IR 05000313/2018013

NRC Confirmatory Action Letter (EA-16-124) Follow-Up Inspection Report 05000313/2018013 and 05000368/2018013 and Assessment Follow-Up Letter

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

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

• Entergy fleet procedures to verify CAL commitments were translated from ANO recovery procedures

• 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)

(LO-ALO-2016-00078)

• 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

2017-00546 DNP SDP

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,

Temporary Modifications, to

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

CARB and CRG), DPICs, OE

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

NSC and CAP expectations.

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

ML18165A206

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