IR 05000293/2017010

Confirmatory Action Letter (EA-17-086) Follow-Up Inspection Report 05000293/2017010

ML18032A463
Person / Time
Site:	Pilgrim
Issue date:	02/01/2018
From:	Anthony Dimitriadis Reactor Projects Branch 1
To:	Brian Sullivan Entergy Nuclear Operations
Dimitriadis A
References
EA-17-086 IR 2017010
Download: ML18032A463 (19)

Text

February 1, 2018

EA-17-086

Mr. Brian Sullivan Site Vice President Entergy Nuclear Operations, Inc.

Pilgrim Nuclear Power Station 600 Rocky Hill Road Plymouth, MA 02360-5508

SUBJECT: PILGRIM NUCLEAR POWER STATION - CONFIRMATORY ACTION LETTER (EA-17-086) FOLLOW-UP INSPECTION REPORT 05000293/2017010

Dear Mr. Sullivan:

On December 8, 2017, the U.S. Nuclear Regulatory Commission (NRC) completed an on-site team inspection at Pilgrim Nuclear Power Station (PNPS). The NRC inspectors discussed the results of this inspection with you and other members of your staff via a teleconference exit on December 21, 2017. The results of this inspection are documented in the enclosed report.

The NRC inspection team reviewed PNPS's prog ress in implementing the actions from the PNPS Comprehensive Recovery Plan (CRP) that were committed to in the Confirmatory Action Letter (CAL) dated August 2, 2017 (NRC's Agencywide Documents Access and Management System (ADAMS) Accession No. ML17214A088) (EA-17-086). Specifically, the team reviewed PNPS's progress to address all of the Procedure Quality Fundamental Problem Area CAL

items, and a sample of other Fundam ental Problem Areas CAL items.

The inspection team conducted a sample review of in-scope procedures that had previously been reviewed and revised per PNPS's process. Through these independent reviews, the team determined that PNPS made progress to improve the quality of important procedures that affect safety-related equipment. No findings or violations of NRC requirements were identified during this inspection. However, the team concluded that additional action was needed to ensure the clarity of acceptance criteria and that procedure action steps were enhanced to support sustained improvement in the area of Procedure Quality. Therefore, while our inspection team determined that PNPS demonstrated progress in the Procedure Quality fundamental problem area, our review concluded that the progress was not sufficient for the NRC to close the CAL Procedure Quality Area Action Plan at this time. PNPS staff entered the issue into the PNPS corrective action process to perform further review. After you notify us that your reviews are completed, we will follow up on the results of your actions to address our concerns in the area of Procedure Quality during a future team inspection.

The attached report documents the CAL issues reviewed by the team and overall CAL status (open or closed) based upon the team's reviews. 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 Title 10 of the Code of Federal Regulations (10 CFR) 2.390, "Public Inspections, Exemptions, Requests for Withholding."

Sincerely,/RA/ Anthony Dimitriadis, Chief Reactor Projects Branch 5

Division of Reactor Projects

Docket No. 50-293 License No. DPR-35

Enclosure:

Inspection Report 05000293/2017010 w/

Attachments:

1. Supplementary Information 2. Confirmatory Action Letter Item Status

cc w/encl: Distribution via ListServ

ML18032A463 SUNSI Review Non-Sensitive Sensitive Publicly Available Non-Publicly Available OFFICE RI/DRP RI/DRP RI/DRP RI/DRP NAME JPfingsten LCline MCatts via email ADimitriadis DATE 2/1/18 2/1/18 2/1/18 2/1/18

1 Enclosure U.S. NUCLEAR REGULATORY COMMISSION REGION I Docket No. 50-293 License No. DPR-35 Report No. 05000293/2017010 Licensee: Entergy Nuclear Operations, Inc. (Entergy)

Facility: Pilgrim Nuclear Power Station (PNPS)

Location: Plymouth, MA Dates: December 4 through December 8, 2017 Team Lead: William Cook, Senior Risk Analyst, Division of Reactor Safety

Inspectors:

Michelle Catts, Senior Project Engineer, Division of Reactor Projects (DRP) Leonard Cline, Senior Project Engineer, DRP Jonathan Pfingsten, Project Engineer, DRP Approved By: Anthony Dimitriadis, Chief Reactor Projects Branch 5

Division of Reactor Projects

2

SUMMARY

IR 05000293/2017010; 12/04/2017 - 12/08/2017; Pilgrim Nuclear Power Station (PNPS); Confirmatory Action Letter (CAL) Follow-up Inspection.

The inspection activities described in this report were performed between December 4, 2017, and December 8, 2017, by four inspectors from the NRC's Region I office. The NRC's program for overseeing the safe operation of commercial nuclear power reactors is described in NUREG-1649, "Reactor Oversight Proc ess," Revision 6, dated July 2016.

The team reviewed 20 of the 156 items from the PNPS Comprehensive Recovery Plan involving commitments made in the CAL (EA-17-086). The team concluded that 17 of the items reviewed were complete and effective in achieving the associated performance improvement objectives; the items are therefore closed. Based upon obs ervations made by the team, three CAL items will remain open pending additional NRC review. Team observations are documented in this report. The Procedure Quality (PQ) Area Action Plan (AAP) of the CAL remains open.

No findings or violations of NRC requirements were identified.

3

REPORT DETAILS

OTHER ACTIVITIES (OA)

Background NRC Region I staff is reviewing Entergy's progress towards resolving performance issues that led to PNPS being placed in Column 4 of the NRC's Reactor Oversight Process Action Matrix. The NRC is perform ing this by conducting periodic CAL follow-up inspections at Pilgrim. These inspections have been and will be conducted when Entergy determines that its corrective actions are reasonably complete and effectiveness reviews confirm adequate progress in each CAL fundamental problem area. The first of these inspections was completed on December 21, 2017.

4OA5 Other Activities

Confirmatory Action Letter Follow-up (Inspection Procedure 92702)

a. Inspection Scope

The inspection team reviewed 20 of the 156 items from the PNPS Comprehensive Recovery Plan involving commitments made in the CAL (EA-17-086). Each CAL item closure package was prepared by PNPS staff and presented for NRC inspection team review after having been subjected to a formal effectiveness review process conducted in accordance with Entergy Procedure EN-FAP-LI-002, "Project Review Board Guide," Revision 5. This review process involves (in addition to the standard condition report action closure process) a review by the responsible CAL item manager; an Action Closure Review Board challenge that includes Regulatory Assurance department participation; and independent reviews conducted by the Nuclear Oversight Committee, Entergy corporate reviewers, and/or independent third party reviewers.

The inspection team examined these areas to determine if:

(1) CAL item actions were completed;

(2) corrective actions were completed in a timely manner consistent with their safety significance;

(3) AAPs, as described in Entergy's recovery plan (EA-17-086, 1), were effective at addressing the performance issues identified in the CAL;

(4) CAL performance metrics were appropriate and indicated progress; and

(5) closure of each CAL item was in accordance with established station procedural guidance. The inspection team also:

(1) conducted station walkdowns, when appropriate to the CAL issue review, verification, and closure;

(2) attended effectiveness review challenge boards;

(3) interviewed station staff responsible for specific CAL issue action items and CAL issue closure reviews; and

(4) reviewed root and apparent causal analyses to assess the veracity and adequacy of the analyses and associated corrective actions.

b. Findings and Observations

No findings or violations of NRC requirements were identified.

.1 CAL Item Closure

The team closed the following 17 CAL items (a narrative description of each item is listed in Enclosure 1 to the PNPS CAL (ML17214A088)):

Procedure Quality (PQ) - 2.1, 2.2, 3.1, 3.2, 3.3, and 5.1 Corrective Action Program (CAP) - 1.1 Engineering Programs (EP) - 1.1 Equipment Reliability (ER) - 1.1 and 1.2 Procedure Use and Adherence (PUA) - 1.1, 1.2, 1.3 and 1.4 Operability Determinations and Functionality Assessments (ODFA) - 1.1 Safety Relief Valve (SRV) White Finding - 1.3 and 2.1 The team reviewed the following CAL Items, but left the items open pending further inspector follow-up and review:

PQ-1.1 and 5.2 (see Section 4OA5.b.2 below for the inspection team's observations) ODFA-1.2. CAL item ODFA-1.2 remains open pending the completion of additional corrective actions related to observations documented in the NRC Inspection Procedure 95003 Supplemental Inspection.

.2 Observation - Implementation of Revised Procedure Standards

The inspection team reviewed 12 procedures that Entergy reviewed and revised to comply with the standards described by PNPS's enhanced Procedure Writer's Guide, Entergy Procedure PPA AP-907-005. The inspectors identified procedure problems associated with procedure acceptance criteria and missing prerequisites and/or precautions and limitations regarding technical specification compliance. Examples of the inspector identified procedure problems in these two areas included:

Procedure 3.M.63-24, Secondary Containment Door Interlock Inspection, Revision 6 The PQ WILL Sheet Section A identified the following standard: "Acceptance Criteria is correct and appropriate for determining successful outcome or failure of the activity being performed." As written, the acceptance criteria statement for this procedure would allow the inspection to be signed off as satisfactory if discrepancies that caused a failure of the activity to meet acceptance criteria were identified, as long as a condition report was written to document the discrepancies. The inspectors determined that as written this was confusing and was not appropriate for determining successful outcome of the activitiy being performed. Entergy entered this observation into the CAP as CR-PNP-2017-12118.

Procedure 8.5.2.13, RHR [residual heat removal] Keep fill Valve Leak Test, Revision 8

PQ WILL Sheet Section A identified the following criteria: "If the procedure causes or requires equipment to be inoperable during performance, Prerequisites and/or Limitations are appropriate to ensure compliance with the Technical Specifications and the FSAR." The inspectors determined t hat the system alignments directed by the procedure affected the operability of the residual heat removal system, but neither the prerequisites nor the precautions and limitations included actions to ensure the residual heat removal system remained in the alignment required by the technical specifications for the applicable mode of plant operation. Entergy entered this observation into the CAP as CR-PNP-2017-12124.

Procedure 8.C.23, Shutdown Transformer Surveillance, Revision 25 PQ WILL Sheet Section A identified the following criteria: "Acceptance Criteria is correct and appropriate for determining successful outcome or failure of the activity being performed." The 8.C.23 acceptance criteria required that the procedure was performed as written with no discrepancies or with appropriate corrective action documents initiated for all discrepancies noted. However, Step 11, Acceptance Criteria Acceptance Verification, indicated that corrective action documents (condition reports) were only required when acceptance criteria were not met. The inspectors determined that as written this was confusing and was not appropriate for determining successful outcome of the activitiy being performed. Entergy entered this observation into the CAP as CR-PNP-2017-12125.

Based upon the team's observations, PNPS implemented the following interim corrective

actions: 1) placed on "hold" all procedures with WILL sheet discrepancies that involved acceptance criteria and technical specification implementation pending completion of the required procedure revisions; 2) initiated a complete re-review of all in-scope (531)station procedures using a "focused" PQ WILL sheet (the focused WILL sheets enhanced two review criteria - acceptance criteria and technical specification applicability/impact); 3) issued a standing order to the Operations department to evaluate all procedures for the adequacy of acceptance criteria and technical specification applicability prior to use; and 4) initiated an apparent cause analysis to understand the causes behind the missed WILL sheet review criteria.

Subsequent to the onsite inspection, PNPS staff informed the team that the complete re-review of the 531 in-scope procedures yielded approximately 50 procedures with additional WILL sheet criteria not satisfied. Based on the results of the team's sample review, the NRC concluded that additional inspection of PNPS actions to address CAL items PQ-1.1 and 5.2, which directed the review of the quality of onsite procedures, was warranted. The inspectors determined that these performance deficiencies were not considered more-than-minor because, each issue, by itself, did not adversely affect a cornerstone objective, could not be considered a precursor to a signicant event, did not affect a performance indicator result, and if uncorrected would not have the potential to lead to a more significant safety concern.

.3 Metrics and Measures to Monitor Improvement

The inspection team reviewed the monthly PNPS CAL performance metrics related to the PQ CAL AAP. The team noted that PNPS developed 37 performance metrics to

track recovery progress across multiple AAPs. The team reviewed the PQ performance metrics which were included as a roll-up assessment as part of the PQ AAP Effectiveness Review, dated November 10, 2017, and as part of the PQ AAP CAL Closure Report, dated December 8, 2017. The team also noted that the PQ AAP Effectiveness Review Challenge Board examines the PQ metrics on a quarterly basis. The team reviewed the current PQ metrics and identified no issues.

.4 Observation - Inadequate Corrective Actions to Address Entergy Identified Ineffective

Actions The team examined Entergy's "PQ Problem Area, CR-PNP-2016-2058 Effectiveness Review," dated November 10, 2017. As part of this review, Entergy staff reviewed procedures that were revised using the results of Pilgrim PQ WILL sheet reviews.

Entergy staff identified weaknesses in the results of the original PQ WILL sheet procedure reviews and the procedure revisions that were completed by the Maintenance department to address discrepancies identified by these reviews. The effectiveness review identified procedure weaknesses identified during the original WILL sheet reviews that were not corrected by the subsequent procedure revision and additional procedure weaknesses that were not identified by the original WILL sheet review. Entergy concluded that their actions in the PQ area were not effective. To address the identified problems, Pilgrim conducted additional training for the staff who completed Maintenance department procedure reviews and added additional supervisor reviews to provide periodic checks of Maintencance department procedure review quality. Entergy will also perform two additional effectiveness reviews in the PQ area, one in March 2018 and one in June 2018.

All actions taken to address the PQ weaknesses Entergy identified during its effectiveness review were complete at the time of this inspection. The results of the inspection team procedure reviews discussed in Section 4OA5b.2 identified additional weaknesses in maintenance procedures and similar weaknesses in Operations department procedures. Based on the results of Entergy's effectiveness review, and the teams independent procedure quality reviews, the team concluded that Entergy's actions taken as part of the PQ AAP had not demonstrated sustainable performance improvement.

As a result of the team's observations, PNPS completed an apparent cause analysis in CR- PNP-2017-12117 and identified broader PQ implementation and performance shortcomings attributed to: 1) a lack of appropriate rigor and accountability on the part of procedure reviewers; 2) management and supervisory oversight standards and expectations were less than adequate; and, 3) WILL sheet review criteria was, in some instances, ambiguous and/or lacked specificity.

.5 CAL AAP Summary Review

Based upon the above team observations, the NRC will keep the PQ area of the PNPS CAL open, pending the completion of Entergy's follow-up effectiveness reviews and an update to the PQ AAP CAL Closure Report.

No additional CAL AAPs were reviewed during this inspection period.

4OA6 Meetings, Including Exit

Exit Meeting Summary

On December 21, 2017, the inspectors presented the inspection results to Mr. Brian Sullivan, Site Vice President, and other members of the Entergy staff. The inspectors verified that no proprietary information was retained by the inspectors or documented in

this report.

ATTACHMENT 1:

SUPPLEMENTARY INFORMATION

KEY POINTS OF CONTACT

Licensee Personnel

B. Sullivan, Site Vice President

D. Pitts, General Manager, Plant Operations

D. Benza, Maintenance Supervisor

B. Chenard, Operations Manager

F. Clifford, Operations Support

G. Flynn, Director of Engineering

M. Jacobs. Nuclear Oversight Manager

D. Noyes, Recovery Manager

E. Perkins, Regulatory Assurance Manager

LIST OF CONFIRMATORY ACTION LETTER ITEMS CLOSED AND DISCUSSED

Closed CAP-1.1 EP-1.1

ER-1.1

ER-1.2

PUA-1.1 PUA-1.2 PUA-1.3

PUA-1.4

ODFA-1.1

PQ-2.1 PQ-2.2 PQ-3.1

PQ-3.2

PQ-3.3

PQ-5.1

SRV-1.3 SRV-2.1

Discussed PQ-1.1

PQ-5.2 ODFA-1.2

LIST OF DOCUMENTS REVIEWED

CAL Item Closure Packages

CAP-1.1

EP-1.1

ER-1.1

ER-1.2

PUA-1.1

PUA-1.2

PUA-1.3

PUA-1.4

ODFA-1.1

ODFA-1.2

PQ-1.1

PQ-2.1

PQ-2.2

PQ-3.1

PQ-3.2

PQ-3.3

PQ-5.1

PQ-5.2

SRV-1.3

SRV-2.1

Procedures

1.3.4-1, Procedure Writer's Guide, Revision 28

1.3.135, Control of Doors, Revision 13

1.3.142, Critical Decision Process, Revision 7

2.1.12.1, Emergency Diesel Generator Surveillance, Revision 83

2.4.167, Flooding, Revision 2

3.M.3-25.10, Weekly Battery Pilot Cell and Charger Inspection, Revision 18

3.M.3-25.10, Weekly Battery Pilot Cell and Charger Inspection, Revision 19

3.M.3-25.10, Weekly Battery Pilot Cell and Charger Inspection, Revision 20

3.M.3-25.10, Weekly Battery Pilot Cell and Charger Inspection, Revision 21

3.M.3-61.1, Emergency Diesel Generator Monthly Preventative Maintenance - Critical Maintenance, Revision 13 3.M.4-14, Rotating Equipment Inpsection Assembly and Disassembly - Critical Maintenance, Revision 51 5.5.2, Special Fire Procedure, Revision 57

8.M.1-32.5, Analog Trip System - Trip Unit Calibration, Revision 45

8.M.2-2.6.4, Reactor Core Isolation Cooling Steam Line Low Pressure - Critical Maintenance, Revision 48

8.Q.3-2, RHR/Core Spray Pump Motor Preventative Maintenance, Revision 25

8.C.23, Shutdown Transformer Surveillance, Revision 25

8.5.2.13, RHR Keepfill Valve Leak Test, Revision 8

ARP-C7L, Alarm Response Procedure

EN-FAP-HU-001 Rev 2, FLEET What it Looks Like (WILL Sheet) Development Process, Revision 2

EN-FAP-LI-002, Project Review Board Guide, Revision 5

EN-FAP-LI-005, Recovery Project Administrative Controls, Revision 4

EN-HU-105, Human Performance - Managed Defenses, Revision 17

EN-HU-106, Procedure and Work Instruction Use and Adherence, Revision 6

EN-LI-100, Process Applicability Determination, Revision 20

EN-LI-102, Corrective Action Program, Revision 30

EN-LI-104, Self-Assessment and Benchmark Process, Revision 13

EN-LI-118, Cause Evaluation Process, Revision 24

EN-LI-121, Trending and Performance Review Process, Revision 24

EN-LI-123-12-PNP-RC, Comprehensive Recovery Plan and Performance Metrics, Revision 2

EN-MS-S-011-MULTI, Conduct of System & Components Engineering, Revision 11

EN-MS-S-016-MULTI, Conduct of Design Engineering, Revision 6

EN-OP-115, Conduct of Operations, Revision 22

EN-QV-109, Audit Process, Revision 13

EN-WM-100, Work Request (WR) Generation, Screening and Classification, Revision 13 NOP98A1, Procedure Process, Revision 42

Condition Reports

(* Indicates NRC identified)

CR-PNP-2016-01621

CR-PNP-2016-02052

CR-PNP-2016-02052

CR-PNP-2016-02054

CR-PNP-2016-02054

CR-PNP-2016-02056

CR-PNP-2016-02056

CR-PNP-2016-02058

CR-PNP-2016-02061

CR-PNP-2016-05329

CR-PNP-2016-07907

CR-PNP-2016-09451

CR-PNP-2016-09479

CR-PNP-2017-00886

CR-PNP-2017-02842

CR-PNP-2017-09108

CR-PNP-2017-09672

CR-PNP-2017-09684

CR-PNP-2017-09947

CR-PNP-2017-10311

CR-PNP-2017-10502

CR-PNP-2017-10511

CR-PNP-2017-10519

CR-PNP-2017-10520

CR-PNP-2017-10523

CR-PNP-2017-10775

CR-PNP-2017-11057

CR-PNP-2017-11086

CR-PNP-2017-11104

CR-PNP-2017-11131

CR-PNP-2017-11131

CR-PNP-2017-11174

CR-PNP-2017-11194

CR-PNP-2017-11207

CR-PNP-2017-11229

CR-PNP-2017-11230

CR-PNP-2017-11231

CR-PNP-2017-11238

CR-PNP-2017-11513

CR-PNP-2017-11521

CR-PNP-2017-11935

CR-PNP-2017-11936

CR-PNP-2017-11937

CR-PNP-2017-11944

CR-PNP-2017-11958

CR-PNP-2017-12015*

CR-PNP-2017-12120CR-PNP-2017-12117

Miscellaneous

3.M.3-25.10 Revision Timeline

AFG-2016-01, LORT As-Found Simulator Exam Scenario, Revision 0

Course Number

CR-PNP-2016-1621, SRV White Finding Root Cause Case Study Course Number

266693, 2016-2018 Cycle 1 Crew Evaluated Scenario Difficulty, Importance, Frequency Analysis for SRV 1.3

DRN 17-P992, Weekly Battery Pilot Cell and Charger Inspection

DRN 17-1924, Weekly Battery Pilot Cell and Charger Inspection

DRN 17-1972, Weekly Battery Pilot Cell and Charger Inspection

LO-PNPLO-2017-0002, PQ M

onthly Self-Assessments ODFA Area Action Plan Effectiveness Review Challenge Board Quarterly Review, 3Q17 Online Master Schedule, December 4-8, 2017

Plan of the Day Wednesday December 6, 2017

Pilgrim 95003 Mentor Team Report for March 16

th , 2017 - April 15

th, 2017 Pilgrim 95003 Mentor Team Report for April 16

th, 2017- May 31

st, 2017 Pilgrim 95003 Mentor Team Report for June 2017 Pilgrim 95003 Mentor Team Report for July 2017

Pilgrim 95003 Mentor Team Report for August 2017

Pilgrim 95003 Mentor Team Report for September 2017

Pilgrim 95003 Mentor Team Report for October 2017

Pilgrim Station Coordinated Meeting Schedule PNPS Recovery Dashboard - September and October 2017 Procedure Quality Problem Area Effectivenss Reviews

Procedure

Quality Problem Closure Report

QS-2017-PNP-03, NIOS Assessment of the Procedure Quality Recovery Problem Area Readiness for NRC Inspection, 10/23/2017 through 10/26/2017 Procedure Professionals Association (PPA) Certification Course Training Materials

LIST OF ACRONYMS

AAP area action plan

CAL confirmatory action letter

CAP corrective action program

PQ procedure quality

WILL What It Looks Like

Attachment 2 Confirmatory Action Letter Item Status

Line Item Area Action Plan

CAL Item Inspection Report Number Closed 1 Nuclear Safety Culture

NSC-1.1 2 Nuclear Safety Culture NSC-1.2 3 Nuclear Safety Culture NSC-1.3 4 Nuclear Safety Culture NSC-1.4 5 Nuclear Safety Culture NSC-1.5 6 Nuclear Safety Culture NSC-1.6 7 Nuclear Safety Culture NSC-1.7 8 Nuclear Safety Culture NSC-1.8 9 Nuclear Safety Culture NSC-1.10 10 Nuclear Safety Culture NSC-2.2 11 Nuclear Safety Culture NSC-2.3 12 Nuclear Safety Culture NSC-3.1 13 Nuclear Safety Culture NSC-3.2 14 Nuclear Safety Culture NSC-3.3 15 Nuclear Safety Culture NSC-3.4 16 Nuclear Safety Culture NSC-3.5 17 Nuclear Safety Culture NSC-3.6 18 Nuclear Safety Culture NSC-3.7 19 Nuclear Safety Culture NSC-3.8 20 Nuclear Safety Culture NSC-4.1 21 Nuclear Safety Culture NSC-4.2 22 Nuclear Safety Culture NSC-5.1 23 Nuclear Safety Culture NSC-5.2 24 Nuclear Safety Culture NSC-5.3 25 Nuclear Safety Culture NSC-5.4 26 Nuclear Safety Culture NSC-6.1 27 Nuclear Safety Culture NSC-7.1 28 Nuclear Safety Culture NSC-8.1 29 Nuclear Safety Culture NSC-8.6 30 Nuclear Safety Culture NSC-8.8 31 Nuclear Safety Culture NSC-8.9 32 Nuclear Safety Culture NSC-8.10 33 Nuclear Safety Culture NSC-8.21 34 Nuclear Safety Culture NSC-8.22 35 Nuclear Safety Culture NSC-8.25 36 Nuclear Safety Culture NSC-8.26 37 Nuclear Safety Culture NSC-8.27 38 Nuclear Safety Culture NSC-8.28 39 Nuclear Safety Culture NSC-8.29 40 Corrective Action Program CAP-1.1 05000293/2017010 Y

Line Item Area Action Plan

CAL Item Inspection Report Number Closed 41 Corrective Action Program

CAP-1.2 42 Corrective Action Program CAP-1.3 43 Corrective Action Program CAP-1.4 44 Corrective Action Program CAP-1.5 45 Corrective Action Program CAP-1.7 46 Corrective Action Program CAP-1.8 47 Corrective Action Program CAP-1.9

Corrective Action Program CAP-1.10 49 Corrective Action Program CAP-1.11 50 Corrective Action Program CAP-2.1 51 Corrective Action Program CAP-2.2 52 Corrective Action Program CAP-2.3 53 Corrective Action Program CAP-3.1 54 Corrective Action Program CAP-3.2 55 Corrective Action Program CAP-4.2 56 Corrective Action Program CAP-4.3 57 Procedure Use and

Adherence PUA-1.1 05000293/2017010 Y 58 Procedure Use and

Adherence PUA-1.2 05000293/2017010 Y 59 Procedure Use and

Adherence PUA-1.3 05000293/2017010 Y 60 Procedure Use and

Adherence PUA-1.4 05000293/2017010 Y 61 Procedure Use and

Adherence PUA-1.6 62 Procedure Use and

Adherence PUA-2.2 63 Procedure Use and

Adherence PUA-2.3 64 Procedure Use and

Adherence PUA-2.4 65 Procedure Use and

Adherence PUA-2.5 66 Procedure Use and

Adherence PUA-3.1 67 Procedure Use and

Adherence PUA-3.2 68 Procedure Use and

Adherence PUA-3.3 69 Procedure Use and

Adherence PUA-3.4

Line Item Area Action Plan CAL Item Inspection Report Number Closed 70 Procedure Use and

Adherence PUA-4.1

Procedure Use and

Adherence PUA-4.2 72 Procedure Use and

Adherence PUA-4.3 73 Procedure Use and

Adherence PUA-5.1 74 Procedure Use and

Adherence PUA-5.2 75 Procedure Use and

Adherence PUA-5.7 76 Procedure Use and

Adherence PUA-5.8 77 Procedure Use and

Adherence PUA-5.9 78 Operability Determinations and Functionality Assessments

ODFA-1.1 05000293/2017010 Y 79 Operability Determinations and Functionality Assessments

ODFA-1.2 Reviewed - 05000293/2017010 N 80 Operability Determinations and Functionality Assessments

ODFA-1.3 81 Operability Determinations and Functionality Assessments

ODFA-1.4 82 Operability Determinations and Functionality Assessments

ODFA-1.5 83 Operability Determinations and Functionality Assessments

ODFA-1.6 84 Operability Determinations and Functionality Assessments

ODFA-2.2 85 Operability Determinations and Functionality Assessments

ODFA-3.1 86 Operability Determinations and Functionality Assessments

ODFA-5.1

Line Item Area Action Plan

CAL Item Inspection Report Number Closed 87 Operability Determinations and Functionality Assessments

ODFA-5.2 88 Operability Determinations and Functionality Assessments

ODFA-5.3 89 Operability Determinations and Functionality Assessments

ODFA-5.4 90 Operability Determinations and Functionality Assessments

ODFA-5.5 91 Operability Determinations and Functionality Assessments

ODFA-5.6 92 Operability Determinations and Functionality Assessments

ODFA-5.7 93 Operability Determinations and Functionality Assessments

ODFA-5.8 94 Operations Department Standards and Leadership OPS-1.1 95 Operations Department Standards and Leadership OPS-1.2 96 Operations Department Standards and Leadership OPS-1.4 97 Operations Department Standards and Leadership OPS-1.6 98 Operations Department Standards and Leadership OPS-1.7 99 Operations Department Standards and Leadership OPS-2.2 100 Operations Department Standards and Leadership OPS-3.1 101 Operations Department Standards and Leadership OPS-3.2 102 Operations Department Standards and Leadership OPS-4.1 103 Operations Department Standards and Leadership OPS-4.2 104 Risk Recognition and Decision Making RRDM-1.1

Line Item Area Action Plan

CAL Item Inspection Report Number Closed 105 Risk Recognition and Decision Making

RRDM "-1.2 106 Risk Recognition and Decision Making RRDM-1.3 107 Risk Recognition and Decision Making RRDM-2.1 108 Risk Recognition and Decision Making RRDM-3.1 109 Risk Recognition and Decision Making RRDM-3.2 110 Risk Recognition and Decision Making RRDM-3.3 111 Risk Recognition and Decision Making RRDM-4.3 112 Risk Recognition and Decision Making RRDM-4.8 113 Risk Recognition and Decision Making RRDM-4.9 114 Procedure Quality PQ-1.1 Reviewed - 05000293/2017010 N 115 Procedure Quality PQ-2.1 05000293/2017010 Y 116 Procedure Quality PQ-2.2 05000293/2017010 Y 117 Procedure Quality PQ-3.1 [[Inspection report" contains a listed "[" character as part of the property label and has therefore been classified as invalid. Y 118 Procedure Quality PQ-3.2 05000293/2017010 Y 119 Procedure Quality PQ-3.3 05000293/2017010 Y 120 Procedure Quality PQ-5.1 05000293/2017010 Y 121 Procedure Quality PQ-5.2 Reviewed - 05000293/2017010 N]]

122 SRV White Finding

SRV -1.1

123 SRV White Finding

SRV -1.2

124 SRV White Finding

SRV -1.3 05000293/2017010 Y

125 SRV White Finding

SRV -2.1 05000293/2017010 Y

126 SRV White Finding

SRV -3.1

127 SRV White Finding

SRV -3.2

128 SRV White Finding

SRV -3.3

129 SRV White Finding

SRV -3.4

130 SRV White Finding

SRV -4.1

131 SRV White Finding

SRV -5.1

132 SRV White Finding

SRV-5.2 133 Engineering Programs EP-1.1 05000293/2017010 Y 134 Engineering Programs EP-1.2 135 Engineering Programs EP-2.1 136 Engineering Programs EP-2.2 137 Engineering Programs EP-2.3 138 Engineering Programs EP-2.4

Line Item Area Action Plan

CAL Item Inspection Report Number Closed 139 Engineering Programs

EP [[-3.1 140 Engineering Programs EP-4.1 141 Equipment Reliability ER-1.1 05000293/2017010 Y 142 Equipment Reliability ER-1.2 05000293/2017010 Y 143 Equipment Reliability ER-1.3 144 Equipment Reliability ER-2.1 145 Equipment Reliability ER-2.2 146 Equipment Reliability ER-3.1 147 Equipment Reliability ER-3.2 148 Equipment Reliability ER-3.3 149 Work Management WM-1.1 150 Work Management WM-1.2 151 Work Management WM-1.3 152 Work Management WM-2.1 153 Work Management WM-2.2 154 Work Management WM-3.1 155 Work Management WM-3.3 156 Work Management WM-4.2]]