IR 05000313/2017012

NRC Confirmatory Action Letter (EA-16-124) Follow-Up Inspection Report 05000313/2017012 and 05000368/2017012

ML17282A018
Person / Time
Site:	Arkansas Nuclear
Issue date:	10/06/2017
From:	O'Keefe N NRC/RGN-IV/DRP/RPB-E
To:	Richard Anderson Entergy Operations
O'Keefe C
References
EA-14-008, EA-14-088, EA-16-124 IR 2017012
Download: ML17282A018 (54)

Text

October 6, 2017

SUBJECT:

ARKANSAS NUCLEAR ONE - NRC CONFIRMATORY ACTION LETTER (EA-16-124) FOLLOW-UP INSPECTION REPORT 05000313/2017012 AND 05000368/2017012

Dear Mr. Anderson:

On August 31, 2017, the U.S. Nuclear Regulatory Commission (NRC) inspection team reviewed your progress in implementing the specific actions from the Arkansas Nuclear One (ANO)

Comprehensive Recovery Plan that were committed to in a Confirmatory Action Letter (CAL)

dated June 17, 2016 (NRCs Agencywide Documents Access and Management System (ADAMS) Accession No. ML16169A193) (EA-16-124). The team discussed the results of this inspection with you and other members of your staff. The team documented the results of this inspection in the enclosed inspection report.

The team reviewed ANOs progress in implementing the ANO Comprehensive Recovery Plan, focusing on 31 actions, which ANO management had concluded were complete and had been determined to be effective. Additionally, the team reviewed progress made toward closing one additional item (PH-12), and will continue to inspect this item going forward. The inspection included a review of corrective actions to address the finding of substantial safety significance (Yellow) involving the failure to adequately approve the design and to load test a temporary lift assembly (EA-14-008) and the finding of substantial safety significance (Yellow) involving requirements for flood mitigation (EA-14-088). The attached report documents the basis for closing 30 of the 31 CAL actions inspected, as well as observations related to the stations progress in addressing the action that was not sufficiently complete and effective to close at this time. The NRC will further review your development and implementation of corrective actions for these risk-significant findings during future inspections.

UNITED STATES NUCLEAR REGULATORY COMMISSION

REGION IV

1600 E. LAMAR BLVD ARLINGTON, TX 76011-4511 The NRC team did not identify any findings or violations of more than minor significance.

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/

Neil F. OKeefe, Branch Chief Project Branch E Division of Reactor Projects

Docket Nos.

50-313; 50-368 License Nos. DPR-51; NPF-6

Enclosure:

Inspection Report 05000313/2017012 and 05000368/2017012 w/ Attachments:

1. Supplemental Information 2. Confirmatory Action Letter Item Status

Enclosure U.S. NUCLEAR REGULATORY COMMISSION

REGION IV

Dockets:

05000313; 05000368 Licenses:

DPR-51; NPF-6 Report:

05000313/2017012; 05000368/2017012 Licensee:

Entergy Operations, Inc.

Facility:

Arkansas Nuclear One, Units 1 and 2 Location:

Junction of Highway 64 West and Highway 333 South Russellville, Arkansas Dates:

August 28 through September 1, 2017 Team Lead:

J. Sowa, Senior Resident Inspector Inspectors:

Accompaniment:

J. Choate, Project Engineer L. Cline, Senior Project Engineer, Region I T. Hartman, Senior Resident Inspector, Region III M. Keefe-Forsyth, Human Factors Specialist, NRR T. Sullivan, Resident Inspector D. You, Resident Inspector

R. Taylor, Senior Project Engineer, Region II Approved By:

N. OKeefe Chief, Project Branch E Division of Reactor Projects

SUMMARY

IR 05000313/2017012; 05000368/2017012; 08/28/2017 - 09/01/2017; Arkansas Nuclear One,

Units 1 and 2; Confirmatory Action Letter (CAL) Follow-up Inspection.

The inspection activities described in this report were performed between August 28, 2017, and September 1, 2017, by team from the NRCs Region I, III and IV offices, the Office of Nuclear Reactor Regulation, and the 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.

The team reviewed 32 actions from the Arkansas Nuclear One Comprehensive Recovery Plan involving commitments made in a Confirmatory Action Letter (EA-16-124). The team concluded that 30 of the actions reviewed were complete and were effective in achieving the associated performance improvement objectives. The team reviewed three completed sub-actions for one action (PH-12), but will continued to review sub-actions as they are completed. The team also concluded that one action was not sufficiently effective to close at this time. This inspection completed closure of the final CAL actions from the Corporate and Independent Oversight Area Action Plan.

No findings were identified.

REPORT DETAILS

4OA5 Other Activities

Confirmatory Action Letter (CAL) Follow-up (IP 92702)

.1 Actions to Address Significant Performance Deficiencies

CO-5 Develop and issue an Entergy change management procedure for planning, OC-5 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. (CR-ANO-C-2015-02836 CA-15, CA-16, CA-28, CA-29, and CA-36)

During their second root cause evaluation following the stator drop event, the licensee identified that the corporate organization had not conducted effective change management for significant organizational changes, such as the elimination of corporate functional area assessments and corporate and independent oversight staffing, which resulted in corporate and Arkansas Nuclear One (ANO) organizational instability. As part of the licensees corrective actions, they revised Procedure EN-PL-155, Entergy Nuclear Change Management, to require an effectiveness review for all changes indicated as High Complexity/Risk on Attachment 3.1, Change Impact Checklist.

Entergy issued new Procedure EN-FAP-OM-023, Entergy Nuclear Change Management, that was based on the Entergy corporate policy, EN-PL-155 and the results of a benchmark self-assessment performed to identify industry best practices by reviewing procedures at other sites. The procedure included steps for planning, execution, and the conduct of effectiveness reviews that were designed to prevent and detect significant unintended consequences during the change process. To confirm the effectiveness of the new procedure, Entergy completed an effectiveness review in the first quarter of 2017 (LO-ALO-2015-00001, Action 23) by evaluating three organizational changes classified as high-risk recently conducted within the Entergy Fleet. They confirmed that the new process was fully implemented for these changes, that the effectiveness reviews for the changes identified appropriate success criteria for the changes, that any deficiencies identified by the effectiveness reviews were documented in the corrective action program, and that the results of the effectiveness reviews were easily retrievable. The results of this review determined that this corrective action item was complete and effective. The item was confirmed to be sustainable based on the implementation of the new fleet-wide change management procedure EN-FAP-OM-023.

The team reviewed the new procedure to confirm that it addressed all the requirements of the fleet policy, EN-PL-155, and recommendations identified by the benchmark self-assessment, LO-ALO-2015-00001, Action 00023.

The team assessed the adequacy of the licensees effectiveness review for this CAL item through the following activities:

1) Independently confirmed, through sampling, that the new change management procedure requirements were implemented for selected high-risk corporate change management plans implemented since March 2016.

2) Independently confirmed the appropriateness of the changes selected for review for benchmark self-assessment LO-ALO-2015-00001, Action 00023. The selected changes were compared to the results of both the corporate and independent oversight and the organizational capacity root cause evaluations.

3) Discussed the planned effectiveness reviews for upcoming high-risk change management plans with responsible Entergy staff to confirm the planned reviews met the intent of the new change management procedure.

4) Reviewed the interim effectiveness review completed in June 2017 for the Nuclear Strategic Plan (NSP) (LO-HQNLO-2017-00041). The team confirmed that identified negative observations and recommendations were tracked for resolution by the corrective action program.

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 CO-5 and OC-5 were effective. Therefore, CO-5 and OC-5 are closed.

DB-1 Establish metrics to monitor performance that would indicate that leadership focus on minimizing risk and nuclear safety results in improvement to the health of Maintenance Rule systems. (CR-ANO-C-2015-02833 CA-13, CA-15, and CA-16, and CR-ANO-C-2016-00614 CA-23)

During the 95003 supplemental inspection, the NRC team noted that ANO decision-making did not always include verifying assumptions and information using design and licensing basis information, and that corrective actions for decision making did not address this aspect. Action DB-1 was created to address this concern.

The team reviewed the actions associated with this item. The licensee developed and implemented metrics as part of the Maintenance Rule system health reports to track:

• number of (a)(1) goals not met in last 18 months

• average number of days to present an (a)(1) system to an expert panel

• the age of (a)(1) ANO plant structures, systems, and components (SSCs)with open corrective actions

• unavailability forecast up to T-20 Work Week

The team noted a positive trend in the number of (a)(1) goals being met in an 18-month period and the number of (a)(1) SSC goals implemented within 18 months. In both cases, the licensee was able to meet or exceed their goals.

The Plant Health Committee meets monthly to establish a regular review of their Maintenance Rule performance indicators.

Based on the actions taken by the licensee, information evaluated by the team, and observations performed on site, the team concluded that the actions to monitor leadership focus on nuclear safety and minimizing risk were effective.

Therefore, DB-1 is closed.

DB-2 Facilitate behavior change by rewarding performance that indicates leadership behaviors are focused on minimizing risk and nuclear safety by incorporating maintenance rule monitoring goals into the supervisor and above incentive plan.

(CR-ANO-C-2015-02833 CA-14 and CA-36)

The team reviewed the actions associated with this item. The licensee developed and implemented the metrics described in DB-1 above, then revised the ANO supervisors Performance, Planning, and Review (i.e., performance appraisal) process to assess each leaders performance based on Maintenance Rule system health. The team verified that those new elements were implemented at the beginning of the current year appraisal cycle, and licensee has already graded leaders performance using this new standard during their written mid-cycle performance evaluation.

Based on the actions taken by the licensee, information evaluated by the team, and observations performed on site, the team concluded that the actions to address DB-2 were effective. Therefore, DB-2 is closed.

DM-7 Develop and implement training on procedures governing risk assessment for work management senior reactor operators (SROs), Work Week Managers, shift managers, and unit coordinators. (CR-ANO-C-2016-00522 CA-2)

During the 95003 supplemental inspection, the NRC team determined that Procedure EN-WM-104, On Line Risk Assessment, Revision 12, and Procedure COPD-024, Risk Assessment Guidelines, Revision 58, were used to assess risk at the station. The NRC team noted that licensed operators assigned as operations work liaisons (who were SROs) were assigned risk management responsibilities, but nearly all of them had limited experience and no specific training to allow them to be effectively implement their responsibilities for risk recognition and management of risk. The operations work liaisons stated that Procedure COPD-24 was confusing and difficult to understand, and as a result, they tended to ask other operators how to perform some actions.

The team reviewed the actions associated with this item. The team reviewed the risk assessment training on COPD-24 and EN-WM-104 and verified that it was given to the appropriate station personnel. The team also concluded that the training content adequately addressed responsibilities for risk recognition and management of risk. The team also conducted interviews with three station personnel involved in station risk management. A quiz based on the training was given to ten station personnel that resulted in an average score of 96.4 percent with no one scoring below 90 percent. The licensee was able to demonstrate sustainability of this action via the implementation of familiarization (FAM) guides for the Work Week Managers and work management SROs. Additionally, shift manager and SRO qualification cards were revised to include evaluating the individuals knowledge on risk assessment. The team concluded that there was improvement in risk recognition and management because between first quarter of 2016 and the first quarter of 2017, the number of condition reports with inadequate risk assessments after the T-2 Technical Rigor Meeting dropped from 10 to four.

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 DM-7 were effective. Therefore, DM-7 is closed.

DM-8 Develop and implement a familiarization (FAM) guide for the function of work management SRO that will ensure clear understanding of job functions.

(CR-ANO-C-2016-00520 CA-3)

During the licensees evaluations as part of the recovery project, ANO identified that the execution of the work management process was not consistently supporting predictable, well-prepared implementation of work, and that there was a weakness in the knowledge and understanding of roles and responsibilities within the work management process. The 95003 inspection team identified that work was delayed or removed from the schedule because preparations were not completed prior to equipment being taken out of service.

The team reviewed the actions associated with this item. The licensee developed and implemented a FAM guide for the function of work management SRO. The FAM guide was incorporated into Procedure COPD-013, Maintenance Interface Standards and Expectations, Attachment O. The team reviewed the FAM guide and concluded the FAM guide adequately addressed work management SRO job functions and responsibilities. The team determined that four of the six current work management SROs completed the guide and the remaining two were near completion. Recurring actions were established to require personnel selected to transition to work management to successfully complete the FAM guide, ensuring sustainability for this action.

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 DM-8 were effective. Therefore, DM-8 is closed.

FP-4 Establish an Engineering Barrier Program to include external and internal flood protection in accordance with the requirements of Procedure EN-DC-329, Engineering Programs Control and Oversight. Assign program owner and backup. Establish preventive maintenance for external and internal flood protection features including scope, frequency, testing criteria, and acceptance criteria. (CR-ANO-C-2013-01304 CA-17 through CA-21, CA-30 through CA-35, CA-37, CA-39, CA-41, CA-43, CA-45, CA-47, CA-49, CA-51, CA-53, CA-55, CA-57, CA-59, CA-61, CA-63, CA-65, CA-67, CA-69, CA-72 through CA-75, and CA-82 through CA-84; CR-ANO-C-2014-00259 CA-12, CA-25, CA-92, CA-118, CA-121, CA-123, CA-126, CA-155, and CA-246; and CR-ANO-C-2015-02833 CA-29)

During the second root cause evaluation following the stator drop event, the licensee identified that, when previous opportunities for identification of degraded flood protection features occurred, ANO personnel had not sufficiently challenged and verified whether the existing plant configuration met the licensing basis requirements for mitigation of flooding events. ANO also noted that the preventative maintenance strategy in place to maintain flood protection features at the time had been inadequate in both frequency and content.

In response to this action, Entergy established an Engineering Passive Barriers Program in accordance with EN-DC-329-ANO-RC, Engineering Programs Control and Oversight, to include protective features for external and internal flooding events. Three new ANO procedures (SEP-PB-ANO-001, ANO Passive Barriers Program, OP-5000.027, Passive Barriers Program, and OP-5000.028, Passive Barrier Breach Permitting Process) were developed and implemented.

The team determined that a primary and backup program owner were assigned and successfully completed qualification training, and a Program Health Report and a Program Notebook were implemented. The team also noted that Entergy established preventive maintenance for credited flood features for external and internal flooding. To confirm the effectiveness of these items, Entergy performed a focused self-assessment on the Flood Protection Program. Objectives 5 and 6 of the self-assessment were specifically applicable to CAL item FP-4. The results of this assessment determined that this corrective action item was complete, effective, and sustainable.

The team reviewed the new procedures for the Passive Barrier Protection Program to confirm that the new program complied with the requirements of EN-DC-329-ANO-RC, Engineering Programs Control and Oversight.

The team reviewed the Passive Barrier Program Health Report and the Program Notebook and discussed the content of these documents with the program engineer. Through plant walk-downs, program document reviews, and discussions with the program engineer, the team independently confirmed that the program was implemented in accordance with the site procedure requirements, that flood protection features were being effectively maintained, and that equipment concerns were adequately addressed in a timely manner.

The team independently confirmed the adequacy of the new preventive maintenance (PM) program implemented for the sites flood protection features by reviewing the PM basis documents and PM procedures for selected newly established PMs. The team also confirmed the status of the PM program through discussion with the program engineer and a review of selected procedures and work control documents.

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 FP-4 were effective. Therefore, FP-4 is closed.

VO-7 Develop and implement initial and continuing training on the procedure for management and oversight of supplemental personnel. Training is for site contract managers and project managers. (CR-ANO-C-2015-02388 CA-14)

The licensee assigned a responsible manager for each project and then implemented a qualification process to allow the use of supplemental supervisors to perform most supervisory duties. During the 95003 supplemental inspection, the NRC team noted that Procedure EN-OM-126, Management and Oversight of Supplemental Personnel, did not contain guidance to ensure that supervisors or oversight personnel had appropriate technical expertise to be fully capable of providing oversight for the specific project or work. Interviews with ANO personnel assigned oversight roles for supplemental workers commented that they did not have the technical expertise to provide oversight of supplemental employees assigned to them.

The licensee developed and implemented initial and annual continuing training per CR-ANO-C-2015-02388 CA 00014. The station sampled the effectiveness of the training by administering a test on the training material to 20 of the 157 contract and project managers who took the training. The average score was 83 percent, which exceeded the licensees acceptance criteria of 80 percent.

The team reviewed the 20 exams and found that 11 individuals scored below 80 percent, and the licensee initiated a corrective action to remediate those individuals. The corrective action for these 11 individuals consisted of completing a read and sign training module with no subsequent test. Since over half of the individuals who took the test did not score over 80 percent, the team concluded that the 80 percent average chosen by the licensee to represent effectiveness was not an adequate demonstration of effectiveness fo rhte training. Specifically, the team determined that the licensee did not have an adequate basis to conclude that the training was adequate for the intended purpose or that individuals qualified to conduct management and oversight of supplemental personnel possessed and demonstrated a sufficient level of technical knowledge to effectively perform their roles.

Based on the actions taken by the licensee and information evaluated by the team, the team concluded that action VO-7 should remain open. This action will be reviewed in a future inspection after the licensee: 1) reviews the adequacy of the training material and makes any appropriate modifications; 2) implements the training, if revised; and 3) concludes that sustained improvement has been demonstrated in individuals who have completed the training on Procedure EN-OM-126, Management and Oversight of Supplemental Personnel.

VO-9 Perform an organizational capacity assessment for vendor oversight, including contract management and administration, critical procurements, and department-specific resource impacts. (CR-ANO-C-2014-02318 CA-169)

During the 95003 supplemental inspection, the NRC team noted that the Entergy business model did not contain sufficient site personnel to oversee all supplemental workers directly. ANO relied upon over 400 supplemental workers between outages, and more during outages and large projects. In focus groups, non-supervisory personnel commented that the strategy to use supplemental employees increased the burden on the staff because of the additional contractor oversight responsibilities.

The team reviewed the organizational capacity assessment performed for the station for vendor oversight, including contract management and administration, critical procurements, and department-specific impacts. The team concluded that the organizational capacity assessment was adequate. Because of the assessment, a subject matter expert was assigned to oversee and manage supplemental personnel, a contract administrator within project management was assigned to support contract administration, and additional personnel increases were in progress or planned for some groups with responsibility to oversee significant levels of vendor support. These personnel changes along with planned increases are consistent with the organizational capacity assessment recommendations.

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 VO-9 were effective. Therefore, VO-9 is closed.

VO-20 Issue a procedure for management and oversight of supplemental personnel including improvements to

(1) defined responsibilities,

(2) assessment of risk, and

(3) vendor oversight plans. (CR-ANO-C-2014-02318 CA-20, CA-30, CA-115, CA-128, CA-129, CA-154, CA-164, CA-198; and CR-ANO-C-2014-02698 CA-14)

During the 95003 supplemental inspection, the NRC team found that Procedure EN-OM-126, Management and Oversight of Supplemental Personnel, did not contain guidance to ensure that supervisors or oversight personnel had appropriate technical expertise to be fully capable of providing oversight for the specific project or work. Interviews with ANO personnel assigned oversight roles for supplemental workers commented that they did not always feel that they had the technical expertise to provide oversight of supplemental employees assigned to them.

During the NRCs first review of VO-20 in Inspection Report 05000313/2017010 and 05000368/2017010 (ML17117A696), the team found that four of the issues identified by the 95003 supplemental inspection team were still not resolved. For example, the licensee had not revised EN-OM-126 to add guidance to ensure that supervisors or oversight personnel had appropriate technical expertise. The team concluded that VO-20 would remain open pending additional action by the licensee.

The team reviewed the four issues identified by the 95003 supplemental inspection team and determined the licensee had adequately addressed these issues. The licensee resolved the issues by revising EN-OM-126 to enhance requirements for supplemental supervisor qualification to require qualification validation prior to assigning individuals to supplemental oversight roles. The team determined the actions effectively implemented the requirements of the area action plan and procedure EN-OM-126 contained guidance to require appropriate technical expertise for supervisors and oversight personnel. The team discussed this action with the area action personnel and a sampling of supervisors and concluded the changes made effectively addressed the issues identified by the 95003 inspection.

Based on the actions taken by the licensee, information previously evaluated by the NRC, and observations performed on site, the team concluded that the actions taken to address VO-20 were effective. Therefore, VO-20 is closed.

.2 Actions to Address Identifying, Assessing, and Correcting Performance Deficiencies

CA-6 Implement training, benchmarking, process improvements, and monitoring/feedback to improve the rigor, attention to detail, and overall quality of operability determinations and functionality assessments.

(CR-ANO-C-2015-01240 CA-14, CA-20, and CA-28)

ANO noted during their initial root cause evaluation for the stator drop event that rigor and attention to detail were not always evident in the documentation associated with operability determinations and functionality assessments. During the 95003 supplemental inspection, the NRC team determined that while the Condition Review Group (CRG) ensured operability/functionality reviews were performed, they did not always ensure the reviews were performed in a timely manner as required by Procedure EN-LI-102-ANO-RC, Corrective Action Program.

During the NRCs first review of CA-6 in Inspection Report 05000313/2017011 and 05000368/2017011 (ML17195A478), the team identified issues with the licensees process for grading operability/functionality evaluations, including inconsistent sampling and implementation of the grading criteria. The team determined that this action would remain open pending additional actions and monitoring by the licensee.

The inspection team reviewed the list of items held open from the previous inspection report. The team found that the licensees effectiveness reviews of operability determinations included all evaluations that required a more complex review (i.e., prompt operability determinations) completed since the last inspection. The team also reviewed operability determinations that were graded as failures to ensure they were followed up on and found no issues.

The team noted that the licensee also implemented measures to ensure that condition reports that require an operability review do not bypass the control room. This requirement was added to procedure EN-OP-115-03, Shift Turnover and Relief, and OPS-B38, Control Room Task Checklist and Miscellaneous Log. The licensee also implemented COPD-028, Attachment H, Operations Performance Tracking Program, to ensure a standardized grading method for evaluating operability determinations. From a sample of ten operability evaluations, the team found them to be adequate and graded uniformly. In their effectiveness review, the licensee identified that the number of graded operability determinations that failed dropped from 2.11 percent in 2016 to 1.86 percent as of August 4, 2017. For sustainability of this item, the station has Procedure EN-LI-102 delineating the responsibilities for performing operability reviews as well as establishing the standards for completeness and accuracy of all operability determinations.

Based on the actions taken by the licensee, information evaluated by the team, and observations performed on site, the team concluded that the actions to address CA-6 are effective. Therefore, CA-6 is closed.

CA-14 For a period of one year, establish Corrective Action Review Board (CARB)oversight of selected operating experience (OE) responses to verify program implementation meets CARB standards. (CR-ANO-C-2015-02834 CA-131)

During the 95003 supplemental inspection, the NRC team found that the OE program allowed ANO to decide that no action was needed to address OE reports that were determined to be applicable to ANO if sufficient pre-existing barriers existed such that the negative outcome would be minimized at ANO.

The NRC team identified examples where the assumed barriers were not verified to be adequate, and also identified barriers that were credited but were inadequate. The NRC team concluded that although ANO appropriately evaluated whether external OE was applicable to ANO, the corrective actions developed to address OE were sometimes insufficient.

The team reviewed the action associated with this item; Procedure EN-OE-100, Operating Experience Program, Revision 27; EN-LI-102, Corrective Action Program, Revision 29; and the five condition reports for OE responses that the licensee identified as not meeting CARB standards (CR-ANO-C-2016-01018, 01338, 02354, 02355, and 03682). The team performed interviews with the owners of this action item as well as the OE specialist responsible for the OE program. The team also reviewed the minutes from the twelve CARB meetings that took place over the one-year period from March 2016 to February 2017 to review operating experience documents.

The NRC team concluded that actions to improve the quality of OE written responses were effective. Technical review and approval of responses and the use of accredited barriers in responses are defined and structured in Procedure EN-OE-100, Revision 27, Attachment 9.1, OE Written Response Template.

The team concluded that the licensee was effectively implementing the OE response requirements. The team concluded that this attachment outlines and addresses concerns identified during the 95003 Inspection and provides sustainability for future OE responses.

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 CA-14 were effective. Therefore, CA-14 is closed.

CA-16 Train each OE point of contact on their responsibilities and skills needed to recognize the applicability of OE, elevate OE, and use search tools to locate OE for evaluation. (CR-ANO-C-2015-00259 CA-115)

During the 95003 supplemental inspection, the NRC team found that the OE program allowed ANO to decide that no action was needed to address OE reports that were determined to be applicable to ANO if sufficient pre-existing barriers existed such that the negative outcome would be minimized at ANO.

The NRC team identified examples where the assumed barriers were not verified to be adequate, and identified barriers that were credited but were inadequate.

The NRC team concluded that although ANO appropriately evaluated whether external OE was applicable to ANO, the corrective actions developed to address OE were sometimes insufficient.

During the NRCs first review of CA-16 in Inspection Report 05000313/2017010 and 05000368/2017010 (ML17117A696), the team discovered that Entergy planned to make significant changes to the fleet OE program, including changes that could significantly change the process for disseminating OE and consideration of eliminating the OE points of contact. While the team concluded that the licensee had completed the action and demonstrated the effectiveness of those actions, the team determined that ANO had failed to determine whether those actions would remain effective due to the planned OE program changes.

The team decided that this action would remain open until Entergy completed planned changes to the OE program and a sufficient time passed to determine whether the intent of the committed action was fulfilled, sustained improvement occurred, and the licensee performed an updated effectiveness review.

The team reviewed the training documents associated with the ANO Point of Contact (POC) to ensure all objectives of CA-16 were captured. The attributes of responsibilities per Procedure EN-OE-100, recognizing applicability of OE, when to elevate OE, and use of the OE database to search and evaluate OE were all properly addressed in the computer based training module. The training is conducted on a 2-year periodicity. The team reviewed the latest list of qualified POCs and determined that a wide spectrum of technical disciplines were represented in the population of qualified POCs.

This item was held open in Inspection Report 2017010 due to a concern that the POCs were to be eliminated by the licensee after reviewing a Nuclear Energy Institute bulletin for Delivering the Nuclear Promise. The team queried the licensee on this subject and determined that the licensee intends to sustain this item. The licensee currently has a full time OE specialist who facilitates the population of POCs and maintains their qualifications up to date on a going forward basis.

Based on the actions taken by the licensee, information previously evaluated by the NRC, and observations performed on site, the team concluded that the actions taken to address CA-16 were effective. Therefore, CA-16 is closed.

PM-6 The Event Report Review Board will review all formal OE evaluations for 12 months and initiate corrective action for any that do not meet management standards for quality. (CR-ANO-C-2015-02834 CA-131)

During ANOs Collective Evaluation, the licensee identified that, at times, OE evaluations tended to justify why an issue was not applicable to ANO rather than finding ways to use the lessons presented in OE reports to improve performance.

ANO also found that management support for the OE process was hampered by competing priorities and limited resources. During the 95003 supplemental inspection, the NRC team noted that the OE program allowed ANO to decide that no action was needed to address OE reports that were determined to be applicable to ANO if sufficient pre-existing barriers existed such that the negative outcome would be minimized at ANO. The NRC team identified examples where the assumed barriers were not verified to be adequate, and also identified barriers that were credited but were inadequate. The NRC team concluded that although ANO appropriately evaluated whether external OE was applicable to ANO, the corrective actions developed to address OE were sometimes insufficient.

The team reviewed the following associated with this item: Procedure EN-OE-100, Operating Experience Program, Revision 27; EN-LI-102, Corrective Action Program, Revision 29; and the five condition reports for OE responses that did not meet the Event Review Boards standards for inadequate susceptibility discussions, inadequate extent of condition reviews, not discussing vendor oversight, or not discussing lessons learned (CR-ANO-C-2016-01018, 01338, 02354, 02355, and 03682). The team also reviewed 17 OE evaluations that were approved by the IERRB with comments and found the comments to be minor enough to not warrant rejection and a resulting condition report:

• NRC-21-EVENT-71-00

• ICES-312915

• NRC-RIS-2015-11

• NRC-RIS-2015-13

• LO-HQNLO-2013-00003 CA-10

• CR-ANO-C-2012-03348 CA-08

• NOE-2015-234 CA-20

• OE-NOE-2016-00059 CA-1

• OE-NOE-2016-00073 CA-15

• OE-NOE-2016-00116

• OE-NOE-2016-00152

• OE-NOE-2016-00033

• OE-NOE-2016-00147

• OE-NOE-2016-00212

• OE-NOE-2016-00227

• OE-NOE-2016-00271 CA-10

• OE-NOE-2016-00272 CA-10 The team performed interviews with the owners of this action item as well as the OE specialist responsible for the OE program. The team also reviewed the minutes from the twelve CARB meetings that took place over the one-year period from March 2016 to February 2017.

The team concluded that actions to improve the quality of OE written evaluations were effective. The team found that technical review and approval of evaluations and the use of accredited barriers in evaluations are defined and structured in Procedure EN-OE-100, Revision 27, Attachment 9.1, OE Written Response Template. The team concluded that the licensee was effectively implementing the OE response requirements. Additionally, the team concluded that this attachment outlines and addresses concerns identified during the 95003 inspection and provides sustainability for future OE responses.

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 PM-6 were effective. Therefore, PM-6 is closed.

TR-2 Define and incorporate guidance in the condition report screening and review process to prompt discussion and/or action for conditions potentially warranting a training solution. (CR-ANO-C-2015-04626 CA-7)

During the 95003 supplemental inspection, neither the licensee nor the NRC inspection team directly addressed this topic.

The team reviewed the actions associated with this item. The team reviewed Procedures EN-LI-121, Trending and Performance Review Process, Revision 22; EN-118, Cause Evaluation Process, Revision 24; EN-FAP-LI-001, Performance Improvement Review Group (PRG) Process, Revision 11; JA-PI-01, Fleet Analysis Manual, Revision 4; EN-LI-102, Corrective Action Program, Revision 30; PI-004, CRG & CRG Screening Desk Guide, Revision 1; PRN-2017-00216; LO-ALO-2016-46 CA-320; and CR-ANO-C-2015-04626. The team also reviewed the last ten Performance Analysis Worksheets (PAWs) submitted.

The team concluded that actions to consider training solutions were effective because additional and more probing questions in the screening process were defined and structured in PAWs documented and maintained in Procedure JA-PI-01, and the licensee was effectively implementing the requirements during CR screening. The team reviewed the last ten PAWs and found the CRG documented considerations supporting or refuting training as a part of the corrective action in all cases. The team also found that the number of PAWs submitted increased from five in May/June 2015 to 72 in May/June 2017, indicating effective implementation of the PAWs during CR screening and more opportunities to consider training solutions. The licensee established measures to ensure sustainability of this action in the most recent revision (Revision 30) of EN-LI-102, which directs the Performance Improvement Review Group to review and discuss CRs that identify a condition potentially warranting a training solution.

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 TR-2 were effective. Therefore, TR-2 is closed.

VO-16 Benchmark an industry leader outside the Entergy fleet to capture best practices in vendor oversight. (CR-ANO-C-2015-02838 CA-12)

During the 95003 supplemental inspection, the NRC team found that benchmarking was not a common practice at ANO. If benchmarking occurred, it was typically within the Entergy fleet. Plant personnel commented that if benchmarking resulted in suggestions for improvements, improvement items typically had not received priority due to limited resources. The team identified that the use of benchmarking was largely absent from the ANO Comprehensive Recovery Plan (CRP) even though ANO identified that they had performed limited benchmarking with plants outside the Entergy fleet and did not keep informed on industry practices. Only one action in the draft CRP utilized benchmarking to help address a performance gap.

Entergy performed a benchmark assessment at Surry Nuclear on August 24, 2016, to capture best practices in vendor oversight. The assessment identified a few gaps and recommendations that were entered into the ANO corrective action program for tracking. Entergy addressed the identified gaps in their oversight process by incorporating the identified best practices into procedure EN-OM-126-ANO-RC, Management and Oversight of Supplemental Personnel.

The team reviewed the results of the completed benchmark self-assessment and confirmed that all issues identified as a result of the assessment were corrected or entered into the appropriate corrective action program tracking system for timely disposition in accordance with the site procedure requirements. The team reviewed the changes incorporated into EN-OM-126-ANO-RC and verified they addressed the identified gaps. The team also reviewed a recently implemented vendor oversight plan (Preventive Maintenance for Startup Transformer 2 during the 10-year system outage) and confirmed it complied with the new procedure requirements.

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 VO-16 were effective. Therefore, VO-16 is closed.

.3 Actions to Address Human Performance Issues

DM-17 Develop roles and responsibilities for the quorum line participants in the work management process. (CR-ANO-C-2014-00259 CA-241, CR-ANO-C-2015-02834 CA-118 and CA-121, and CR-ANO-C-2015-03034 CA-5 and CA-12)

ANO performed a work management program review by observing field activities, work week planning meetings, daily schedule execution, and reviewing work management program procedures, work management performance indicators, and the CR database. The licensee identified that there was a weakness in the knowledge and understanding of roles and responsibilities in multiple areas, including adding work to a schedule and the subsequent impact on risk management, resources, and other scheduled work. During the 95003 supplemental inspection, the NRC team identified cases where work was delayed or removed from the schedule because preparations were not completed prior to equipment being taken out of service. Examples included unavailable workers, missing parts not being available, and incomplete maintenance risk evaluations.

The team reviewed the roles and responsibilities for each of the identified positions in the work management process to ensure all attributes of the fleet procedure, On-line Work Management Process, EN-WM-101, revision 14, were incorporated into the stations roles and responsibilities website. The need to review and acknowledge the roles and responsibilities was originally conveyed to ANO Unit 1 supervisors via e-mail. All supervisors were required to review their particular list of roles and responsibilities. Key action DM-18, which is an open CAL item, will be evaluated for fulfillment of the roles and responsibilities that have been inserted into the ANO-1 Online Scheduling website. This will be realized by the pending training of supervisors on their respective roles and responsibilities. At this time, supervisors will be required to confirm that their roles and responsibilities were reviewed.

The team interviewed the Decision Making and Risk Management area action plan owner to determine how the supervisor is prompted to refer to their applicable list of roles and responsibilities and apply them to the daily performance of their duties. The licensee stated that the use of the roles and responsibilities is not proceduralized, and is instead considered part of the job description for maintaining supervisor qualifications. The licensee stated that the use of the roles and responsibilities, as well as other tools located on the ANO online scheduling website, provide positive benefits to the supervisor during the daily administering of their jobs. The team accessed the list of roles and responsibilities on the licensee ANO online scheduling website. The list was easily retrieved and user friendly.

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 DM-17 were effective. Therefore, DM-17 is closed.

NF-1 Implement a What It Looks Like (WILL) sheet for nuclear professional behaviors based on objectives in Performance Objectives and Criteria. Include a continued focus on the following four performance issues:

(CR-ANO-C-2015-03031 CA-11)

• Procedure use and adherence

• Challenging assumptions and decision making

• Conservative bias and risk recognition

• Low threshold for reporting issues.

During the licensees second root cause evaluation following the stator drop event, ANO identified that a significant contributor to performance problems at the station was that worker performance had been inconsistent in fundamental behaviors including procedure adherence, risk awareness, and questioning attitude.

The team reviewed the Performance Objectives and Criteria document to ensure the objectives, scope, and direction provided were properly conveyed to and captured by the licensee WILL sheet criteria. The performance issues associated with procedure use and adherence, challenging assumptions and decision making, conservative bias and risk recognition, and low threshold for reporting issues were properly addressed by the WILL sheet. The team observed that the WILL sheet criteria were paraphrased from the source document. However, the team concluded that the WILL sheet wording captured the essential message. A representative sampling of completed and filled out WILL sheets were reviewed by the team.

The team observed a licensee supervisor implement the attributes of the WILL sheet in the plant on August 29, 2017. The licensee supervisor observed two Unit 1 auxiliary operators performing a screen wash evolution at the intake structure. The station has transitioned to using an electronic version of the WILL sheet. The supervisor stated that the electronic version of the WILL sheet was more efficient and reduced the time and effort associated with the processing of paper copies. The supervisor went on to say that the implementation of the electronic version of the WILL sheet improved the observers ability to watch the evolution at hand

The licensee supervisor and the Unit 1 operators were observed referring to their own copies of the ANO Standards and Expectations pocket sized notebook before, during, and after the evolution. The team reviewed the notebook and noted that the source document attributes were captured within this notebook and were referred to by the supervisor. After the intake structure evolution, the supervisor provided immediate feedback on the performance observations. The team also noted that the transition to the electronic version of the WILL sheet resulted in some of the source document attributes being expanded to further define the attributes.

The team noted that this action would still be captured in a new behavior observation database being implemented fleet wide in August 2017.

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 NF-1 were effective. Therefore, NF-1 is closed.

NF-3 Develop content for the Employee Handbook that addresses procedure use and adherence. (CR-ANO-C-2015-04647 CA-13)

During the 95003 supplemental inspection, the NRC team noted that procedure adherence problems were identified in the root cause evaluations for the white unplanned scrams performance indicator and the two Yellow findings, but the licensee did not perform any cause evaluation for procedure adherence problems. Corrective actions developed by the licensee to improve procedure adherence were focused on establishing clear standards and improving procedure quality and human factoring, but initially did not include actions to monitor and coach procedure adherence.

The licenssee initiated CR-ANO-C-2015-04647 CA-00013 to provide input on procedure use and adherence for the ANO Standards & Expectations (S&E)handbook that was developed under CR-ANO-C-2015-02829 CA-00025. This input was incorporated into the employee handbook.

The rollout of the ANO S&E handbook was tracked per the ANO CAL under action LF-2, which ANO has not determined to be ready for closure. However, the the licensee rolled out the handbook at ANO in March of 2016, and a revision was issued and rolled out in February 2017. Additionally, as part of the Entergy Fleet Nuclear Excellence Model, Entergy will replace the ANO S&E handbook with a Fleet Employee Handbook in the near future. Copies of the handbook were already onsite, but have not yet been distributed.

The team reviewed the content of the February 2017 ANO S&E handbook and confirmed that it adequately covered the procedure use and adherence topics required by NF-3. The team also confirmed that the content of the pending fleet employee handbook adequately covered these topics and would sustain the actions required by this item. Additionally, although according to site procedures and management expectations the handbook itself was not required to be used at the jobsite, the team did observe ANO staff referring to the handbook in the field.

The team confirmed that behavioral observations regarding procedure use and adherence based on WILL sheets and rapid trending indicate that the staff is adhering to expectations regarding procedure use and adherence. In addition, trends in monthly consequential error rate indicate a negative trend in errors caused by inadequate procedure use and adherence. The team also noted that of the 39 findings identified at ANO since the handbook was rolled out to the staff in March 2016, only two findings were assigned a procedure use and adherence cross-cutting aspect.

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 NF-3 were effective. Therefore, NF-3 is closed.

NF-5 Develop content for the ANO supervisor training that addresses procedure use and adherence. (CR-ANO-C-2015-04647 CA-15)

During the 95003 supplemental inspection, the NRC team noted that procedure adherence problems were identified in the root cause evaluations for the White unplanned scrams performance indicator and the two Yellow findings, but the licensee did not perform any cause evaluation for procedure adherence problems. Corrective actions developed by the licensee to improve procedure adherence were focused on establishing clear standards and improving procedure quality and human factoring, but initially did not include actions to monitor and coach procedure adherence.

Entergy developed a lesson plan to incorporate the establishment of procedure use and adherence expectations into supervisor training. This training was incorporated into nuclear safety culture training plan ASLP-ADM-NSC_SCWE.

This training plan was presented to plant staff as part of CAL action items SC-10 and NF-8. This training was intended to reinforce the traits and behaviors of a healthy nuclear safety culture including adhering to procedural guidance.

ASLP-ADM-NSC_SCWE was developed specifically for ANO as a one-time effort. General and site-specific plant access computer based training includes nuclear safety culture and procedure use and adherence and is required for all Entergy personnel on a yearly basis. Entergy performed a CRP action item closure review in accordance with EN-FAP-LI-002 and determined that this item was adequately completed and documented.

The team reviewed the lesson plan and confirmed it to be adequate and incorporated into the nuclear safety culture lesson plan that was implemented to address actions NF-08 and SC-10. Additionally, procedure use and adherence trends in monthly consequential error rate indicate an improving trend regarding errors made due to inadequate procedure use and adherence.

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 NF-5 were effective. Therefore, NF-5 is closed.

OC-1 Perform organizational capacity assessments to determine staffing 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.

(CR-ANO-C-2015-00991 CA-7, and CR-ANO-C-2015-02831 CA-17, CA-20, and CA-21)

During the 95003 supplemental inspection, the NRC team determined that ANOs multi-year gradual performance decline occurred in part because of policy changes, changing workforce composition, and leadership responses. The Entergy fleet staffing reduction initiatives starting in 2007 caused ANO to reduce staffing from being even with industry average for a 2-unit site to below average.

These initiatives also did not account for the unique aspects at ANO created by having two units that used different designs. While nuclear safety remained a priority, actions to balance competing priorities, manage problems, and prioritize workload resulted in reduced safety margins.

The team reviewed the actions associated with this item. The team reviewed EN-HR-108-ANO-RC, ANO Integrated Strategic Workforce Planning Process, Revision 3; EN-HR-107-ANO-RC, ANO People Health Committee (APHC),

Revision 2; EN-FAP-HR-004, Knowledge Transfer & Retention (KT&R)

Process, Revision 3; and ANO Integrated Strategic Workforce Plan. The team performed interviews with the owners of this action item as well as the Human Resources Business Partner who is a member of the ANO People Health Committee (APHC). The team also reviewed the two external organizational capacity assessments from Heller Consulting and Goodnight Consulting, Organizational Risk Management Reviews from the Maintenance, Operations, Engineering, Production, and Radiation Protection departments, and the benchmarking data from ten other 2-unit, pressurized water reactor sites provided by the Electric Utility Cost Group.

The NRC team concluded that actions to determine staffing requirements were effective because of the licensee used valid and diverse sources of capacity information from similar nuclear units, and developed an appropriate standardized method for individual departments to evaluate their staffing requirements using EN-HR-107-ANO-RC, Attachment 9.1, Organizational Metrics,; EN-HR-108-ANO-RC, Attachment 9.1, ANO Workforce Planning Dashboard Template,; and EN-FAP-HR-004. The team reviewed the inputs and adequacy of departmental evaluations by reviewing the Organizational Risk Management Reviews from the departments listed above. The team found that the licensee used this information effectively to develop a staffing plan and that the proposed staffing levels are comparable with the levels proposed from the independent capacity assessments. The team also found during their review of the Integrated Strategic Workforce Plan that the licensee had a hiring plan in place to reach their proposed staffing levels by the end of 2018. The team concluded that the procedure attachments outline and address concerns identified during the 95003 inspection and provide sustainability for tracking future changes staffing requirements.

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 OC-1 were effective. Therefore, OC-1 is closed.

OC-2 Authorize the hiring of Entergy personnel and/or contractor positions identified as immediate staffing requirements by the APHC during organizational capacity assessment reviews. (CR-ANO-C-2015-02831 CA-18, CA-19, and CA-41)

During the 95003 supplemental inspection, the NRC team noted that the APHC was approving only a portion of the recommended additions for immediate hiring, while approval for the majority of the staff increases was held for future consideration. This action was intended to address the positions for immediate hiring.

The team reviewed the actions associated with this item. The team reviewed EN-HR-108-ANO-RC, ANO Integrated Strategic Workforce Planning Process, Revision 3, and EN-HR-107-ANO-RC, ANO People Health Committee, Revision 2. The team performed interviews with the owners of this action item as well as the Human Resources Business Partner who is a member of the APHC.

The team also reviewed the Organizational Risk Management Reviews from the Maintenance, Operations, Engineering, Production, and Radiation Protection departments and the licensees Corrective Action Program backlog data from June through August 2017.

The NRC team concluded that the licensee took effective actions to hire personnel for positions identified as requiring immediate staffing. The team found that the initial APHC evaluations called for 44 additional full-time employees with 24 of these positions designated as immediate staffing requirements. By the date of this inspection, the licensee immediate staffing needs positions had been authorized, and 43 of the 44 positions had been filled, with a potential candidate selected for the remaining position.

The team verified proper departmental evaluations and inputs by reviewing the Organizational Risk Management Reviews from five departments: Maintenance, Operations, Engineering, Production, and Radiation Protection. The team confirmed the effectiveness of these staff additions by analyzing the licensees Backlog Reduction Plan and backlog data. This information showed that the backlog has been steadily decreasing since additional employees were hired and trained. The team concluded that the procedure attachments outline and address concerns identified during the 95003 inspection and provide sustainability for tracking future changes in staffing requirements.

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 OC-2 were effective. Therefore, OC-2 is closed.

OC-3 Establish and implement an ANO Integrated Strategic Workforce 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 examines a five-year projection, gets updated annually, and was reviewed quarterly by the APHC. (CR-ANO-C-2015-02831 CA-23)

During the licensees second root cause evaluation following the stator drop event, the licensee identified that the ANO leadership team did not consistently apply a strategic approach in allocation of resources to support the safe long-term operation of the station. In some areas, this behavior resulted in the leadership team providing inadequate long-term plans that resulted in degraded equipment and margins. At the start of the 95003 supplemental inspection, the NRC team identified that the licensee had no specific milestones to complete hiring to address long-term staffing needs.

The team reviewed the actions associated with this item. The team reviewed procedures EN-HR-108-ANO-RC, ANO Integrated Strategic Workforce Planning Process, Revision 3; EN-HR-107-ANO-RC, ANO People Health Committee, Revision 2; and the ANO Integrated Strategic Workforce Plan. The team performed interviews with the owners of this action item as well as the Human Resources Business Partner who is a member of the APHC. The team also reviewed the Organizational Risk Management Reviews from the Maintenance, Operations, Engineering, Production, and Radiation Protection departments and the minutes from the last three APHC Meetings.

The NRC team concluded that actions to establish and implement an ANO ISWP were effective because the ISWP helps the APHC monitor staffing needs from 2017 through 2022 and was being updated annually using Organizational Risk Management Reviews provided by each department. Each department provided the APHC quarterly reports of their staff experience needs, training needs, knowledge management needs, timing of expected retirements, resignations and reassignments, and other site-specific needs. The team reviewed the last three months of APHC meeting minutes and verified that the APHC received this information in the ISWP and discussed actions to fill vacancies and plan for potential vacancies over the next five years. The team concluded that the procedure attachments outline and address concerns identified during the 95003 inspection and provide sustainability for tracking future changes staffing requirements.

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 OC-3 were effective. Therefore, OC-3 is closed.

PM-13 Perform a resource allocation study of the PM program that identifies positions needed to maintain a continuously improving PM program.

(CR-ANO-C-2015-02834 CA-117)

During the licensees second root cause evaluation following the stator drop event, the licensee identified that the ANO leadership team had not provided the organizational structure, the staffs priorities, or dedicated resources to support the PM program.

The team interviewed station personnel to discuss this action item. The licensee initiated a resource allocation study of the PM program to identify the positions required to maintain a continuously improving PM program for those disciplines that support the PM program (engineering, maintenance, and production). Each department manager was provided with an Organizational Assessment Guide to aide in determining their organizational capacities and to address gaps in those capacities. The results of each departmental assessment were presented to the APHC. A number of new positions were immediately filled, mostly in the engineering, operations, and training disciplines, with a plan to fill the remaining positions.

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 PM-13 were effective. Therefore, PM-13 is closed.

PQ-7 Upgrade procedures classified as important. (CR-ANO-C-2015-03033 CA-24 and CA-25)

During the 95003 supplemental inspection, the NRC team agreed with ANOs assessment that the leadership team had not consistently provided the organizational structure, staff priorities, or dedicated resources to support high quality procedures and work instructions, and had not consistently applied current industry guidance for procedure content, structure, and human factoring.

The team reviewed the list of upgraded procedures designated as important.

The licensee upgraded three subsets of procedures. Priority was placed on those procedures designated as safety significant. The next priority involved the upgrade of those procedures designated as important. The final group of upgraded procedures involved those procedures designated as normal. This item addresses only those procedures designated as important. The licensee performed upgrades on operations, chemistry, and radiation protection procedures and evaluated the upgrades using Procedure Professionals Association (PPA) AP-907-005, Procedure Writers Manual, to verify that each procedure met the nuclear industry consensus standard.

The team discussed the procedure upgrade process with the licensee. The licensee stated that the Procedure Writers Manual (AP-907-005) was used as a standard to review and evaluate the upgrades performed on those operations, chemistry, and radiation protection procedures designated as important. A procedure review process/checklist was developed to provide a standard approach during the review and evaluation of the procedure upgrades. The licensee analyzed and graded ten different categories of procedure quality items.

The licensee reported an overall success rate of 99.51 percent. The licensee did report one failure to meet the 85 percent acceptance rate and the procedure was assigned to operations for further revision (CR-ANO-2-2017-03537). The licensee also referred to AP-907-001, Procedure Process Description, and Guideline for Excellence in Procedure and Work Instruction Use and Adherence, as sources that were also used as references during the procedure upgrade grading process.

The team reviewed a sample of upgraded procedures: two from operations, one from chemistry, and one from radiation protection. The procedures were reviewed and compared to AP-907-005 and the team noted no discrepancies. A review showed all four procedures conformed to the format and structure as written in AP-907-005.

The team reviewed surveys that were conducted after the procedure upgrades and targeted the end users to measure the effectiveness of the upgrades. Most comments concerning the condition of those upgraded procedures stated either no change or an improvement in the readability and format of the procedures.

The new font and the newly bolded action words were cited as an improvement by multiple end users. The team noted no significant negative comments.

The team noted that the licensee maintains their own procedure writers guide (CPG-001), which provides guidance for the development, review, approval, and maintenance of ANO procedures for future reviews and revisions.

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 PQ-7 were effective. Therefore, PQ-7 is closed.

.4 Actions to Address Equipment Reliability and Engineering Program Deficiencies

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 (SPV) 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 found to have challenges. The licensee committed to complete multiple actions to improve equipment reliability related to items in the SIPD process. Most of these actions are addressed through actions PH-1 through PH-6 in the Plant Health AAP. However, detailed plans to improve specific equipment reliability issues were not available at the time of the 95003 inspection. The NRC plans to review the results of the equipment reliability issues to be addressed under actions PH-12 and PH-13 as those projects are completed.

The team reviewed the licensees progress in resolving equipment reliability issues by evaluating the actions taken to address the following:

• Unit 1 NI-501 detector replacement

• Unit 1 letdown heat exchanger replacement

• Unit 2 cooling tower crane replacement

The team reviewed the system health reports and work orders and interviewed plant personnel regarding the specific equipment reliability issues. In each of the three cases, the licensee had replaced the equipment. The team noted the equipment has been operating with no major issues since these replacements.

Based on the long term goals of this action item, PH-12 will remain open. This action will be reviewed in future inspections to verify the licensee is resolving the equipment reliability issues listed over the next two unit operating cycles.

PM-5 The Preventive Maintenance Oversight Group (PMOG) will review all PM change requests for a minimum of 12 months and initiate corrective action for any that do not meet management standards for quality. (CR-ANO-C-2015-02834 CA-103 and CA-104)

The licensee identified during their PM root cause evaluation that engineering evaluations did not address all aspects needed for PM change request evaluations, and existing PM change request evaluations had been inadequate to prevent events.

The team reviewed the actions associated with this item. The licensee implemented Procedure EN-DC-324-ANO-RC, Preventative Maintenance Program, establishing the responsibilities of the PMOG. This procedure also provided a standard to grade preventative maintenance change requests (PMCRs) which the team evaluated to be adequate. The team reviewed a sample of PCMRs rejected by the PMOG, condition reports written for failed PCMRs, and PCMRs approved by the PMOG. The team evaluated that the grading criteria was consistently applies. Based on the samples, the team concluded that the process of improving the quality of PCMRs was effective. The team also reviewed data that showed the PMOG initially approving 77 percent of PCMRs in the second quarter of 2016. This approval rate increased to 96 percent in the first quarter of 2017.

Based on the actions taken by the licensee, information evaluated by the team, and observations performed on site, the team concluded that the actions to address PM-5 were effective. Therefore, PM-5 is closed.

PM-12 Implement training for all personnel who are qualified to establish PM requirements. (CR-ANO-C-2015-02834 CA-110)

During the 95003 supplemental inspection, the NRC team reviewed the licensees evaluation of the differences in implementation of the Critical PM Program by engineering and Non-Critical PM Program by maintenance as part of the PM root cause evaluation. The licensee identified that station leaders made the decision to transfer responsibility for PM strategies of non-critical components to maintenance without adequate change management. The licensee discovered that maintenance personnel lacked the proper training and qualification to manage the population of components expanded by the change in definition of non-critical.

The team reviewed the actions associated with this item. The team reviewed the training document, Preventive Maintenance, ASLP-ESPP-PM, Rev. 0 that was developed and implemented for ANO personnel qualified as PM program owners or qualified to establish PM requirements. The team also interviewed six system engineers regarding the training provided. The engineers were able to recall the preventive maintenance requirements and discuss prior station operating experience that involved preventative maintenance deficiencies both of which were presented in the training. An effectiveness review shows that the PMCRs that screened through the PMOG climbed from 77 percent (second quarter 2016)to 96 percent (first quarter 2017), demonstrating that the responsible personnel were meeting the new standards for PM quality and rigor.

Based on the actions taken by the licensee, information evaluated by the team, and observations performed on site, the team concluded that the actions to address PM-12 were effective. Therefore, PM-12 is closed.

PM-18 Develop mitigation strategies to address cancelled projects in the Site Integrated Planning Database (SIPD) including embedded subcomponent projects.

(CR-ANO-C-2015-02834 CA-128 and CA-138)

During the 95003 supplemental inspection, the NRC team identified multiple problems with the implementation of the SIPD process used for planning and approving plant modifications, replacements, and other capital projects. ANO had 1,745 issues in the process, and a recovery team reconciliation subsequently closed 1,350 as being already complete or no longer needed.

Many items lacked management sponsors or project leads, or lacked information needed to proceed through the process. Many items were in the SIPD process for years without being resolved due to deferments, insufficient funding, or unavailable parts.

The licensee committed to complete multiple actions to improve equipment reliability related to items in the SIPD process. Most of these actions are addressed through actions PH-1 through PH-6 in the Plant Health AAP. Those actions included reviewing all open SIPD items to cancel items that were completed or no longer needed, and to ensure that mitigation strategies are developed if needed. Action PM-18 is related to that larger effort.

The team met with the licensee to discuss this action item. The team reviewed the mitigation strategy developed by the licensee to identify those plant subcomponents that were not identified with unique equipment identification numbers to ensure PM requirements were established if necessary. The team reviewed the list of embedded subcomponents which were previously identified by the embedded subcomponent project (CR-ANO-C-2009-1400-CA68), and the electrical drawing upgrade project (CR-ANO-C-2007-0001-CA20). These projects were previously cancelled due to a lack of funding. The lists also contain additional embedded subcomponents that were identified by the licensee during report preparation. The team reviewed five sample entries in the SIPD of safety-related equipment that were addressed by this item. The team determined that the effectiveness criteria specified in the area action plan for key action item PM-18 were met for each of the five sample entries.

The licensee performed effectiveness reviews on each of the embedded subcomponents. Components determined to perform a critical function were reviewed against applicable preventive maintenance templates and gaps between current preventive maintenance strategy and template requirements were identified. Condition reports and preventive maintenance change requests were initiated for those components where a more than minimal risk was determined.

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 PM-18 were effective. Therefore, PM-18 is closed.

.5 Actions to Address Safety Culture Issues

SC-10 Develop and present training to ANO workforce to include case studies that NF-8 illustrate the right picture of nuclear safety culture. Include what it means to be an engaged and thinking individual nuclear worker. (CR-ANO-C-2015-01709 CA-9, CR-ANO-C-2015-02829 CA-24, and CR-ANO-C-2016-00748 CA-10)

During the licensees second root cause evaluation following the stator drop event, ANO identified that a significant contributor to performance problems at the station was that worker performance had been inconsistent in fundamental behaviors including procedure adherence, risk awareness, and questioning attitude. The team was concerned that station personnel did not understand the difference between nuclear safety culture and safety conscious work environment.

To evaluate the licensees corrective action effectiveness, the team reviewed the nuclear safety culture training provided to all station personnel and interviewed personnel from Operations, Maintenance Services/Site Projects, I&C, Systems Engineering, as well as a group of contractors and a mixed group of first line supervisors. With the exception of one organization, station personnel acknowledged they had received training and were able to differentiate between safety culture and safety conscious work environment and demonstrated that the training was effective in meeting the lesson objectives. The inspection team reviewed the training materials, ASLP-ADM-NSC_SCWE, Nuclear Safety Culture and Safety Conscious Work Environment, and determined that the training was adequate. The inspection team identified one group as a gap in effectiveness, and communicated the observation to the licensee. The licensee was aware of the issue and planned to address the gap under LO-ANO-2017-00024; specifically, the leader of the department will brief the Nuclear Safety Culture Monitoring Panel on the Priority Group action plan to address this gap.

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 SC-10 and NF-8 were effective. Therefore, SC-10 and NF-8 are closed.

SC-11 Implement priority group specific action plans to address safety culture issues.

(CR-ANO-C-2015-01445 CA-8, CA-9, CA-10, CA-18 through CA-21, CA-23 through CA-34, CA-36 through CA-41, CA-44 through CA-80, CA-82 through CA-86, CA-88, CA-89, CA-90, CA-93, CA-94, CA-101, CA-104, CA-113, CA-114, and CA-132 through CA-140)

During the 95003 supplemental inspection, the NRC team reviewed the seven individual root cause evaluations performed by the ANO recovery team and evaluated the safety culture attributes of each. The NRC team noted that ANO identified that some safety culture attributes were contributors to several of the root cause evaluation problem statements, but ANO did not consider the collective significance. In response, the licensee performed a common cause analysis of all identified safety culture attributes and found that ANO did not have an adequate explicit management focus on safety culture and the associated infrastructure to support a healthy nuclear safety culture.

To evaluate the licensees corrective action effectiveness, the team reviewed the results of the 2016 Synergy Nuclear Safety Culture Assessment survey, the 2017 Synergy Nuclear Safety Culture Assessment survey, and the 2017 Conger-Elsea Integrated Safety Culture Assessment survey. The team also performed several focus group interviews.

The 2016 Synergy survey identified priority organizations and ANO developed action plans to address the issues in those groups identified by the assessment.

The priority groups identified in the 2016 assessment were no longer identified as priority organizations in the 2017 Synergy assessment; however, the team did note that several new organizations emerged as lower level priority organizations in the 2017 assessment. During the inspection, the team conducted focus group interviews with 50 employees from those priority organizations and determined that safety culture was adequate to protect health and safety. Most of those interviewed stated that there has been a noticeable change in the recent months with regard to an increased emphasis on nuclear and industrial safety. Everyone interviewed stated he or she would feel comfortable raising nuclear safety concerns.

Almost all personnel stated they would use the corrective action program or chain of command to address issues. Most personnel stated that overall effectiveness of the corrective action program has improved since the 95003 inspection. Additionally, most everyone interviewed stated that conservative decision making regarding issues that had the potential to impact nuclear safety had improved. Almost all personnel interviewed stated that they had received training in nuclear safety culture and safety conscious work environment and could differentiate between them. While resources and staffing continue to be the concerns, most personnel were aware that ANO management was working to close staffing gaps and hire and qualify new personnel.

Teamwork continues to be perceived to be a challenge at the station. Most of those interviewed stated that while teamwork and coordination between work groups was better, there was still room for improvement. Almost everyone interviewed stated that they had faith and trust in their new management team, and felt that station performance was moving in the right direction. All of them stated that this new management team emphasizes safety over production as their core message. While there remains some wait and see attitude, almost all stated they were hopeful and optimistic about the future of ANO.

The team interviewed the site Safety Culture Manager and the corporate Organizational Health manager to discuss ANOs plans for continuing to monitor safety culture through surveys and assessments. Since Synergy is no longer available to perform safety culture assessments, Entergy developed a plan to use the fleets organizational health index survey in combination with mid-cycle assessments, which will include interviews and focus groups as well as observations. The team determined that the use of these data collection methods appear to be adequate for continuing to monitor safety culture.

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 SC-11 were effective. Therefore, SC-11 is closed.

4OA6 Meetings, Including Exit

Exit Meeting Summary

On August 31, 2017, the team presented the inspection results to Mr. Richard Anderson, Site Vice President, and other members of the licensee staff. The licensee acknowledged the issues presented. The licensee confirmed that any proprietary information reviewed by the team had been returned or destroyed.

SUPPLEMENTAL INFORMATION

KEY POINTS OF CONTACT

Licensee Personnel

R. Anderson, Site Vice President

T. Arnold, Recovery Manager

L. Blocker, Recovery Director

P. Butler, Design Engineering Manager

B. Daiber, Engineering Programs and Components Manager

D. Edgell, Recovery Manager

A. Martin, Unit 2 Shift Manager

P. McCray, Senior Manager Site Projects

N. Mosher, Regulatory Assurance

E. Nicholson, Performance Improvement Manager

B. Patrick, Maintenance Manager

S. Pyle, Regulatory Assurance Manager

F. Shewmake, Unit 2 Operations Manager

M. Skartvedt, System Engineering Manager

G. Stephenson, Acting Corrective Action Program Manager

G. Sullins, Regulatory and Performance Improvement Director

J. Toben, Nuclear Safety Culture Manager

D. Vogt, Operations Manager

LIST OF CONFIRMATORY ACTION LETTER ITEMS CLOSED AND DISCUSSED

Closed

Significant Performance Deficiencies CO-5/OC-5

(Section 4OA5.1)

DB-1

(Section 4OA5.1)

DB-2

(Section 4OA5.1)

DM-7

(Section 4OA5.1)

DM-8

(Section 4OA5.1)

FP-4

(Section 4OA5.1)

VO-9

(Section 4OA5.1)

VO-20

(Section 4OA5.1)

Identifying, Assessing and Correcting Performance Deficiencies CA-6

(Section 4OA5.2)

CA-14

(Section 4OA5.2)

Closed

CA-16

(Section 4OA5.2)

PM-6

(Section 4OA5.2)

TR-2

(Section 4OA5.2)

VO-16

(Section 4OA5.2)

Human Performance Issues DM-17

(Section 4OA5.3)

NF-1

(Section 4OA5.3)

NF-3

(Section 4OA5.3)

NF-5

(Section 4OA5.3)

OC-1

(Section 4OA5.3)

OC-2

(Section 4OA5.3)

OC-3

(Section 4OA5.3)

PM-13

(Section 4OA5.3)

PQ-7

(Section 4OA5.3)

Equipment Reliability and Engineering Program Deficiencies PM-5 (Section 4OA5.4)

PM-12 (Section 4OA5.4)

PM-18 (Section 4OA5.4)

Safety Culture Issues SC-10/NF-8

(Section 4OA5.5)

SC-11

(Section 4OA5.5)

Discussed

Significant Performance Deficiencies VO-7

(Section 4OA5.1)

Equipment Reliability and Engineering Program Deficiencies PH-12

(Section 4OA5.4)