2/27/17 - 05000313/2017010, Closed
organization for leadership 3/3/17 05000368/2017010
fundamentals and develop
improvement actions as warranted
based upon the results.
LF-8 As an interim measure, establish 8/29/16 - 05000313/2016010, Closed
and implement external coaching 9/16/16 05000368/2016010
for a sample of department and
station performance review
meetings in the Trending and
Performance Review process.
LF-10 Establish and implement a paired 8/29/16 - 05000313/2016010, Closed
NF-10 observation program. This is a 9/16/16 05000368/2016010
coach the coach program to
improve the quality of interactions
between supervisors and those
they supervise.
NF-1 Implement a What It Looks Like 8/28/17 - 05000313/2017012, Closed
sheet for nuclear professional 9/1/17 05000368/2017012
behaviors based on objectives in
Performance Objectives and
Criteria. Include a continued
focus on the following four
performance issues:
- Procedure use and adherence
- Challenging assumptions and
decision making
- Conservative bias and risk
recognition
- Low threshold for reporting
issues.
Area
Inspection Inspection Report
Action Description Status
Dates Number
Plan
NF-3 Develop content for the Employee 8/28/17 - 05000313/2017012, Closed
Handbook that addresses 9/1/17 05000368/2017012
procedure use and adherence.
NF-5 Develop content for the ANO 8/28/17 - 05000313/2017012, Closed
supervisor training that addresses 9/1/17 05000368/2017012
procedure use and adherence.
NF-6 Revise procedure EN-OM-126, 5/22/17 - 05000313/2017011, Closed
Management and Oversight of 5/26/17 05000368/2017011
Supplemental Personnel, to
ensure that supplemental
employees receive the Site
Handbook.
NF-9 Develop and implement a field 11/27/17 - 05000313/2017013, Closed
SC-8 presence initiative that promotes 12/1/17 05000368/2017013
and measures leader field
presence. The objective is to drive
and verify field presence by
leaders to engage with employees
and reinforce high standards.
OC-1 Perform organizational capacity 8/28/17 - 05000313/2017012, Closed
assessments to determine staffing 9/1/17 05000368/2017012
requirements for 16 key
departments based on experience,
training needs, knowledge
management needs, timing of
expected retirements, resignations
and reassignments and the needs
for a site with two dissimilar units.
OC-2 Authorize the hiring of Entergy 8/28/17 - 05000313/2017012, Closed
personnel and/or contractor 9/1/17 05000368/2017012
positions identified as immediate
staffing requirements by the ANO
People Health Committee (APHC)
during organizational capacity
assessment reviews.
OC-3 Establish and implement an ANO 8/28/17 - 05000313/2017012, Closed
Integrated Strategic Workforce 9/1/17 05000368/2017012
Plan that provides a strategic long-
term perspective of future staffing
needs with a focus on ensuring
staffing is sufficient to support
nuclear safety. The workforce
planning process will look into the
future at least five-years, be
updated annually, and reviewed
quarterly by the ANO People
Health Committee.
Area
Inspection Inspection Report
Action Description Status
Dates Number
Plan
OC-4 Establish and implement an ANO 11/27/17 - 05000313/2017013, Closed
People Health Committee to place 12/1/17 05000368/2017013
priority on staffing and retention
issues that are impacting ANO
employees or could impact nuclear
safety.
PM-13 Perform a resource allocation 8/28/17 - 05000313/2017012, Closed
study of the Preventive 9/1/17 05000368/2017012
Maintenance (PM) Program that
identifies positions needed to
maintain a continuously improving
PM Program.
PM-14 Address gaps in the Preventive 2/12/18 - 05000313/2018012, Closed
Maintenance Program baseline 2/16/18 05000368/2018012
staffing level based on the current
levels of experience in the
departments and at the site.
PM-19 Revise the Preventive 11/27/17 - 05000313/2017013, Closed
Maintenance (PM) procedure to 12/1/17 05000368/2017013
require that craft work order
feedback is monitored and
incorporated within 90 days or
model work order placed into
plan status.
PQ-1 Develop and implement a site 2/27/17 - 05000313/2017010, Closed
procedure writers guide based on 3/3/17 05000368/2017010
applicable industry standards.
PQ-2 Develop and implement a work 2/27/17 - 05000313/2017010, Closed
order instruction guide based on 3/3/17 05000368/2017010
applicable industry standards.
PQ-3 Perform scoping reviews to assess 8/29/16 - 05000313/2016010, Closed
extent of procedure and work 9/16/16 05000368/2016010
instruction quality issues.
PQ-4 Conduct a Procedure 2/27/17 - 05000313/2017010, Discussed,
Professionals Association 3/3/17 05000368/2017010 awaiting
certification course for selected licensee
plant personnel. action
11/27/17 - 05000313/2017013, Closed
2/1/17 05000368/2017013
PQ-5 Risk rank station procedures as 8/29/16 - 05000313/2016010, Closed
safety significant, important, or 9/16/16 05000368/2016010
normal to facilitate procedure
upgrade project scoping.
PQ-6 Upgrade safety significant 5/22/17 - 05000313/2017011, Closed
procedures. 5/26/17 05000368/2017011
PQ-7 Upgrade procedures classified as 8/28/17 - 05000313/2017012, Closed
important. 9/1/17 05000368/2017012
Area
Inspection Inspection Report
Action Description Status
Dates Number
Plan
PQ-8 Upgrade procedures classified as 2/12/18 - 05000313/2018012, Closed
normal. 2/16/18 05000368/2018012
PQ-9 Upgrade Critical 1-4 Model Work 2/12/18 - 05000313/2018012, Closed
Orders with a frequency of greater 2/16/18 05000368/2018012
than or equal to 2 years or 2
refueling outages.
PQ-10 Review and correct station 5/22/17 - 05000313/2017011, Closed
procedures with respect to gaps in 5/26/17 05000368/2017011
use of notes and cautions, and
ensure needed corrections are
entered into the appropriate station
processes for completion.
PQ-11 Establish a periodic review and 5/22/17 - 05000313/2017011, Closed
validation of station procedures. 5/26/17 05000368/2017011
This will also support a systematic
approach to revising the station
procedures not included in other
actions to the standards contained
in the new writers guide.
Equipment Reliability and Engineering Programs
Area
Inspection Inspection Report
Action Description Status
Dates Number
Plan
DB-10 Resolve standards performance 2/12/18 - 05000313/2018012, Closed
deficiencies from the engineering 2/16/18 05000368/2018012
program assessments completed
during the Preventive Maintenance
(PM) Program extent of condition
review.
DB-11 Perform one benchmark or one 2/12/18 - 05000313/2018012, Discussed,
self-assessment between March 1, 2/16/18 05000368/2018012 awaiting
2016, and March 1, 2020, for each licensee
of 24 engineering programs. action
4/2/18 - 05000313/2018013, Closed
5/31/18 05000368/2018013
Area
Inspection Inspection Report
Action Description Status
Dates Number
Plan
DB-12 Training and industry exposure will 11/27/17 - 05000313/2017013, Closed
be used to build the knowledge, 12/1/17 05000368/2017013
proficiency and standards within
the program and component areas
as the owners of each program
listed in DB-11 will participate in at
least one industry meeting or
specialized training course focused
in their program area between
March 1, 2016 and March 1, 2020.
DM-18 Develop and implement work 2/12/18 - 05000313/2018012, Closed
management training for senior 2/16/18 05000368/2018012
managers, managers, and each of
the identified work management
positions with respect to their roles
and responsibilities.
DM-20 Develop and implement a supply 8/29/16 - 05000313/2016010, Discussed,
vs. demand model and metrics to 9/16/16 05000368/2016010 awaiting
determine and monitor resource licensee
needs to meet workload demand. action
The metrics will be used to 2/12/18 - 05000313/2018012, Closed
measure resource demand and 2/16/18 05000368/2018012
supply so that scheduled work has
the correct resources assigned to
complete the work scope.
PH-1 For open Site Integrated Plant 5/22/17 - 05000313/2017011, Closed
Database (SIPD) items, ensure 5/26/17 05000368/2017011
management sponsors and project
managers are assigned to verify
database content is updated. This
action supports effective decision
making by ensuring the accuracy
and completeness of existing SIPD
records.
PH-2 Perform a review of the Site 5/22/17 - 05000313/2017011, Closed
Integrated Plant Database (SIPD) 5/26/17 05000368/2017011
database from 2007 to present to
identify PM or equipment reliability
projects related to critical
equipment that have been
cancelled without mitigation
strategies.
Area
Inspection Inspection Report
Action Description Status
Dates Number
Plan
PH-3 Review and update the current 11/27/17 - 05000313/2017013, Closed
Aging/Obsolescence List, Critical 12/1/17 05000368/2017013
Spares List, and Equipment
Reliability Issues List to identify
items that should be included in
the 2017 and 2018 business
cycles.
PH-4 Review and update the current site 11/27/17 - 05000313/2017013, Closed
Unit Commitment List to identify 12/1/17 05000368/2017013
operations and maintenance and
capital projects which are required
to be resolved by completion of
refueling outages 1R27 and 2R26.
PH-5 Develop and implement a 11/27/17 - 05000313/2017013, Closed
comprehensive site plan for 12/1/17 05000368/2017013
equipment reliability that identifies
the implementing resources
(people, materials, funding, and
time) needed to support on-line
and outage Unit Commitment List
items that require resolution by
completion of 1R27 and 2R26.
PH-6 Obtain an independent third party 11/27/17 - 05000313/2017013, Closed
review of the selection of Site 12/1/17 05000368/2017013
Integrated Planning Database
(SIPD) items that are targeted on
the comprehensive site plan for
equipment reliability to ensure the
decisions for inclusion and
exclusion are aligned with industry
standards and expectations
associated with timely resolution of
degraded equipment and design
margins.
PH-10 Develop educational materials for 5/22/17 - 05000313/2017011, Closed
the plant heath process including 5/26/17 05000368/2017011
SIPD processing. Include a
detailed flowchart, workbook, and
detailed presentation materials.
Deliver the presentation to system,
component, and program
engineers and to selected
supervisory personnel. Have the
workbook completed by personnel
following the presentation.
Area
Inspection Inspection Report
Action Description Status
Dates Number
Plan
PH-11 Develop a job familiarization guide 2/27/17 - 05000313/2017010, Closed
for Plant Health Working Group 3/3/17 05000368/2017010
and Plant Health Committee
members and alternates. Have all
members and alternates complete
the guide.
PH-12 The following list contains 8/25/17 - 05000313/2017012, Additional
equipment reliability issues in 9/1/17 05000368/2017012 information
systems or components necessary added
for the safe and reliable operation 11/27/17 - 05000313/2017013, Additional
of the unit(s) that will be resolved 12/1/17 05000368/2017013 information
over the next two unit operating added
cycles. The intent of this action is 4/2/18 - 05000313/2018013, Closed
to demonstrate improved 5/31/18 05000368/2018013
equipment reliability by resolving
long-standing equipment issues.
PH-13 The following list contains 2/12/18 - 05000313/2018012, Additional
equipment reliability issues that 2/16/18 05000368/2018012 information
are being evaluated by the Plant added
Health Committee for resolution 4/2/18 - 05000313/2018013, Closed
commensurate with the potential 5/31/18 05000368/2018013
impact on safe and reliable
operation of the units by December
20, 2018. For items not resolved
by the due date, the Plant Health
Committee will provide the safety
basis for the extension.
PH-14 Review and update the current site 4/2/18 - 05000313/2018013, Closed
Unit Commitment List to identify 5/31/18 05000368/2018013
operations and maintenance and
capital projects which are required
to be resolved by completion of
refueling outages 1R27 and 2R26.
PM-1 Create a site specific procedure for 10/31/16 - 05000313/2016008, Closed
component classification that will 12/2/16 05000368/2016008
ensure appropriate classification of
equipment for PM based upon risk
and safety.
PM-2 Create a site-specific PM program 2/27/17 - 05000313/2017010, Closed
procedure that includes lessons 3/3/17 05000368/2017010
learned from the PM FPA root
cause related to critical input to PM
changes.
Area
Inspection Inspection Report
Action Description Status
Dates Number
Plan
PM-4 Transfer responsibility for PM 2/27/17 - 05000313/2017010, Closed
evaluations of all maintenance rule 3/3/17 05000368/2017010
components and critical system
redundancy components to
engineering to ensure that
appropriate expertise is brought to
bear on these evaluations.
PM-5 The Preventive Maintenance (PM) 8/28/17 - 05000313/2017012, Closed
Oversight Group will review all PM 9/1/17 05000368/2017012
change requests for a minimum of
months and initiate corrective
action for any that do not meet
management standards for quality.
PM-7 The Planning Quality Review 2/12/18 - 05000313/2018012, Closed
Team will perform an enhanced 2/16/18 05000368/2018012
review of critical work orders for a
minimum of 12 months and
feedback the results to the
planning staff.
PM-11 Implement a new qualification card 2/27/17 - 05000313/2017010, Closed
for maintenance personnel who 3/3/17 05000368/2017010
perform PM evaluations.
PM-12 Implement training for all 8/28/17 - 05000313/2017012, Closed
personnel who are qualified to 9/1/17 05000368/2017012
establish Preventive Maintenance
(PM) requirements.
PM-15 Review a sample of component 2/12/18 - 05000313/2018012, Closed
criticality classifications to validate 2/16/18 05000368/2018012
that the stations risk significant
equipment is classified correctly.
PM-18 Develop mitigation strategies to 8/28/17 - 05000313/2017012, Closed
address cancelled projects in the 9/1/17 05000368/2017012
Site Integrated Planning Database
(SIPD) including embedded sub
component projects.
Safety Culture
Area
Inspection Inspection Report
Action Description Status
Dates Number
Plan
CO-1 Revise procedure EN-FAP-OM- 5/22/17 - 05000313/2017011, Closed
011, Corporate Oversight Model, 5/26/17 05000368/2017011
to include station nuclear safety
culture output from the Nuclear
Safety Culture Monitoring Panel
(NSCMP) as inputs to the
Oversight Analysis Meeting and
Oversight Review Board.
CO-4 Revise procedures that govern 2/27/17 - 05000313/2017010, Closed
Nuclear Oversight Performance 3/3/17 05000368/2017010
Assessments to include NSC trend
codes. Apply relevant safety
culture trend code(s) during the
trending process. Based on report
frequency, roll up codes to provide
a perspective on NSC and include
in established reporting process.
DM-2 Establish a decision making 8/29/16 - 05000313/2016010, Closed
nuclear safety culture observation 9/16/16 05000368/2016010
form to include the top leader
behaviors to be demonstrated and
reinforced at ANO meetings. The
form should include decision
making practices that emphasize
prudent choices over those that
are simply allowable.
DM-3 Establish decision making and risk 11/27/17 - 05000313/2017013, Closed
management content in the ANO 12/1/17 05000368/2017013
Employee Handbook to include
behaviors for making effective
decisions and appropriately
managing risk with the expectation
for employees and leaders to use
the book in communicating,
demonstrating, and reinforcing
appropriate behaviors.
LF-5 Provide supervisory training on 5/22/17 - 05000313/2017011, Closed
- SII* nuclear safety culture (NSC) and 5/26/17 05000368/2017011
safety conscious work
environment.
NF-4 Develop content for the NSC 2/27/17 - 05000313/2017010, Closed
observation process that 3/3/17 05000368/2017010
addresses procedure use and
adherence.
Area
Inspection Inspection Report
Action Description Status
Dates Number
Plan
PM-20 Track Leadership Fundamentals 2/27/17 - 05000313/2017010, Discussed,
RCE CR-ANO-C-2015-02829 CA- 3/3/17 05000368/2017010 awaiting
2. Improve the performance licensee
review process for leadership action
fundamentals supportive of long 11/27/17 - 05000313/2017013, Closed
term strategic improvement. 12/1/17 05000368/2017013
SC-2 Revise procedure EN-QV-136, 2/27/17 - 05000313/2017010, Closed
Nuclear Safety Culture 3/3/17 05000368/2017010
Monitoring, to define the roles and
responsibilities of the ANO NSC
Manager.
SC-3 Revise procedure EN-QV-136, 2/27/17 - 05000313/2017010, Closed
Nuclear Safety Culture 3/3/17 05000368/2017010
Monitoring, to add NSC monitor
orientation training for Nuclear
Safety Culture Monitoring Panel
(NSCMP) and Safety Culture
Leadership Team members.
SC-4 Conduct a structured off-site 2/27/17 - 05000313/2017010, Closed
meeting among the ANO Senior 3/3/17 05000368/2017010
Leadership Team to align on what
a strategic commitment to safety
looks like at ANO and the leader
behaviors that will demonstrate
that commitment.
SC-5 Create an ANO Employee 11/27/17 - 05000313/2017013, Closed
Handbook that includes nuclear 12/1/17 05000368/2017013
safety culture, safety conscious
work environment, and corrective
action program (CAP) standards
and expectations, and provide
orientation and expectations to
ANO personnel on the contents
and use of this handbook as a
daily tool for communicating,
reinforcing, and demonstrating
SC-6 Conduct meetings facilitated by 11/27/17 - 05000313/2017013, Closed
members of site management to 12/1/17 05000368/2017013
familiarize personnel with the
contents of the ANO Employee
Handbook and expectations for its
use.
Area
Inspection Inspection Report
Action Description Status
Dates Number
Plan
SC-7 Establish a small group meeting 2/27/17 - 05000313/2017010, Closed
schedule to facilitate face-to-face 3/3/17 05000368/2017010
interaction between ANO senior
leadership and station employees.
This activity should span a
minimum period through the end of
2016 and include the following
attributes: 1) purpose is open
dialogue on safety performance
with emphasis on employee
questions and feedback; and 2)
schedule should be coordinated to
facilitate broad exposure, with
emphasis on workers on shift
rotation who cant routinely
participate in other communication
forums.
SC-9 Develop and provide training to 2/12/18 - 05000313/2018012, Closed
NF-7 ANO leaders, including 2/16/18 05000368/2018012
supervisory training on nuclear
safety culture and safety conscious
work environment, constructive
conversation skills, and how to
foster a strong nuclear safety
culture within their organizations.
SC-10 Develop and present training to 8/28/17 - 05000313/2017012, Closed
NF-8 ANO workforce to include case 9/1/17 05000368/2017012
studies that illustrate the right
picture of nuclear safety culture.
Include what it means to be an
engaged and thinking individual
nuclear worker.
SC-11 Implement priority group specific 8/28/17 - 05000313/2017012, Closed
action plans to address safety 9/1/17 05000368/2017012
culture issues.
SC-14 Establish and implement a Nuclear 8/29/16 - 05000313/2016010, Discussed,
LF-9 Safety Culture Observations 9/16/16 05000368/2016010 awaiting
CA-2 process including elements of licensee
leader behaviors, nuclear safety action
Area
Inspection Inspection Report
Action Description Status
Dates Number
Plan
culture, and safety conscious work 2/27/17 - 05000313/2017010, Closed
environment. The observer 3/3/17 05000368/2017010
monitors leader performance on a
daily basis and provides feedback
to correct adverse trends in
behaviors.
SC-15 Raise the priority and visibility of 5/22/17 - 05000313/2017011, Closed
nuclear safety culture (NSC) at the 5/26/17 05000368/2017011
fleet level by revising the
Corporate Oversight Model to
include station NSC output from
the Nuclear Safety Culture
Monitoring Panel (NSCMP) as
input to fleet oversight analysis
meetings and oversight review
boards.
Service Water System Self-Assessment
Inspection Inspection Report
Description Status
Dates Number
10/31/16 - 05000313/2016008, Discussed
Service Water System Operational 12/2/16 05000368/2016008
Performance Inspection 5/22/17 - 05000313/2017011, Closed
5/26/17 05000368/2017011
SUNSI Review ADAMS: Non-Publicly Available Non-Sensitive Keyword:
By: JDixon/rdr Yes No Publicly Available Sensitive NRC-002
OFFICE RIV/DRP RIV/DRP RIII/DRP NRR/DIRS/IRAB OE/AT RIV/ACES
NAME JDixon MTobin EDuncan MKeefe-Forsyth DWillis MVasquez
SIGNATURE /RA/ /RA/ /RA/ /RA-E/ /RA-E/ /RA/
DATE 5/10/2018 5/9/2018 5/9/18 5/11/2018 5/11/2018 5/22/18
OFFICE RIV/DRP:BC RIV/DNMS:D RIV/DRP:D RIV/DRS:D RIV/ORA:RA
NAME NOKeefe TPruett AVegel MShaffer KKennedy
SIGNATURE /RA/ /RA/ /RA/ /RA/ /RA/
DATE 5/19/18 5/29/18 5/23/18 5/24/18 6/18/18