ML052430549

Reply to a Notice of Violation, EA-05-089

ML052430549
Person / Time
Site:	Pilgrim
Issue date:	08/09/2005
From:	Balduzzi M Entergy Nuclear Operations
To:	NRC/OE
References
2.05.056, EA-05-039, RI-2001-A-0126
Download: ML052430549 (7)

Text

Entergy Nuclear Operations, Inc.

' E n tergy Pilgrim Nuclear Power Station 600 Rocky Hill Road Plymouth, MA 02360 Michael A. Balduzzi August 9, 2005 Site Vice President Director, Office of Enforcement Nuclear Regulatory Commission One White Flint North 11555 Rockville Pike, Rockville, MD 20852-2738

Subject:

Entergy Nuclear Operations, Inc.

Pilgrim Nuclear Power Station Docket No.: 50-293 License No.: DPR-35 Reply to a Notice of Violation; EA-05-039

References:

1.

NRC letter, Notice of Violation and Proposed Imposition of Civil Penalty - $60,000, dated July 14, 2005

2.

Entergy Letter Number 2.04.102, Response to NRC Request for Investigation (RI-2004-A-0126), dated October 22, 2004

[Attachment 1 - Not For Public Disclosure]

LETTER NUMBER:

2.05.056

Dear Sir:

This letter provides Entergy's Reply to the Notice of Violation, EA-05-039 (Reference 1).

Reference 2 provided the causes and corrective actions taken to address the specific violations included in the Notice of Violation. Additionally, these were discussed with the NRC staff at the predecisional Enforcement Conference held on April 8, 2005. Attachment 1 summarizes the causes and corrective actions taken. Attachment 2 identifies the commitments made in this letter.

The imposed civil penalty of $60,000 was paid by electronic funds transfer on August 1, 2005.

Please do not hesitate to contact me or Mr. Bryan Ford of my staff, at (508) 830-8403, if you have any questions concerning this subject.

Sincerely, Michael A. Balduzzi WGUdm : Reply to Notice of Violation EA-05-039 (4 pages) : Summary of Commitments (1 page)

Entergy Nuclear Operations, Inc.

Pilgrim Nuclear Power Station cc:

Regional Administrator, Region I Nuclear Regulatory Commission 475 Allendale Road King of Prussia, PA 19406-1415 Letter Number: 2.05.056 Page 2 NRC Senior Resident Inspector Pilgrim Nuclear Power Station

ATTACHMENT 1 Reply to Notice of Violation EA-05-039 NRC CITED VIOLATIONS:

Based on an NRC investigation conducted by the Office of Investigations, Region I Field Office, the report of which was issued on February 4, 2005, four violations of NRC requirements were identified. In accordance with the NRC Enforcement Policy, the NRC proposes to impose a civil penalty pursuant to Section 234 of the Atomic Energy Act of 1954, as amended (Act), 42 U.S.C.

2282, and 10 CFR 2.205. The particular violations and associated civil penalty are set forth below:

Technical Specification 5.4.1 of Facility Operating License No. DPR-35 for the Pilgrim Nuclear Power Station (PNPS) requires the establishment and implementation of procedures covering the applicable procedures recommended in Regulatory Guide 1.33, Revision 2, February 1978.

Regulatory Guide 1.33 recommends, in part, administrative procedures covering authorities and responsibilities for safe operation and shutdown, and shift and relief turnover.

10 CFR Part 50, Appendix B, requires a quality assurance program for nuclear power plants to assure that conditions adverse to quality are promptly identified and corrected, and includes, in part, written policies, procedures or instructions.

10 CFR Part 26, "Fitness For Duty Programs," prescribes requirements and standards for the establishment and maintenance of certain aspects of fitness for duty programs and procedures by licensees, and each licensee subject to this part shall establish and implement written policies and procedures to meet these objectives.

A.

PNPS Procedure Number 1.3.34, "Conduct of Operations", Section 5.15, requires, in part, that Operations personnel on duty will remain alert and awake so that they may respond to plant conditions or emergencies. PNPS Procedure Number 1.3.34 is required by Technical Specification 5.4.1.

Contrary to the above, for approximately four minutes on June 29,2004, the on duty Control Room Supervisor (CRS) was not alert to his duties in the control room in that he was asleep in a chair, and therefore, not in a condition to respond to plant conditions or emergencies.

B.

PNPS Procedure ENN-LI-1102, "Corrective Action Process", Section 4.1, requires, in part, that all personnel working at Entergy Nuclear Northeast (ENN) facilities are responsible for identifying and reporting problems. Section 5.1.1.4, requires, in part, that any individual who discovers an adverse condition is expected to ensure that: immediate actions are taken as necessary to minimize the consequence of the condition; appropriate site personnel are notified of the identified condition; and the condition is promptly documented in a Condition Report (CR). ENN-LI-102 is required by 10 CFR Part 50, Appendix B.

Page 1 of 4

Contrary to the above, on June 29, 2004:

1.

A Reactor Operator (RO), at approximately 4:40 a.m., became aware of an adverse condition (the RO observed the CRS to be asleep in a chair), and the RO did not take immediate actions to awaken the CRS and minimize the consequence of the condition, did not inform appropriate site personnel that he had observed the CRS to be asleep, and did not document the condition in a CR.

2.

A Shift Manager (SM), at approximately 4:45 a.m., became aware of an adverse condition (the SM observed the CRS "head-bobbing" in a chair, and was therefore, inattentive to his duties and not fully alert), and the SM did not inform appropriate site personnel of the condition and did not document the condition in a CR.

C.

PNPS Procedure ENN-NS-102, "Fitness For Duty Program," Section 3.0, defines, in part, for-cause testing as testing that is conducted as soon as possible following an observed behavior that indicates questionable fitness for duty. Section 5.3 states, in part, that factors such as fatigue, mental stress and illness may affect an individual's fitness for duty. Section 5.7 further states, in part, that testing for-cause shall be based on observation or information received from a credible source that indicates possible impairment of an individual's ability to work safely. ENN-NS-102 is required by 10 CFR Part 26.

Contrary to the above, for approximately four minutes on June 29, 2004, the on duty CRS was asleep in a chair in the control room and not fit for duty, and appropriate measures were not taken to relieve the CRS from duty and have him for-cause FFD tested.

These violations constitute a Severity Level IlIl problem.

Civil Penalty - $60,000. (EA-05-039)

ENTERGY REPLY TO NRC CITED VIOLATIONS:

1.

Entergy admits that the violations occurred.

2.

Reason for the Violations By letter dated October 22, 2004 (Reference 1 below), Entergy submitted to the NRC the results of the internal investigation into these violations. That letter included a discussion of the causes of the violations, significance of the violations, and corrective actions. The results of the investigation were further discussed at the pre-decisional Enforcement Conference held on April 8, 2005.

The root cause of the observed inattentiveness was that the CRS involved failed to exercise appropriate and prudent judgment with respect to fitness-for-duty self-determination prior to and while executing his licensed duties. This was the result of overconfidence and an inadequate appreciation of the role fatigue plays with respect to fitness-for-duty.

Page 2 of 4

The contributing causes were:

A licensed individual (the RO), who witnessed the state of fatigue of the CRS, failed to intervene and initiate immediate corrective action to mitigate the event. These actions represent the RO's failure to execute obligations to adhere to station operating procedures and license conditions. The RO identified during the investigation that he understood the condition was a safety issue and that he did not intervene.

The Shift Manager (SM) did take immediate actions to address the condition. The SM brought the CRS to full attentiveness, assessed the ability of the CRS to continue to fulfill his duties, and coached the individual concerning attentiveness. The investigation concluded the SM felt that the incident was a personnel performance issue in that he believed he observed the onset of drowsiness and that drugs or alcohol were not a factor. The SM felt that he had 'handled' the situation appropriately through coaching.

The decisions concerning reporting and fitness for duty testing are judgment decisions for the individual involved and the perceived correctness of the decisions depends greatly upon the conclusions of the investigators concerning the conditions witnessed.

Although, there is disagreement concerning the exact conditions witnessed, Entergy agrees that the SM did not take all of the corrective actions necessary. The failure to complete all required actions was the result of an inadequate appreciation of the role fatigue plays with respect to fitness-for-duty, and inadequate sensitivity to the reporting threshold.

The inattentiveness took place for approximately four (4) minutes and there were other licensed operators in the control room at the time of the inattentiveness. The independent investigation completed an extent review and concluded that this was an isolated incident.

3.

The Corrective SteDs that have been Taken and the Results Achieved:

A.

As described in Reference 1 and the pre-decisional Enforcement Conference held on April 8, 2005, the following immediate corrective actions were taken as a result of the June 29, 2004 event:

Entergy coached the operating crews on the need to maintain their alertness on shift, through getting the requisite amount of rest.

Entergy reinforced fitness for duty requirements with plant personnel.

Entergy relieved the RO, CRS, and SM from licensed duties during the investigation.

Entergy terminated the RO and CRS from employment at Pilgrim.

Entergy imposed certain management actions against the SM as described in Reference 1.

B.

The following additional corrective actions have been taken:

Entergy implemented revised Pilgrim procedures detailing prohibited activities in the control room.

Page 3 of 4

Entergy implemented a fleet-wide procedure concerning the use of recording equipment in the control room.

Entergy issued an internal and external Operating Experience (OE) Notice concerning the event.

Entergy revised the Pilgrim training modules for General Employee Training (GET), Fitness-for-Duty (FFD), and the Continual Behavioral Observation Program (CBOP).

C.

The following corrective actions are planned:

Entergy has developed an operating crew development and team work training module for all Pilgrim operator crews. This training is planned for completion by December 1, 2005.

Entergy will provide shift work and lifestyle management training for Pilgrim shift workers (Operations, Chemistry, Radiation Protection, and Security personnel). This training is planned for completion by December 31, 2005.

The SM has received additional Operator License conditions, as specified in Reference 2 below.

4.

The Corrective Steps That Will Be Taken to Avoid Further Violations:

The corrective steps discussed in item 3 above are the corrective steps that have been taken and will be taken to avoid further violations.

5.

The Date When Full Compliance Will Be Achieved:

Full compliance was achieved with the corrective actions taken.

References:

1.

Entergy Letter Number 2.04.102, Response to NRC Request for Investigation (RI-2004-A-0126), dated October 22, 2004

[Attachment 1-Not For Public Disclosure]

2.

NRC letter to Mr. Richard M. Probasco, dated July 14, 2005 Page 4 of 4

ATTACHMENT 2 Summary of Commitments This table identifies actions discussed in this letter for which Entergy commits to perform. Any other actions discussed in this letter submittal are described for the NRC's information and are not commitments.

COMMITMENT ONE-TIME CONTINUING SCHEDULED ACTION COMPLIANCE COMPLETION DATE Provide operating crew development X

December 1, 2005 and team work training.

Provide shift work and lifestyle X

December 31, 2005 management training.