IR 05000416/2018010

NRC Biennial Problem Identification and Resolution Inspection Report 05000416/2018010

ML18351A276
Person / Time
Site:	Grand Gulf
Issue date:	12/17/2018
From:	Geoffrey Miller Division of Reactor Safety IV
To:	Emily Larson Entergy Operations
Miller G
References
IR 2018010
Download: ML18351A276 (29)

Text

ber 17, 2018

SUBJECT:

GRAND GULF NUCLEAR STATION - NRC BIENNIAL PROBLEM IDENTIFICATION AND RESOLUTION INSPECTION REPORT 05000416/2018010

Dear Mr. Larson:

On November 8, 2018, the U.S. Nuclear Regulatory Commission (NRC) completed a problem identification and resolution inspection at your Grand Gulf Nuclear Station. The NRC inspection team discussed the results of this inspection with you and members of your staff. The results of this inspection are documented in the enclosed report.

The NRC inspection team reviewed the stations corrective action program and the stations implementation of the program to evaluate its effectiveness in identifying, prioritizing, evaluating, and correcting problems, and to confirm that the station was complying with NRC regulations and licensee standards for corrective action programs. Based on the samples reviewed, the team determined that your staffs performance in each of these areas adequately supported nuclear safety.

The team also evaluated the stations processes for use of industry and NRC operating experience information and the effectiveness of the stations audits and self-assessments.

Based on the samples reviewed, the team determined that your staffs performance in each of these areas adequately supported nuclear safety.

Finally the team reviewed the stations programs to establish and maintain a safety-conscious work environment, and interviewed station personnel to evaluate the effectiveness of these programs. Based on the teams observations and the results of these interviews, the team found that most Grand Gulf Nuclear Station employees appeared willing to raise nuclear safety concerns through at least one of the several means available. However, the team found evidence of challenges to the safety-conscious work environment in one work group; the team provided additional details to the stations Employee Concerns Program Coordinator, Mr. R. Pierson.

NRC inspectors documented three findings of very low safety significance (Green) in this report, two of which involved a violation of NRC requirements. Additionally, inspectors documented two licensee-identified violations that were determined to be of very low safety significance. The NRC is treating all of these violations as non-cited violations (NCVs) consistent with Section 2.3.2 of the Enforcement Policy.

If you contest these violations or their significance, you should provide a response within 30 days of the date of this inspection report, with the basis for your denial, to the U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555-0001; with copies to the Regional Administrator, Region IV; the Director, Office of Enforcement; and the NRC resident inspector at the Grand Gulf Nuclear Station.

Likewise, if you disagree with a cross-cutting aspect assignment in this report, you should provide a response within 30 days of the date of this inspection report, with the basis for your disagreement, to the U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, Washington, DC 20555-0001; with copies to the Regional Administrator, Region IV; and the NRC resident inspector at the Grand Gulf Nuclear Station.

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/

Geoffrey B. Miller, Team Leader Inspection Program and Assessment Team Division of Reactor Safety Docket No. 50-416 License Nos. NPF-29 Enclosure:

Inspection Report 05000416/2018010 w/ Attachment:

Information Request

U.S. NUCLEAR REGULATORY COMMISSION

Inspection Report

Docket Number(s): 05000416 License Number(s): NPF-29 Report Number(s): 05000416/2018010 Enterprise Identifier: I-2018-010-0072 Licensee: Entergy Operations, Inc.

Facility: Grand Gulf Nuclear Station, Unit 1 Location: Port Gibson, Mississippi Inspection Dates: October 22, 2018, to January 8, 2019 Inspectors: E. Ruesch, J.D., Sr. Reactor Inspector (Team Lead)

R. Alexander, Sr. Project Engineer H. Freeman, Sr. Reactor Inspector T. Steadham, Sr. Resident Inspector (Grand Gulf Nuclear Station)

T. Sullivan, Resident Inspector (Arkansas Nuclear One)

Approved By: Geoffrey B. Miller Team Leader, Inspection Program and Assessments Team Division of Reactor Safety Enclosure

SUMMARY

The U.S. Nuclear Regulatory Commission (NRC) continued monitoring the licensees performance by conducting a biennial problem identification and resolution inspection at Grand Gulf Nuclear Station, Unit 1, in accordance with the Reactor Oversight Process. The Reactor Oversight Process is the NRCs program for overseeing the safe operation of commercial nuclear power reactors. Refer to https://www.nrc.gov/reactors/operating/oversight.html for more information. Findings and violations being considered in the NRCs assessment are summarized in the table below. Two licensee-identified non-cited violations are discussed in Inspection Procedure 71152.

List of Findings and Violations Conditions adverse to quality not promptly corrected using work management system Cornerstone Significance Cross-cutting Inspection Aspect Procedure Mitigating Green H.5 71152Problem Systems NCV 05000416/2018010-01 Identification and Closed Resolution The inspectors identified a Green non-cited violation of 10 CFR Part 50, Appendix B,

Criterion XVI, Corrective Action, for the licensees failure to promptly identify and correct conditions adverse to quality when corrective actions were moved from the corrective action program to the work management system.

Failure to promptly identify and correct adverse conditions related to barrier doors Cornerstone Significance Cross-cutting Inspection Aspect Procedure Mitigating Green P.2 71152Problem Systems NCV 05000416/2018010-02 Identification and Closed Resolution The inspectors identified a Green non-cited violation of 10 CFR Part 50, Appendix B,

Criterion XVI, Corrective Action, for the licensees failure to promptly identify and correct adverse conditions related to degraded barrier doors as required by regulations, license conditions, and station procedures.

Immediate operability determinations not documented in accordance with procedures Cornerstone Significance Cross-cutting Inspection Aspect Procedure Mitigating Green P.3 71152Problem Systems FIN 05000416/2018010-03 Identification and Closed Resolution The inspectors identified a Green finding for the licensees failure to consistently complete immediate operability determinations in accordance with station procedures.

INSPECTION SCOPE

Inspections were conducted using the appropriate portions of the inspection procedures (IPs)in effect at the beginning of the inspection unless otherwise noted. Currently approved IPs with their attached revision histories are located on the public website at http://www.nrc.gov/reading-rm/doc-collections/insp-manual/inspection-procedure/index.html.

Samples were declared complete when the IP requirements most appropriate to the inspection activity were met consistent with Inspection Manual Chapter (IMC) 2515, Light-Water Reactor Inspection Program - Operations Phase. The inspectors reviewed selected procedures and records, observed activities, and interviewed personnel to assess licensee performance and compliance with Commission rules and regulations, license conditions, site procedures, and standards.

OTHER ACTIVITIES - BASELINE

71152Problem Identification and Resolution - Biennial Team Inspection

The inspectors performed a biennial assessment of the licensees corrective action program (CAP), use of operating experience, self-assessments and audits, and safety-conscious work environment. The assessment is documented below.

(1) Corrective Action Program Effectiveness: Problem Identification, Problem Prioritization and Evaluation, and Corrective Actions - The inspection team reviewed the stations CAP and the stations implementation of the program to evaluate its effectiveness in identifying, prioritizing, evaluating, and correcting problems, and to confirm that the station was complying with NRC regulations and licensee standards for CAPs. The sample included review of over 200 condition reports (CRs) and associated records, and an in-depth 5-year review of CRs associated with the high-pressure core spray system both mechanical and electrical componentsincluding actuation logic and room coolers.

(2) Operating Experience, Self-Assessments, and Audits - The team evaluated the stations processes for use of industry and NRC operating experience. The team also evaluated the effectiveness of the stations audits and self-assessments program by reviewing a sample of several self-assessments and audits.

(3) Safety-Conscious Work Environment - The team evaluated the stations safety-conscious work environment. The team interviewed 42 station personnel in 6 group interviews. These included personnel from operations, work management, maintenance, radiological protection, chemistry, engineering, station projects, and security. The team also interviewed employee concerns program personnel, reviewed employee concerns files, and reviewed the results of the most recent safety culture survey and the licensees actions to address priority groups identified through that survey.

71153Follow-up of Events and Notices of Enforcement Discretion Licensee Event Reports

The inspectors evaluated seven licensee event reports (LERs):

(1) 05000416/2017-002: Loss of Secondary Containment and Inoperability of the Standby Gas Treatment Systems as a Result of a Damaged Power Supply (ADAMS Accession No. ML18081B210)

(2) 05000416/2017-005: Loss of Safety Function and Control Room Envelope Due to an Open Boundary Door (ML17250A201)

(3) 05000416/2017-008: Inadequate Diesel Generator Common Mode Failure Evaluations Result in Condition Prohibited by Technical Specifications (ML18100B300)

(4) 05000416/2017-009*: Reactor Core Isolation Cooling System Inoperability Due to Lockout Circuit Settings (ML18085A078)

(5) 05000416/2018-003: Inoperable Reactor Protection Functions During Main Steam Isolation Valve and Turbine Stop Valve Channel Functional Tests Due to Use of a Test Box (ML18117A482)

(6) 05000416/2018-005: Secondary Containment Door Misaligned, Due to Inadequate Criteria, Could Have Prevented Fulfillment of a Safety Function (ML18145A292)

(7) 05000416/2018-006: Secondary Containment Roof Hatch Left Open Due To Inadequate Corrective Actions (ML18145A291)

The inspectors identified one finding and reviewed one licensee-identified non-cited violation associated with these LERs. These are described in the inspection results below. Licensee Event Report 05000416/2017-009 is associated with previously documented violation NCV 05000416/2018002-01 (ML18215A026); no further issues related to this LER were identified during this inspection.

INSPECTION RESULTS

- OBSERVATIONS/ASSESSMENT Assessment of Corrective Action Program 71152Problem Identification and Resolution Effectiveness of Problem Identification: Overall, the team found that the licensees identification and documentation of problems were adequate to support nuclear safety, though some challenges were noted. Licensee employees entered issues into the CAP at a very low threshold. However, the team identified opportunities for improvement in the identification and screening of potential trends and other aggregate issues, particularly through management oversight processes designed to diagnose and address organizational and programmatic challenges. These are described in observations, findings, and violations below.

Effectiveness of Prioritization and Evaluation of Issues: Overall, the team found that the licensees prioritization and evaluation of issues were adequate to support nuclear safety.

The licensee continues to work to improve management oversight of the CAP, which has been consistently identified as an area for improvement by both third party and internal reviews. The licensee has several ongoing initiatives under its recovery Blueprint that appear to be initially successful at driving improvement. However, the team noted that challenges remain, particularly in the identification of aggregate trends. Examples are discussed below.

Effectiveness of Corrective Actions: Overall, the team found that the licensees corrective actions, when accomplished, generally supported nuclear safety. However, the team noted that the licensee failed to appropriately manage its backlog of corrective actions for adverse conditions when those actions were closed to the work management system; this is discussed below as non-cited violation. Additionally, the licensee did not always adequately document the completed actions in the CRs, making review and verification challenging.

Observations on the Corrective Action Program 71152Problem Identification and Resolution The inspectors observed that the licensee had improved its implementation of the CAP since the previous problem identification and resolution inspection in 2017. However, the organization continued to be challenged to provide adequate management oversight of the program. To wit:

The inspectors observed meetings of the stations Plant Health Committee (PHC) on October 22 and November 5, 2018. According to the licensees governing Procedure EN-DC-336, The primary mission of the PHC is to identify, prioritize, and drive resolution of issues challenging unit reliability, by focusing on things such as, safety system health and organizational alignment . . . to resolve equipment reliability issues. The procedure further provides that the PHC meetings should be, action oriented and results driven, rather than weighted more to status / update / discussion. While this PHC process is not a safety-related or quality process as is the CAP, it serves an important oversight function of problem identification and resolution processes, particularly for ensuring appropriate attention and resources are focused on broad challenges that are evidenced by a series of more discrete issues that may be documented and addressed in the CAP. The inspectors observed that contrary to PHC goals and procedural direction, discussions at the meetings were focused almost entirely on what actions had been complete, rather than proactive discussions of strategies for issue resolution.

The inspectors also identified that the licensee had yet to complete an Aggregate Performance Review Meeting (APRM) to review trend and performance data for 2018.

Procedure EN-LI-121, Trending and Performance Review Process, a quality procedure, establishes Aggregate Performance Review Meetings. The purpose of these meetings conducted by the site leadership team is to review performance monitoring inputs, assess performance, identify and monitor performance trends, and conduct analysis and planning for actions to resolve performance trends at the site level. The meetings also fulfill a commitment in the Entergy Quality Assurance Manual to ensure that conditions adverse to quality are analyzed to identify trends in quality performance. The meetings are required by Procedure EN-LI-121 to be completed four times per calendar year. Similar to the PHC meetings, these meetings are an important management oversight function for the CAP and other problem identification and resolution processes. The failure to conduct the required APRMs is documented as a minor performance deficiency below.

Assessment of Use of Operating Experience 71152Problem Identification and Resolution Based on the samples reviewed, the team determined that the licensee appropriately evaluated industry operating experience for its relevance to the facility. Operating experience information was incorporated into plant procedures and processes as appropriate. The team further determined that the licensee appropriately evaluated industry operating experience when performing root cause analyses and adverse condition analyses. The licensee appropriately incorporated both internal and external operating experience into lessons learned for training and pre-job briefs.

In particular, the team noted one example where, during a review of operating experience information from the Boiling Water Reactor (BWR) Owners Group, the licensee identified a concern with the use of a reactor protection system (RPS) test box during main steam isolation and turbine stop valve surveillance procedures, which affected the operability of the RPS. The licensee promptly entered the issue into the CAP and initiated corrective actions to address the deficiency. This is an example of an effective review of operating experience promptly identifying the relevance of the operating experience information to the station, and taking timely actions to correct the vulnerability. This issue is further described in a licensee-identified violation below and in LER 05000416/2018-003.

Assessment of Self-Assessments and Audits 71152Problem Identification and Resolution Based on the samples reviewed over a cross-section of departments and disciplines, the team determined that station performance in these areas adequately supported nuclear safety.

Self-assessments and audits were generally effective at identifying deficiencies and enhancements. Additionally, identified deficiencies were generally documented in CRs for both self-assessments and audits. However, in two of ten self-assessments reviewed by the team, the licensee had failed to document some negative observations in CRs or other Learning Organization tracking items as required by Procedure EN-LI-104, Self-Assessment and Benchmark Process.

Additionally, in a 2016 maintenance self-assessment the licensee determined that a deficiency existed with the control of maintenance and test equipment. The self-assessment identified a large number of maintenance and test equipment that was lost. Consequently, the licensee implemented corrective actions to ensure maintenance and test equipment was returned to the tool crib as required. However, through a review of work orders for jobs where maintenance and test equipment was used, the inspectors identified a continued trend of failure to control maintenance and test equipment in accordance with station procedures.

Specifically, the licensee failed to properly log all of the work orders where maintenance and test equipment was used. Therefore, the inspectors determined that the 2016 maintenance self-assessment missed an opportunity to identify a larger scope of the failure to control maintenance and test equipment beyond the lack of returning maintenance and test equipment to the tool crib on time. The failure to properly log the use of maintenance and test equipment greatly affects the licensees ability to identify previous work that would need to be reviewed should a piece of maintenance and test equipment be found to be out-of-calibration.

The inspectors noted that during a June 2018 nuclear independent oversight audit, the licensee identified the maintenance and test equipment program control issues and entered the concern into their CAP as Condition Report CR-GGN-2018-06609. However, at the time of this inspection, corrective actions for this CR remained open. This issue is documented as a licensee-identified NCV below.

Assessment of Safety-Conscious Work Environment 71152Problem Identification and Resolution The team found no evidence of site-wide challenges to the organizations safety-conscious work environment. Employees generally appeared willing to raise nuclear safety concerns through at least one of the several means available. The team identified some indications of safety-conscious work environment weaknesses in one work group, though no employee stated that he or she would not raise a nuclear safety concern as a result. The team provided details on this observation to the stations employee concerns program coordinator for further evaluation and resolution.

INSPECTION RESULTS

- ISSUES/FINDINGS Minor Performance Deficiency 71152Problem Identification and Resolution Minor Performance Deficiency: The failure to complete APRMs, as required by station procedures, is a performance deficiency. Procedure EN-LI-121, Trending and Performance Review Process, establishes APRMs. Step 5.2[15] of that procedure states, APRMs are conducted in the months of February, May, August, and November, and requires that in all cases, a minimum of four APRMs SHALL be conducted annually. This step was established, in part, to meet a commitment in the Entergy Quality Assurance Program (QAP) manual to ensure that conditions adverse to quality are analyzed to identify trends in quality performance. Prior to November 8 the license had yet to complete an APRM to review data and trends for calendar year 2018. The licensee documented this performance deficiency in Condition Report CR-GGN-2018-11491.

Screening: The performance deficiency is minor because if left uncorrected it would not have led to a more significant safety concern and it did not adversely affect any cornerstone objectives.

Enforcement:

This failure to comply with the stations QAP manual and procedures constitutes a minor performance deficiency with no associated violation of NRC regulations.

Minor Violation 71152Problem Identification and Resolution Minor Violation: The failure to control the issuance of documents, such as instructions, procedures, and drawings, including changes thereto, which prescribe all activities affecting quality as required by 10 CFR Part 50, Appendix B, Criterion VI, Document Control.

The team identified that Procedure EN-LI-118, Cause Analysis, and other CAP-related quality procedures directed the use of the Analysis Manual (a non-quality controlled Job Aid) in performing some cause evaluations and methods. This cause evaluation process is an activity affecting quality required by 10 CFR Part 50, Appendix B, and the licensees QAP.

The licensee failed to control the Cause Analysis Manual in accordance with the Entergy QAP Manual, Revision 34, Section B.14, Document Control. The licensee documented this violation in Condition Report CR-HQN-2018-02364.

Screening: The performance deficiency is minor because if left uncorrected it would not have led to a more significant safety concern and it did not adversely affect any cornerstone objectives.

Enforcement:

This failure to comply with 10 CFR Part 50, Appendix B, Criterion VI, constitutes a minor violation that is not subject to enforcement action in accordance with the NRCs Enforcement Policy.

Licensee-Identified Non-Cited Violation 71153 Follow-up of Events and Notices of Enforcement Discretion This violation of very low safety-significant was identified by the licensee and has been entered into the licensee CAP and is being treated as a non-cited violation, consistent with Section 2.3.2 of the Enforcement Policy.

Violation: As required, in part, by 10 CFR Part 50, Appendix B, Criterion III, design control measures shall provide for verifying the adequacy of design. Contrary to the above, on August 22, 2014, the licensee failed to verify the adequacy of the design and use of the RPS test box approved by Engineering Change 45409. This violation is associated with Licensee Event Report 05000416/2018-003.

Significance/Severity: Using IMC 0609, Appendix A, Exhibit 2, the inspectors screened the issue as Green because they answered No to all three Reactivity Control Systems screening questions. Specifically, based on a review of the historical use of the test boxes, the inspectors concluded that although the main steam isolation valve closure and turbine control valve closure RPS trip functions were inoperable while the RPS test box was in use, RPS safety function was not lost as a result of the use of the test boxes.

Corrective Action References: CR-GGN-2018-01346 and CR-GGN-2018-01740 Licensee-Identified Non-Cited Violation 71153 Follow-up of Events and Notices of Enforcement Discretion This violation of very low safety-significant was identified by the licensee and has been entered into the licensee CAP and is being treated as a non-cited violation, consistent with Section 2.3.2 of the Enforcement Policy.

Violation: As required, in part, by 10 CFR Part 50, Appendix B, Criterion XII, measures shall be established to assure that tools, gauges, instruments, and other measuring and test devices used in activities affecting quality are properly controlled. Contrary to the above, on June 6, 2018, the licensee failed to properly control the use of measuring and test equipment.

Significance/Severity: Using IMC 0609, Appendix A, Exhibit 2, the inspectors screened the issue as Green because they answered Yes to Mitigating System screening question 1.

Specifically, although the inspectors identified work orders where the maintenance and test equipment used was not properly logged in the maintenance and test equipment accounting system, none of the applicable maintenance and test equipment used was later found to be out-of-calibration.

Correction Action Reference: CR-GGN-2018-06609 NCV: Conditions adverse to quality not promptly corrected using work management system Cornerstone Significance Cross-cutting Inspection Aspect Procedure Mitigating Green H.5: Work 71152Problem Systems NCV 05000416/2018010-01 Management Identification and Closed Resolution The inspectors identified a Green non-cited violation of 10 CFR Part 50, Appendix B, Criterion XVI, for the licensees failure to promptly identify and correct conditions adverse to quality when corrective actions were moved from the CAP to the work management system.

Description:

The licensees CAP permits certain CRs that document uncorrected adverse conditions to be closed to the work management system if certain criteria are met, as described in Procedure EN-LI-102, Corrective Action Program, Revision 34, Attachment 9.5.

In reviewing a list of open work orders that were generated from adverse-condition CRs, the inspectors identified that the licensee had failed to verify that some of these work orders had promptly corrected the associated conditions adverse to quality:

(1) As of October 22, 2018, the licensees work management system included 28 open, past-due work orders that had originated from the closure of adverse CRs to the work management system; the oldest of these had been due in July 2013.

(2) Also as of October 22, 2018, the licensees work management system included two open priority 1 work orders and eleven open priority 2 work orders that had originated from the closure of adverse CRs to the work management system. The oldest of these had been generated in early 2017. The licensees work management Procedure EN-WM-100, Work Request (WR) Generation, Screening, and Classification, requires that work under a priority 1 work order begin immediately and work around the clock; priority 2 work orders are required to be scheduled at the earliest opportunity within T-3. T-3 refers to a 3-week window beginning when the Work Request is generated.

After review, the licensee stated that most or all of these work orders had been superseded by other work, later deemed unnecessary but not canceled, or remained open for administrative reasons. The inspectors verified this for a sample of the affected work orders.

However, the inspectors determined that this condition represented a programmatic deficiency in that the licensees implementation of its work management process was inadequate to ensure that corrective actions closed to the work management system were timely accomplished.

Corrective Action: As an immediate corrective action, the licensee reviewed the past-due work orders and the aging priority 1 and 2 work orders and verified that no failures or significant degradations of critical components continued to exist as a result of the work orders not having been fully completed. The licensee initiated a CR to evaluate process changes.

Corrective Action Reference: CR-GGN-2018-12031

Performance Assessment:

Performance Deficiency: The failure to promptly identify and correct conditions adverse to quality as required by 10 CFR Part 50, Appendix B, Criterion XVI, and station procedures was a performance deficiency.

Screening: The performance deficiency was more than minor, and therefore a finding, because if left uncorrected it would have the potential to lead to a more significant safety concern. Specifically, uncorrected conditions adverse to quality could adversely affect the capability and reliability of safety-related structures, systems, and components (SSCs).

Significance: The inspectors performed the initial significance determination using NRC IMC 0609, Appendix A, Exhibit 2, Mitigating Systems Screening Questions. The inspectors determined that the finding was of very low safety significance (Green) because it did not result in the loss of operability or functionality of any system or train.

Cross-Cutting Aspect: This finding had a work management cross-cutting aspect in the human performance cross-cutting area (H.5) because the licensees organization failed to implement a process of planning, controlling, and executing work activities such that nuclear safety is the overriding priority. Specifically, the licensee failed to ensure that work was effectively planned and executed by incorporating risk insights, job site conditions, and the need for coordination with different groups or job activities.

Enforcement:

Violation: Title 10 CFR Part 50, Appendix B, Criterion XVI, Corrective Action, requires, in part, that measures shall be established to assure that conditions adverse to quality, such as failures, malfunctions, deficiencies, deviations, defective material and equipment, and nonconformances are promptly identified and corrected.

Contrary to this requirement, prior to October 22, 2018, the licensee failed to establish measures to assure that conditions adverse to quality were promptly identified and corrected.

Specifically, processes allowing closure of certain conditions adverse to quality to the licensees work management system were inadequate to assure that those conditions were promptly identified and corrected.

Disposition: This violation is being treated as a non-cited violation (NCV), consistent with Section 2.3.2 of the Enforcement Policy.

NCV: Failure to promptly identify and correct adverse conditions related to barrier doors Cornerstone Significance Cross-cutting Inspection Aspect Procedure Mitigating Green P.2 71152Problem Systems NCV 05000416/2018010-02 Identification and Closed Resolution The inspectors identified a Green non-cited violation of 10 CFR Part 50, Appendix B, Criterion XVI, Corrective Action, for the licensees failure to promptly identify and correct adverse conditions related to degraded barrier doors as required by regulations, license conditions, and station procedures.

Description:

During an October 22, 2018, daily review of CRs initiated over the previous 24-72 hours, the inspectors noted a large number of CRs documenting door-related adverse conditions. This collection of door-related CRs was not identified as a potential adverse trend by either the licensees pre-screen committee, which performs initial classification of CRs, or by the performance improvement review group (PRG), which provides management oversight to the CAP. A member of the pre-screen committee explicitly stated that there were no cognitive trends resulting from the committees review of the CR package.

After the inspectors questioned the pre-screen and PRG decision not to identify and document a potential trend, the licensee provided Condition Report CR-GGN-2017-01183.

This CR, initiated February 2, 2017, stated, During PRG on 2/2/17, a potential CR trend was identified for Plant Door issues. The CR was classified as a non-adverse broke-fix. After several due date extensions, a trend analysis was performed, and an action was assigned to engineering on May 11, 2017, to evaluate and add the Trend Validation . . . to their Department DPRM PIIM,1 and to determine which doors have similar failures or repeated failures. Engineering added the issue to the PIIM and closed the evaluation tracking to a work tracker, which is outside of the CAP.

On May 31, 2017, engineering opened a new corrective action to replace the incorrectly closed one, correctly stating that corrective actions for adverse trends needed to be tracked in the CAP. On August 29, 2017, after further due date extension, the evaluation was completed by the mechanical/civil engineering group. The evaluation stated, There are very few plant doors that have a preventative maintenance [PM] strategy associated with them.

The doors are generally classified as run to failure and are only repaired when degradation is discovered. . . . If it is desired for doors to remain intact at all times, then a pm [sic] strategy should be considered based on the importance of the affected door. The engineer then closed the action stating, The failure mechanisms listed in the categories above are not uncommon for doors especially for those which are used very frequently. From a Department Performance Improvement standpoint, there is no gap in engineering performance associated with this adverse trend. After one final due date extension, the final action in the CR was closed on January 31, 2018, with no corrective actions taken.

The inspectors observed that on July 9, 2017, the licensee experienced a loss of both divisions of Standby Fresh Air due to a breach in the control room envelope. This breach reported to the NRC in licensee event report (LER) 05000416/2017-005 as an event that could have prevented the fulfillment of a safety functionoccurred because of degradation to a safety-related boundary door. The LER stated, The organization failed to understand the nuclear safety consequence associated with the degraded condition and failed to implement a mitigating strategy. The licensee also noted that a human performance error contributed to the event.

On March 31, 2018, the licensee experienced a loss of secondary containment due to malfunction of the auxiliary building rail bay door due to door misalignment during operation.

This too was reported to the NRC as an event that could have prevented fulfillment of a safety function in LER 05000416/2018-005. The licensee again identified human performance as a contributor to the event.

The DPRM PIIM, or Department Performance Review Meeting Performance Improvement Integrated Matrix, is a document listing performance issues, including trends, and how those issues are being tracked and addressed. It is reviewed by department leadership at quarterly DPRMs.

Corrective actions to attempt to address the human performance aspects of these events included site-wide communications reinforcing expectations for door operationthat individuals check to ensure doors are latched after passing through them. However, on July 18, 2018, and again on August 20, 2018, the resident inspectors identified several instances of plant personnel not checking doors after opening and closing them. The licensee documented these instances in Condition Reports CR-GGN-2018-09163 and CR-GGN-2018-09551.

The inspectors concluded that despite the previous opportunities to identify and correct human performance issues and potentially inadequate maintenance practices associated with important doors, the licensee had failed to take prompt and adequate corrective actions.

Specifically, as evidenced by two reportable events and several documented inspector observations, corrective actions relative to human performance had not been successful and maintenance strategies had not been evaluated for doors other than the control room envelope doors.

Corrective Action: The licensee initiated a CR to evaluate why previous corrective actions had not been effective at preventing further door-related events.

Corrective Action Reference: CR-GGN-2018-12069

Performance Assessment:

Performance Deficiency: The failure to promptly identify and correct a condition adverse to quality as required by 10 CFR Part 50, Appendix B, Criterion XVI, and plant procedures was a performance deficiency.

Screening: The performance deficiency was more than minor, and therefore a finding, because if left uncorrected it would have the potential to lead to a more significant safety concern. Specifically, uncorrected conditions adverse to quality could adversely affect the capability and reliability of safety-related SSCs.

Significance: The inspectors performed the initial significance determination using NRC IMC 0609, Appendix A, Exhibit 2, Mitigating Systems Screening Questions. The inspectors determined that the finding was of very low safety significance (Green) because it did not result in the loss of operability or functionality of any system or train.

Cross-Cutting Aspect: This finding had an evaluation (P.2) cross-cutting aspect in the problem identification and resolution cross-cutting area because the licensee failed to thoroughly evaluate problems to ensure that resolutions address causes and extent of conditions, commensurate with their safety significance. Specifically, the licensee failed to thoroughly investigate an identified issue according to its safety significance.

Enforcement:

Violation: Title 10 CFR Part 50, Appendix B, Criterion XVI, Corrective Action, requires, in part, that measures shall be established to assure that conditions adverse to quality, such as failures, malfunctions, deficiencies, deviations, defective material and equipment, and nonconformances are promptly identified and corrected.

Contrary to this requirement, from February 2, 2017, through at least November 8, 2018, the licensee failed to establish measures to assure that conditions adverse to quality were promptly identified and corrected. Specifically, the licensee failed to correct inadequate maintenance procedures and poor human performance practices that, in at least two cases, resulted in the inoperability of safety-related SSCs.

Disposition: This violation is being treated as a non-cited violation (NCV), consistent with Section 2.3.2 of the Enforcement Policy.

FIN: Immediate operability determinations not documented in accordance with procedures Cornerstone Significance Cross-cutting Inspection Aspect Procedure Mitigating Green P.3 71152Problem Systems FIN 05000416/2018010-03 Identification and Closed Resolution The inspectors identified a Green NRC identified finding for the licensees failure to consistently complete immediate operability determinations in accordance with station procedures.

Description:

On July 24, 2017, the licensees nuclear independent oversight group (NIOS), documented a Quality Assurance Finding in the CAP (Condition Report CR-GGN-2017-07180), identifying that five operability determinations for safety-significant SSCs were not performed in an accurate or timely manner, and at least some of the compensatory measures were not recognized or correctly implemented. This CR was characterized as a Level B Adverse Condition, which requires an Adverse Condition

Analysis.

The Adverse Condition Analysis was approved by the PRG on September 8, 2017, and identified three causal factorstwo associated with inadequate procedural guidance in Procedure EN-OP-104, Operability Determination Process, and OPG-11 (Grand Gulf Nuclear Station-specific guidance to support operability determination completion), and one identifying that Operations and Engineering operability documentation indicated a lack of fundamental knowledge related to providing reasonable assurance of component operability.

The stations planned corrective actions were to:

(1) revise Procedure EN-OP-104 to ensure the procedure contained industry best guidance performing operability determinations;

(2) revise or delete OPG-11 to ensure consistent guidance between Fleet procedure and the Grand Gulf Nuclear Station guidance document; and

(3) perform operability determination training during Licensed Operator requalification training and with engineering staff to reinforce necessary fundamental knowledge necessary for these tasks. Further, the effectiveness of the corrective actions were to be assessed by completing operability determination Review Boards to assess the quality of the determinations from a sample of operability determinations conducted at points of 3 and 6 months following completion of the corrective actions.

In reviewing the Adverse Condition Analysis, and corrective actions and effectiveness reviews completed, the inspectors determined that a number of other CRs documenting incomplete and/or untimely operability determinations and functionality assessments (for non-safety related SSCs) were closed to Condition Report CR-GGN-2017-07180 as it was expected that the corrective actions would be appropriate to resolve those issues as well. This included the Condition Report CR-GGN-2017-11265 which documented and evaluated the NRC Finding 05000416/2017011-06 in which NRC inspectors identified that the licensee had not conducted functionality assessments for adverse conditions related to the offgas system in accordance with Procedure EN-OP-104.

Further, the inspectors determined that the corrective actions and effectiveness reviews for Condition Report CR-GGN-2017-07180 were not completed as intended and approved by PRG. Specifically, the training for Operations was conducted prior to revisions to Procedure EN-OP-104 were completed. Further, the station only completed one effectiveness review (in November - December 2017), before Procedure EN-OP-104 was revised, while the second effectiveness review was not completed. The fact that the second effectiveness review was not completed was not identified in the CR closure reviews.

Additionally, the inspectors determined that the licensees corrective actions did not seem to address the timeliness aspect of the original NIOS Quality Assurance Finding in the evaluation and corrective actions taken.

To independently evaluate the effectiveness of the corrective actions, the inspectors reviewed a selection of operability determinations completed in the period of late July through late October 2018 to assess the quality and timeliness attributes of the determinations. The inspectors review of these recent operability determinations for quality and complete information found that generally the operability determinations contained the appropriate level of detail to support operability/functionality decision. For those operability determinations with multiple revisions, 26 percent appeared to have additional information added by subsequent management/peer reviews which are driven by procedure and, in part, are intended to provide a quality check to the products.

However, the data set showed that Operations continues to not complete immediate operability determinations in a timely fashion in accordance with Procedure EN-OP-104.

Specifically, the procedure in Step 8.2.1.b requires the station to, ensure immediate operability determination is not delayed for extensive research and testing after confirmation of the existence of a degraded or nonconforming condition. The inspectors determined that for immediate operability determinations completed where the component was declared inoperable in the sample period (a total of 23 CRs) only 4 (17 percent) were completed in less than 1 hour1.157407e-5 days <br />2.777778e-4 hours <br />1.653439e-6 weeks <br />3.805e-7 months <br /> after discovery, 11 (48 percent) required 2 to 10 hours1.157407e-4 days <br />0.00278 hours <br />1.653439e-5 weeks <br />3.805e-6 months <br /> to complete, 6 (26 percent)required 10 to 20 hours2.314815e-4 days <br />0.00556 hours <br />3.306878e-5 weeks <br />7.61e-6 months <br /> to complete, and 2 (9 percent) required more than 20 hours2.314815e-4 days <br />0.00556 hours <br />3.306878e-5 weeks <br />7.61e-6 months <br /> for the immediate operability determination to be completed.

Further, the same data shows that Shift Managers are also not consistently reviewing and approving the immediate operability determinations consistent with Procedure EN-OP-104, in that about half of the 23 inoperable immediate operability determinations took more than an additional 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br /> to be approved. (In the worst case it took up to 13.5 hours5.787037e-5 days <br />0.00139 hours <br />8.267196e-6 weeks <br />1.9025e-6 months <br /> for the determination to be approved by the Shift Manager.) The inspectors noted that Procedure EN-OP-104 had been previously revised to address a corrective action to prevent recurrence at another Entergy site to ensure Shift Managers were responsible for approving operability determinations in a timely manner, and to ensure that the information was thoroughly reviewed and challenged to validate the accuracy of the operability determination.

As such, the inspectors determined that despite the corrective actions and effectiveness, reviews were not completed consistent with the corrective action plan, the quality and accuracy of the completed operability determinations had improved. However, the corrective actions implemented have not corrected the issue to ensure that operability determinations are completed following discovery without delay and in a controlled manner using the best information available.

Corrective Action: The licensee entered this issue into the CAP for further evaluation and action.

Corrective Action Reference: CR-GGN-2018-11960

Performance Assessment:

Performance Deficiency: The failure to assess operability immediately following discovery without delay and in a controlled manner using the best information available, per Procedure EN-OP-104, Operability Determination Process, was a performance deficiency.

Screening: The inspectors determined the performance deficiency was more than minor, and therefore a finding, because if left uncorrected, it would have the potential to lead to a more significant safety concern. Specifically, the failure of an on-shift licensed senior reactor operator to promptly assess and make an operability determination has the potential to result in the station not taking timely and appropriate actions to mitigate inoperable safety-related equipment in accordance with technical specifications and station procedures.

Significance: The inspectors assessed the significance of the finding using NRC IMC 0609, Appendix A, Exhibit 2, Mitigating Systems Screening Questions. The team determined that the finding was of very low safety significance (Green) because all of the screening questions were answered in the negative; in the sample of inoperable determinations reviewed, none of the determinations were completed at a point in excess of the applicable technical specification allowed outage time.

Cross-Cutting Aspect: The finding had a resolution (P.3) cross-cutting aspect in the problem identification and resolution cross-cutting area because the licensee failed to take effective corrective actions to address an issue in a timely manner commensurate with its safety significance. Specifically, the licensee failed to ensure corrective actions resolved and corrected identified issues, including causes and extent of condition.

Licensee Event LER 05000416/2017-002: Loss of 71153 Follow-up of Report Secondary Containment and Inoperability of Events and Notices of (Closed) the Standby Gas Treatment Systems as a Enforcement Discretion Result of a Damaged Power Supply Licensee Event LER 05000416/2017-005: Loss of Safety 71153 Follow-up of Report Function and Control Room Envelope Due to Events and Notices of (Closed) an Open Boundary Door Enforcement Discretion Licensee Event LER 05000416/2017-008: Inadequate Diesel 71153 Follow-up of Report Generator Common Mode Failure Events and Notices of (Closed) Evaluations Result in Condition Prohibited by Enforcement Discretion Technical Specifications Licensee Event LER 05000416/2017-009: Reactor Core 71153 Follow-up of Report Isolation Cooling System Inoperability Due to Events and Notices of (Closed) Lockout Circuit Settings Enforcement Discretion Licensee Event LER 05000416/2018-003: Inoperable 71153 Follow-up of Report Reactor Protection Functions During Main Events and Notices of (Closed) Steam Isolation Valve and Turbine Stop Enforcement Discretion Valve Channel Functional Tests Due to Use of a Test Box Licensee Event LER 05000416/2018-005: Secondary 71153 Follow-up of Report Containment Door Misaligned, Due to Events and Notices of (Closed) Inadequate Criteria, Could Have Prevented Enforcement Discretion Fulfillment of a Safety Function Licensee Event LER 05000416/2018-006: Secondary 71153 Follow-up of Report Containment Roof Hatch Left Open Due To Events and Notices of (Closed) Inadequate Corrective Actions Enforcement Discretion

EXIT MEETINGS AND DEBRIEFS

On November 8, 2018, the inspectors presented the inspection results to Mr. E. Larson, Site Vice President, and other members of the licensee staff. The inspectors confirmed that any proprietary or sensitive information reviewed was controlled to protect from public disclosure.

DOCUMENTS REVIEWED

Condition Reports (CR-GGN-20YY-XXXXX):

13-06725 16-08398 17-04475 17-10866 18-01403 18-05889 18-09613

13-07417 16-08403 17-04538 17-10884 18-01480 18-06236 18-09887

13-07436 16-09050 17-04776 17-10896 18-01512 18-06552 18-10024

13-07478 17-00047 17-05582 17-10900 18-01527 18-06608 18-10138

13-07525 17-00085 17-05583 17-10915 18-01740 18-06609 18-10253

13-07751 17-00256 17-05584 17-10954 18-01764 18-06863 18-10353

14-00452 17-00458 17-05789 17-11007 18-01936 18-07431 18-10414

14-00873 17-00916 17-06421 17-11029 18-02165 18-07554 18-10416

14-01706 17-01183 17-06705 17-11080 18-02211 18-07611 18-10441

14-02859 17-01356 17-06973 17-11094 18-02336 18-07679 18-10532

14-03912 17-01570 17-07180 17-11344 18-02352 18-07753 18-10633

14-04996 17-01590 17-07469 17-11354 18-02397 18-07777 18-11096

14-05534 17-01612 17-07656 17-11393 18-02697 18-07795 18-11102

14-06215 17-01701 17-08346 17-11626 18-02718 18-08063 18-11122

15-00315 17-01702 17-08349 17-11982 18-02942 18-08304 18-11171

15-03985 17-01763 17-08350 17-12012 18-02962 18-08387 18-11371

15-04612 17-02096 17-08355 17-12250 18-02979 18-08516 18-11457

15-04627 17-02291 17-08356 17-12283 18-03185 18-08553 18-11465

15-04682 17-02519 17-08386 17-12284 18-03388 18-08654 18-11491

15-06193 17-02643 17-08434 17-12285 18-04228 18-08671 18-11573

15-06199 17-02697 17-09154 17-12292 18-04298 18-08706 18-11584

15-06231 17-02698 17-09390 17-12314 18-04660 18-09003 18-11805

15-06831 17-02968 17-09643 17-12461 18-04863 18-09004 18-11954

16-03707 17-03072 17-09747 18-00098 18-04934 18-09005 18-11957

16-04400 17-03191 17-09749 18-00275 18-04984 18-09006 18-11960

16-04834 17-03231 17-09780 18-00342 18-04999 18-09007 18-12626

16-08066 17-03321 17-10042 18-00702 18-05198 18-09011

16-08085 17-03333 17-10261 18-00977 18-05261 18-09147

16-08306 17-03334 17-10788 18-01265 18-05360 18-09304

16-08324 17-04211 17-10839 18-01347 18-05519 18-09341

Plus a number of anonymous CRs initiated since November 2017, the text of most of

the several hundred CRs issued while the team was on site, and corporate Condition

Report HQN-2018-02364.

Work Orders

357849 448700 465663 488509 50297212 52617951 52788155

369168 455705 474597 492983 52326760 52623801 52789048

375435 459577 474598 496016 52370665 52707910 52831944

2188 459755 488372 504874 52498741 52757341

445248 462039 488414 505048 52583929 52788154

Engineering Changes 59355 59401 65769 71757 74757 78505

Procedures

Number Title Revision

2-S-01-17 Control of Limiting Conditions for Operation

2-S-01-25 Operations Section Procedure - Deficient

Equipment Identification - Safety-Related

04-1-01-P81-1 High Pressure Core Spray Diesel Generator 81

04-1-01-R21-17 ESF Bus 17AC System Operating Instruction 11

06-IC-1B21-R-2005 Reactor Vessel Water Level Calibration 108

06-IC-1E12-R-0001 LPCI System Discharge Line High/Low Pressure 103

Calibration

06-IC-1E21-R-0001 Low Pressure Core Spray Discharge Line 104

Calibration

06-IC-1E22-R-0001 HPCS Discharge Line Low Pressure Calibration 102

06-OP-1E12-Q-0024 LPCI/RHR Subsystem B Quarterly Functional Test 120

06-OP-1E22-Q-0002 HPCS Quarterly Valve Test 112

06-OP-1P41-Q-0004 Standby Service Water Loop A Valve and Pump 128

Operability Test

06-OP-1P81-M-0002 HPCS Diesel Generator Functional Test 135

07-S-01-60 Calibration and Control of Measuring and Test 25

Equipment

07-S-12-61 Inspection of GE Magne Blast Circuit Breakers 6

EH-LI-118

EN-DC-205 Maintenance Rule Monitoring

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

EN-DC-213 Engineering Quality Review 9

EN-DC-324

EN-LI-104 Self-Assessment and Benchmark Process 14

EN-LI-118 Cause Evaluation Process 28

EN-LI-121 Trending and Performance Review Process 24-25

EN-MA-105 Control of Measuring and Test Equipment 13

EN-OE-100 Operating Experience Program 30

EN-OP-104 Operability Determination Process 16

JA-PI-01 Analysis Manual (Job Aid) 7

JA-PI-03 OE Screening 4

Management Standard Performance Improvement Interim Actions 007

TQF-201-AN07 Training Analysis and Design Worksheet

Revision

Miscellaneous Title or Date

2018 Personal Contamination Event Log September 9,

2018

AR 18007669 PM Change Request for Secondary Containment June 22, 2018

Doors

AR 18008481 PM Change Request for Secondary Containment June 22, 2018

Doors

EC 74267 Evaluation of SSW Passive Failure of 24 Inch Line October 3,

Break 2017

EN-LI-121, Att. 9.1 Grand Gulf Nuclear Station - APRM Report 4Q/2017

EN-LI-121, Att. 9.1 Grand Gulf Nuclear Station - Operations DPRM 3Q/2018

Report

EN-LI-121, Att. 9.1 Grand Gulf Nuclear Station - Work Management October 2018

DPRM Report

EN-LI-121, Att. 9.1 Grand Gulf Nuclear Station - Engineering DPRM October 2018

Report

EN-LI-121, Att. 9.1 Grand Gulf Nuclear Station - Security DPRM Report October 2018

LO-GLO-2017- Self-Assessment: 92723 Inspection for December 1,

00032 50.59 Traditional Enforcement Violations 2017

LO-GLO-2017- Self-Assessment: Force-on-Force Testing May 3, 2018

00047

LO-GLO-2017- RF21 In-Service Inspection (ISI) Pre-NRC January 15,

00050 (71111.08) Assessment 2018

LO-GLO-2017- Self-Assessment: Pre-NRC Radiological Hazard November 15,

00051 Assessment and Exposure Controls (71124.01) 2017

LO-GLO-2017- Pre-NRC Inspection: Occupational ALARA Planning November 19,

00052 and Controls Assessment (IP71124.02) 2017

LO-GLO-2017- Self-Assessment: Radioactive Gaseous and Liquid August 16,

00063 Effluent Treatment 2018

LO-GLO-2017- 2017 Operations Comprehensive Self-Assessment January 8,

00081 2018

LO-GLO-2017- Perform Effectiveness Review for Operability November 16,

00091, CA-1 Determinations 2017

LO-GLO-2018- Self-Assessment: Exam Security June 12, 2018

00045

LO-GLO-2018- Self-Assessment: Chemistry Lab QA/QC Program September 4,

00073 2018

LO-GLO-2018- Self-Assessment: Training Absences September 8,

00112 2018

Revision

Miscellaneous Title or Date

OE-NOE-2018- NRC-IN-2018-04 - Operating Experience Regarding May 12, 2018

00084 Failure of Operators to Trip the Plant When

Experiencing Unstable Conditions

OE-NOE-2018- NRC-21-Event-53262 - Nextera Inadequate March 21,

00121 Dedication of Relays 2018

OE-NOE-2018- NRC-IN-2018-07 - Pump Turbine Bearing Oil Sight August 16,

247 Glass Problems 2018

OE-NOE-2018- NRC-21-2018-12-00 - Event - 53442 - Framatome - June 27, 2018

248 Eaton NBF66F Relay Failure of Relays to Change

State

OE-NOE-2018- NRC-IN-2018-11 - Kobe Steel Quality Assurance September 26,

00397 Record Falsification Misconduct 2018

PR-PRHQN-2018- Training Evaluation for Procedure EN-OP-104, June 1, 2018

241 Revision 16

QAPM Entergy Quality Assurance Program Manual 34

INFORMATION REQUESTS

ML18351A276

SUNSI Review: ADAMS: Non-Publicly Available Non-Sensitive Keyword: NRC-002

By: EAR Yes No Publicly Available Sensitive

OFFICE SPE/DRP RI/DRP SRI/DRP SRI/DRS TL/DRS C/DRP TL/DRS

NAME RAlexander TSullivan TSteadham ERuesch GMiller JKozal GMiller

SIGNATURE /RA-e/ /RA-e/ /RA-e/ /RA/ /RA HAF /RA/ /RA TRF

for/ for/

DATE 11/30/2018 12/10/2018 12/12/2018 12/13/2018 12/13/2018 12/14/2018 12/17/2018