ML061090843

IR 05000440-06-008; on 2/6/2006 - 3/14/2006; Perry Nuclear Power Plant; Confirmatory Action Letter (CAL) Followup Inspection: Corrective Action Program Effectiveness - Action Item Implementation Inspection

ML061090843
Person / Time
Site:	Perry
Issue date:	04/19/2006
From:	Satorius M Division Reactor Projects III
To:	Pearce L FirstEnergy Nuclear Operating Co
References
CA 03-05-001 IR-06-008
Download: ML061090843 (55)

See also: IR 05000440/2006008

Text

April 19, 2006

CA 03-05-001

Mr. L. William Pearce

Vice President

FirstEnergy Nuclear Operating Company

Perry Nuclear Power Plant

P. O. Box 97, A290

10 Center Road

Perry, OH 44081

SUBJECT:

PERRY NUCLEAR POWER PLANT CONFIRMATORY ACTION LETTER (CAL)

FOLLOWUP INSPECTION CORRECTIVE ACTION PROGRAM

EFFECTIVENESS - ACTION ITEM IMPLEMENTATION INSPECTION

NRC INSPECTION REPORT 05000440/2006008

Dear Mr. Pearce:

The purpose of this letter is to provide you with Inspection Report (IR) 05000440/2006008,

detailing the results of our recent review of actions that you completed to address issues

associated with the implementation of your corrective action program. You and other members

of your staff attended the March 14, 2006, public exit meeting, held at the Quail Hollow Resort

in Painesville, Ohio, during which the results of this CAL followup inspection activity were

presented. A summary of the public meeting was documented in a letter to you dated

March 17, 2006.

As a result of poor performance, the Nuclear Regulatory Commission (NRC) designated the

Perry Nuclear Power Plant as a Multiple/Repetitive Degraded Cornerstone column facility in the

NRCs Action Matrix in August 2004. Accordingly, a supplemental inspection was performed in

accordance with Inspection Procedure (IP) 95003, Supplemental Inspection for Repetitive

Degraded Cornerstones, Multiple Degraded Cornerstones, Multiple Yellow Inputs, or One Red

Input. As documented in IP 95003 Supplemental Inspection Report 50-440/2005003, the NRC

determined Perry was being operated safely. The NRC also determined that the programs and

processes to identify, evaluate, and correct problems, as well as other programs and processes

in the Reactor Safety strategic performance area were adequate. Notwithstanding these overall

conclusions, the NRC determined that the performance deficiencies that occurred prior to and

during the inspection were often the result of inadequate implementation of your corrective

action program.

The purpose of this inspection was to review your accomplishment of actions associated with

improving your implementation of the corrective action program. In particular, this inspection

focused on determining whether your commitments associated with the corrective action

program that were identified in your August 8 and 17, 2005, letters that responded to our

L. Pearce

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IP 95003 supplemental inspection report, as well as selected completed actions prescribed in

the Perry Phase 1 and Phase 2 Detailed Action and Monitoring Plan (DAMP) to improve the

corrective action program, were adequately implemented. A review of the overall effectiveness

of these actions toward realizing improvements in the corrective action program will be

conducted at a later date.

Based on the results of this inspection, no findings of significance were identified and the team

confirmed that all three of your commitments associated with the corrective action program that

the team reviewed were adequately implemented. In particular, the team observed that during

work meetings to assess and resolve issues entered into the corrective action program,

managers were responding to these issues in a manner consistent with senior management

expectations on an increasingly consistent basis. Similarly, some positive improvement was

reflected in your performance indicators associated with the corrective action program.

However, notwithstanding this overall positive result, the team also identified that 4 of the

31 action items that were reviewed had not been implemented to a level that was considered

adequate by the NRC to allow these items to be considered closed. The reasons for this

varied. In one case, the team identified that one of your completed actions inadvertently

invalidated the qualifications for all of your root cause evaluators, which required that the

corrective action be rescinded. In another case, an action was improperly re-classified as a

temporary measure. In a third case, a section of a procedure was not revised as required by an

action, although other sections were properly revised. And in a final case, a sufficient number

of examples of the accomplishment of an action were not present for the action to be

considered to have been implemented.

In addition, of the actions that were determined to have been adequately implemented, in a

number of cases the implementation of those actions was judged to not be comprehensive.

As a result, it was not clear whether these actions would be lasting and effective. In particular,

some examples were identified in which the lack of a formalized process to ensure the

continuation of actions taken could impact the overall long-term effectiveness of the actions.

Although none of these issues in and of themselves has had a direct impact on the safe

operation of the facility, the fact that the NRC team, and not your staff, identified these issues

causes us to question the quality of your measures to ensure that planned actions are properly

accomplished in a high quality manner, and whether the actions accomplished will have a

lasting and effective impact.

You are requested to respond within 30 days of the date of your receipt of this letter. Your

response should describe the specific actions that you plan to take to address the issues raised

during this inspection. In particular, if you intend to or have revised your planned actions as a

result of the observations in this report, please describe for us the changes you have made or

intend to make and your basis for those changes.

The NRC will continue to provide increased oversight of activities at your Perry Nuclear

Power Plant until you have demonstrated that your corrective actions are lasting and effective.

Consistent with Inspection Manual Chapter (IMC) 0305 guidance regarding the oversight of

plants in the Multiple/Repetitive Degraded Cornerstone column of the NRCs Action Matrix, the

L. Pearce

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NRC will continue to assess performance at Perry and will consider at each quarterly

performance assessment review the following options: (1) declaring plant performance to be

unacceptable in accordance with the guidance in IMC 0305; (2) transferring the facility to the

IMC 0350, Oversight of Operating Reactor Facilities in a Shutdown Condition with

Performance Problems process; and (3) taking additional regulatory actions, as appropriate.

Until you have demonstrated lasting and effective corrective actions, Perry will remain in the

Multiple/Repetitive Degraded Cornerstone column of the NRCs Action Matrix.

In accordance with 10 CFR 2.390 of the NRC's "Rules of Practice," a copy of this letter

and its enclosure will be available electronically for public inspection in the NRC Public

Document Room or from the Publicly Available Records (PARS) component of the NRC's

document system (ADAMS), accessible from the NRC Web site at

http://www.nrc.gov/reading-rm/adams.html (the Public Electronic Reading Room).

Sincerely,

/RA/

Mark A. Satorius, Director

Division of Reactor Projects

Docket No. 50-440

License No. NPF-58

Enclosure:

Inspection Report 05000440/2006008

cc w/encl:

G. Leidich, President - FENOC

J. Hagan, Chief Operating Officer, FENOC

D. Pace, Senior Vice President Engineering and Services, FENOC

Director, Site Operations

Director, Regulatory Affairs

M. Wayland, Director, Maintenance Department

Manager, Regulatory Compliance

T. Lentz, Director, Performance Improvement

J. Shaw, Director, Nuclear Engineering Department

D. Jenkins, Attorney, FirstEnergy

Public Utilities Commission of Ohio

Ohio State Liaison Officer

R. Owen, Ohio Department of Health

L. Pearce

-3-

NRC will continue to assess performance at Perry and will consider at each quarterly

performance assessment review the following options: (1) declaring plant performance to be

unacceptable in accordance with the guidance in IMC 0305; (2) transferring the facility to the

IMC 0350, Oversight of Operating Reactor Facilities in a Shutdown Condition with

Performance Problems process; and (3) taking additional regulatory actions, as appropriate.

Until you have demonstrated lasting and effective corrective actions, Perry will remain in the

Multiple/Repetitive Degraded Cornerstone column of the NRCs Action Matrix.

In accordance with 10 CFR 2.390 of the NRC's "Rules of Practice," a copy of this letter

and its enclosure will be available electronically for public inspection in the NRC Public

Document Room or from the Publicly Available Records (PARS) component of the NRC's

document system (ADAMS), accessible from the NRC Web site at

http://www.nrc.gov/reading-rm/adams.html (the Public Electronic Reading Room).

Sincerely,

/RA/

Mark A. Satorius, Director

Division of Reactor Projects

Docket No. 50-440

License No. NPF-58

Enclosure:

Inspection Report 05000440/2006008

cc w/encl:

G. Leidich, President - FENOC

J. Hagan, Chief Operating Officer, FENOC

D. Pace, Senior Vice President Engineering and Services, FENOC

Director, Site Operations

Director, Regulatory Affairs

M. Wayland, Director, Maintenance Department

Manager, Regulatory Compliance

T. Lentz, Director, Performance Improvement

J. Shaw, Director, Nuclear Engineering Department

D. Jenkins, Attorney, FirstEnergy

Public Utilities Commission of Ohio

Ohio State Liaison Officer

R. Owen, Ohio Department of Health

DOCUMENT NAME: G:\\Perr\\ML061090843.wpd

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Satorius

DATE

4/10/06

4/10/06

4/11/06

04/19/06

OFFICIAL RECORD COPY

L. Pearce

-4-

ADAMS Distribution:

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ROPreports@nrc.gov (inspection reports, final SDP letters, any letter with an IR number)

Enclosure

U.S. NUCLEAR REGULATORY COMMISSION

REGION III

Docket No:

50-440

License No:

NPF-58

Report No:

05000440/2006008

Licensee:

FirstEnergy Nuclear Operating Company (FENOC)

Facility:

Perry Nuclear Power Plant

Location:

10 Center Road

Perry, Ohio 44081

Dates:

February 6 - March 14, 2006

Inspectors:

G. Wright, Lead Inspector, Project Engineer, DRP Branch 6, RIII

R. Morris, Senior Resident Inspector - Fermi Power Plant, RIII

D. Eskins, Resident Inspector - LaSalle County Station, RIII

D. Stearns, Plant Support Branch, DRS, RIV

Approved by:

Eric R. Duncan, Chief

Branch 6

Division of Reactor Projects

Enclosure

1

SUMMARY OF FINDINGS

IR 05000440/2006008; 2/6/2006 - 3/14/2006; Perry Nuclear Power Plant; Confirmatory Action

Letter (CAL) Followup Inspection: Corrective Action Program Effectiveness - Action Item

Implementation Inspection

This report covers a 2-week period of supplemental inspection by resident and region-based

inspectors. No findings of significance were identified during this inspection. The NRCs

program for overseeing the safe operation of commercial nuclear power reactors is described in

NUREG-1649, "Reactor Oversight Process," Revision 3, dated July 2000.

A.

NRC-Identified and Self-Revealed Findings

None.

B.

Licensee-Identified Violations

None.

Enclosure

2

REPORT DETAILS

1.0

Background

As a result of poor performance, the Nuclear Regulatory Commission (NRC) designated

the Perry Nuclear Power Plant as a Multiple/Repetitive Degraded Cornerstone column

facility in the NRCs Action Matrix in August 2004. A summary of the performance

issues that resulted in this designation is discussed in Attachment 2, Perry

Performance Background, of this report.

In accordance with Inspection Manual Chapter (IMC) 0305, Operating Reactor

Assessment Program, a supplemental inspection was performed in accordance with

Inspection Procedure (IP) 95003, Supplemental Inspection for Repetitive Degraded

Cornerstones, Multiple Degraded Cornerstones, Multiple Yellow Inputs, or One Red

Input. As documented in IP 95003 Supplemental Inspection Report 50-440/2005003,

the NRC determined Perry was being operated safely. The NRC also determined that

the programs and processes to identify, evaluate, and correct problems, as well as other

programs and processes in the Reactor Safety strategic performance area were

adequate.

Notwithstanding these overall conclusions, the NRC determined that the performance

problems that occurred were often the result of inadequate implementation of the

corrective action program. The IP 95003 inspection team identified that a number of

factors contributed to corrective action program problems. A lack of rigor in the

evaluation of problems was a major contributor to the ineffective corrective actions. For

example, when problems were identified, a lack of technical rigor in the evaluation of

those problems, at times, resulted in an incorrect conclusion, which in turn affected the

ability to establish appropriate corrective actions. The IP 95003 inspection team also

determined that corrective actions were often narrowly focused. In many cases a single

barrier was established to prevent a problem from recurring. However, other barriers

were also available that, if identified and implemented, would have provided a defense-

in-depth against the recurrence of problems. The IP 95003 inspection team also

identified that problems were not always appropriately prioritized, which led to the

untimely implementation of corrective actions.

A number of programmatic issues were identified that had resulted in the observed

corrective action program weaknesses. For example, the IP 95003 inspection team

identified a relatively high threshold for classifying deficiencies for root cause analysis.

As a result, few issues were reviewed in detail. In addition, for the problems that were

identified that required a root cause evaluation, the IP 95003 inspection team found that

the qualification requirements for root cause evaluators were limited and

multi-disciplinary assessment teams were not required. The IP 95003 inspection team

also identified that a lack of independence of evaluators existed. This resulted in the

same individuals repeatedly reviewing the same issues without independent and

separate review. In addition, the IP 95003 inspection team identified weaknesses in the

trending of problems, which hindered the ability to correct problems at an early stage

before they became more significant issues. Finally, the IP 95003 inspection team

determined that a lack of adequate effectiveness reviews was a barrier to the

Enclosure

3

identification of problems with corrective actions that had been implemented. A

summary of all of the IP 95003 inspection results is discussed in Attachment 3,

"Perry IP 95003 Inspection Results," of this report.

By letter dated September 30, 2004, and prior to the NRCs IP 95003 inspection

activities, FirstEnergy Nuclear Operating Company (FENOC) advised the NRC that

actions were underway to improve plant performance. To facilitate these performance

improvements, FENOC developed the Perry Performance Improvement Initiative (PII).

As documented in the IP 95003 supplemental inspection report, in the assessment of

the performance improvements planned and implemented through the PII, the NRC

determined that the PII had a broad scope and addressed many important performance

areas. The IP 95003 inspection team also observed that although substantially

completed, the PII had not resulted in a significant improvement in plant performance in

several areas, including the licensees implementation of the corrective action program.

By letters dated August 8, 2005, "Response to NRC Inspection Procedure 95003

Supplemental Inspection, Inspection Report 05000440/2005003," (ML052210512) and

August 17, 2005, "Corrections for Response to NRC Inspection Procedure 95003

Supplemental Inspection, Inspection Report 05000440/2005003," (ML052370357) the

licensee responded to the inspection results documented in the IP 95003 supplemental

inspection report.

As discussed in these letters, the Perry leadership team reviewed the achievements

realized by the PII, the results of the NRC's IP 95003 supplemental inspection activities,

and the conclusions from various additional assessments, and developed updates to the

Perry PII. The Perry leadership team restructured the PII, referred to as the Phase 2

PII, into the following six initiatives that are briefly described in Attachment 4, "Summary

of Phase 2 PII Initiatives," of this report:

Corrective Action Program Implementation Improvement

Excellence in Human Performance

Training to Improve Performance

Effective Work Management

Employee Engagement and Job Satisfaction

Operational Focused Organization

In addition to a discussion of the Phase 2 PII, the licensee's August 8 and August 17

letters also included actions planned to address the NRC's findings and observations

detailed in the IP 95003 supplemental inspection report. Attachment 3, "Actions to

Address Key Issues Identified in the IP 95003 Inspection Report," of these letters

focused on the following areas and summarized the actions that FENOC had taken or

planned to take to address those issues:

Implementation of the Corrective Action Program

Human Performance

Performance Improvement Initiative

IP 95002 Inspection Follow-Up Issues

Emergency Planning

Enclosure

4

2.0

Inspection Scope

The purpose of this inspection was to review the licensees accomplishment of actions

associated with improving the implementation of the corrective action program. In

particular, this inspection focused on determining whether the commitments associated

with the corrective action program that were identified in the August 8 and 17, 2005,

letters that responded to the IP 95003 supplemental inspection report, as well as

selected completed actions prescribed in the Perry Phase 1 and Phase 2 Detailed

Action and Monitoring Plan (DAMP) to improve the corrective action program, were

adequately implemented.

To accomplish this objective, commitments and action items grouped in the following

eight areas were reviewed, consistent with Revision 5 of Perry Business Practice

(PYBP) PII-002, Performance Improvement Initiative Detailed Action and Monitoring

Plan (DAMP).

Improve Ownership and Station Focus

Focus on Improving the Stations Ability to Self-Identify Problems Using the

Corrective Action Program

Focus on Prioritization of Problems Identified in the Corrective Action Program

Improve Quality of Evaluations and Corrective Actions

Improve Ability to Correct Problems Early Before They Become Significant

Issues

Focus on Improving Quality of Closure Documentation

Improve Oversight of the Corrective Action Program

PII Phase 1 Carry Over Activities

In addition, the team reviewed validated and closed Phase 1 PII Action Items to

determine whether these items had been adequately implemented as well as key

performance indicators (KPIs) associated with the corrective action program to evaluate

the quality of the indicators and to evaluate the licensees use of the corrective action

program when the indicators suggested a decline in performance in a specific area.

3.0

Improve Ownership and Station Focus

The following Commitments and Action Items in the Improve Ownership and Station

Focus area of PYBP-PII-002, Performance Improvement Initiative Detailed Action and

Monitoring Plan (DAMP), Revision 5, were reviewed:

Commitment 2.a: Develop expectations necessary for successful

implementation of the corrective action program (CAP). Train the site to the

expectations and the accountability methods that will be used to improve

implementation of the CAP.

Commitment 2.b/DAMP Item I.1.2: Implement management controls to improve

line ownership and accountability at the individual level for successful

implementation of the CAP.

Enclosure

5

DAMP Item I.1.1: Train all managers and supervisors on the role of a corrective

action program in a learning organization and how it must be used to drive

station performance improvement.

DAMP Item I.1.5: Establish a periodic meeting for all managers and supervisors

to improve organizational alignment. Periodically brief issues with CAP and

overall performance.

DAMP Item I.1.6: Publicize CAP success stories in the FENOC fleet

newsletter.

DAMP Item I.1.8: Develop and communicate a CAP PII Communication Plan

that outlines the initiative purpose, implementation plan and success measures

that demonstrate effective improvement in corrective action program

implementation.

DAMP Item I.1.9: Perform an interim effectiveness review of the #1 action items

in this table.

To accomplish these reviews, the team reviewed selected documentation such as

condition reports, corrective action program closure documentation, original and revised

procedures, training plans and training attendance records, meeting schedules and

minutes, and FENOC newsletters. In addition, the team conducted interviews of

cognizant licensee personnel to determine whether actions had been accomplished.

For example, in some cases the team interviewed licensee personnel whose names

appeared on training attendance sheets to determine whether these personnel had

received the subject training and to determine whether the personnel were

knowledgeable of the training material.

3.1

Commitment 2.a

a.

Inspection Scope

The team reviewed Commitment 2.a: Develop expectations necessary for successful

implementation of the corrective action program (CAP). Train the site to the

expectations and the accountability methods that will be used to improve implementation

of the CAP.

The following DAMP items addressed the areas of CAP expectations development,

training, and accountability. Taken collectively, the accomplishment of these DAMP

items implemented Commitment 2.a:

DAMP Item l.1.1:

Training of supervisors, managers, and directors on CAP

implementation expectations

DAMP Item l.1.2:

CAP implementation accountability

DAMP Item l.1.8:

Communications Plan for CAP implementation

expectations and accountability

DAMP Item l.2.1:

Training of staff on CAP implementation expectations

Enclosure

6

DAMP Item l.2.2:

Development and distribution of CAP implementation

expectations

To determine whether this commitment had been adequately implemented, the team

reviewed condition reports, corrective action program closure documentation, original

and revised procedures, training plans, and training attendance records associated with

each of these DAMP items individually and collectively. In addition, the team

interviewed licensee personnel whose names appeared on training attendance sheets to

determine whether these personnel had received the subject training and to determine

whether the personnel were knowledgeable of the training material. In particular, the

team reviewed PYBP-SITE-0046, Corrective Action Program Implementation

Expectations; Nuclear Operating Business Practice (NOBP) LP-2019, Corrective

Action Program Supplemental Expectations and Guidance; and Nuclear Operating

Procedure (NOP) LP-2001, Condition Report Process, that were developed to

promulgate licensee management expectations for implementation of the corrective

action program.

b.

Observations and Findings

No findings of significance were identified and the team concluded that the DAMP items

that collectively addressed Commitment 2.a were adequately implemented.

The individual DAMP items that accomplished Commitment 2.a are also discussed in

this report.

3.2

Commitment 2.b/DAMP Item I.1.2

a.

Inspection Scope

The team reviewed Commitment 2.b/DAMP Item I.1.2: Implement management

controls to improve line ownership and accountability at the individual level for

successful implementation of the CAP.

To determine whether this commitment and DAMP item had been adequately

implemented, the team reviewed condition reports, corrective action program closure

documentation, and performance expectations contained in performance appraisals. In

particular, the team reviewed revisions to performance appraisal elements and

determined whether the revised appraisal elements included individual accountability for

successful implementation of the corrective action program. The team also reviewed

documentation that verified that all required appraisals had been revised.

b.

Observations and Findings

No findings of significance were identified and the team concluded that the licensees

actions adequately implemented Commitment 2.b.

Enclosure

7

The licensee revised the expectations in the staff performance appraisals to address

this DAMP item. In particular, to reflect the differences in responsibility for implementing

the corrective action program, individual performance appraisal elements were modified

for each department position. Licensee personnel provided specific examples from

recent performance appraisals to demonstrate that the action item had been adequately

addressed on an individual basis.

3.3

DAMP Item I.1.1

a.

Inspection Scope

The team reviewed DAMP Item I.1.1: Train all managers and supervisors on the role of

a corrective action program in a learning organization and how it must be used to drive

station performance improvement.

To determine whether this DAMP item had been adequately implemented, the team

reviewed condition reports, corrective action program closure documentation, training

plans, and training attendance records. In addition, the team conducted interviews of

cognizant licensee personnel to determine whether actions had been accomplished. In

particular, the team interviewed licensee personnel whose names appeared on training

attendance sheets to determine whether these personnel had received the subject

training and to determine whether the personnel were knowledgeable of the training

material. In addition, the team reviewed PYBP-SITE-0046, Corrective Action Program

Implementation Expectations; training course CAPC-200501_PY, Corrective Action

Program Implementation Improvement; and Condition Report (CR) 05-08057,

Disposition/Tracking of Personnel Not Trained Per CAPC-200501_PY.

b.

Observations and Findings

No findings of significance were identified and the team concluded that the licensees

actions adequately implemented DAMP Item I.1.1.

The team reviewed the training material and concluded that it was adequate.

Specifically, the material addressed the role of a corrective action program in a learning

organization, FENOC and Perry management expectations for the corrective action

program in improving performance, and individual responsibilities in the implementation

of the corrective action program. The training was initially provided to managers and

supervisors, prior to being provided to all site personnel. Typical training sessions were

1 to 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br /> in length. Attendance lists were generated and individuals who were

unable to attend due to extenuating circumstances were identified. Condition

Report 05-08057, Disposition/Tracking of Personnel not Trained per

CAPC-200501_PY, was generated to identify individuals who were initially offsite and

unavailable for the training to ensure that they received the training when they returned

to the site. At the end of the inspection, licensee personnel stated that the list would be

reviewed after about 3 months and 6 months to identify if any individuals still required

the training.

Enclosure

8

The team noted that the licensee combined DAMP Item l.1.1 and DAMP Item l.2.1 and

provided the same training to all required site personnel.

3.4

DAMP Item I.1.2

Refer to Section 3.2 of this report.

3.5

DAMP Item I.1.5

a.

Inspection Scope

The team reviewed DAMP Item I.1.5: Establish a periodic meeting for all managers

and supervisors to improve organizational alignment. Periodically brief issues with CAP

and overall performance.

To determine whether this DAMP item had been adequately implemented, the team

reviewed condition reports, corrective action program closure documentation, training

plans, and training attendance records. In particular, the team reviewed training plan

SSC-200502_PY-01, Supervisory Continuing Training, which included corrective action

program elements and was used during periodic manager/supervisor meetings

designed to improve organizational alignment. Team members also attended a

manager/supervisor meeting on February 16, 2006, where corrective action program

implementation expectations were discussed.

b.

Observations and Findings

No findings of significance were identified and the team concluded that the licensees

actions adequately implemented DAMP Item I.1.5.

The training material associated with SSC-200502_PY-01 was of appropriate depth and

breadth to establish an adequate understanding of managements expectations for

corrective action program implementation and management/supervisory oversight of

work activities. The observed management meeting included appropriate reinforcement

of corrective action program implementation expectations.

3.6

DAMP Item I.1.6

a.

Inspection Scope

The team reviewed DAMP Item I.1.6: Publicize CAP success stories in the FENOC

fleet newsletter.

To determine whether this DAMP item had been adequately implemented, the team

reviewed condition reports, corrective action program closure documentation, and

FENOC fleet newsletters. In particular, the team reviewed FENOC fleet newsletters to

Enclosure

9

identify where corrective action program success stories had been published, corrective

action (CA) 05-07233-03, and PYBP-PII-0006, Process Improvement Initiative

Process.

b.

Observations and Findings

No findings of significance were identified; however, the team concluded that the

licensees actions had not adequately implemented DAMP Item D.1.6.

The team identified that the only CAP success story that had been published appeared

in the November 17, 2005, FENOC fleet newsletter. DAMP Item I.1.6 was closed after

that newsletter was published. However, PYBP-PII-0006, Process Improvement

Initiative Process, prescribed DAMP item closure only after several examples of an

action involving periodic activities had been accomplished. Following discussions with

the team, licensee personnel stated that additional stories would be published.

The team also concluded that due to a lack of quality and attention to detail, licensee

personnel failed to identify that this DAMP item had not been adequately implemented

during the DAMP item review and closure process. However, since the inadequate

closure of DAMP Item I.1.6 had no actual impact on the facility, the issue was of only

minor significance.

3.7

DAMP Item I.1.8

a.

Inspection Scope

The team reviewed DAMP Item I.1.8: Develop and communicate a CAP PII

Communication Plan that outlines the initiative, purpose, implementation plan and

success measures that demonstrate effective improvement in corrective action program

implementation.

To determine whether this DAMP item had been adequately implemented, the team

reviewed condition reports, corrective action program closure documentation, and

original and revised procedures. In particular, the team reviewed the licensees CAP

Improvement Plan: Communications Roadmap, to determine whether the plan

adequately outlined the elements contained in the DAMP item for the improvement of

the corrective action program. The team also reviewed a summary of the actions taken

to address the individual items in the communications roadmap to determine whether

those actions had been properly implemented.

b.

Observations and Findings

No findings of significance were identified and the team concluded that the licensees

actions adequately implemented DAMP Item I.1.8.

The CAP Improvement Plan: Communications Roadmap included the initiative and

purpose prescribed by the DAMP item. Training requirements, necessary management

Enclosure

10

enhancements, Corrective Action Review Board (CARB) improvements, root cause

improvements, and performance monitoring improvements were also included to

address the implementation plan and success measure aspects of the DAMP item. The

team also determined that the actions prescribed by the plan had been adequately

implemented.

3.8

DAMP Item I.1.9

a.

Inspection Scope

The team reviewed DAMP Item I.1.9: Perform an interim effectiveness review of the #1

action items in this table.

To determine whether this DAMP item had been adequately implemented, the team

reviewed condition reports, corrective action program closure documentation, and

self-assessment documentation. In particular, the team reviewed Snapshot Assessment

810PII2005, Perry Nuclear Power Plant Performance Improvement Initiative -

Corrective Action Program Implementation Effectiveness, conducted as an interim

effectiveness review, and assessed how well it had been performed; and

CA 05-07223-05, which implemented the DAMP item.

b.

Observations and Findings

No findings of significance were identified and the team concluded that the licensees

actions adequately implemented DAMP Item I.1.9.

The team noted that the assessment was thorough and identified a number of issues

that warranted additional licensee attention. Issues identified in the assessment

included incomplete supervisor and worker understanding of corrective action program

implementation expectations, and the untimely completion of root cause and apparent

cause evaluations.

4.0

Focus on Improving the Stations Ability to Self-Identify Problems Using the

Corrective Action Program

The following action items in the Focus on Improving the Stations Ability to Self-Identify

Problems Using the Corrective Action Program area of PYBP-PII-002, Performance

Improvement Initiative Detailed Action and Monitoring Plan (DAMP), Revision 5, were

reviewed:

DAMP Item I.2.1: Train site personnel to the expectations and accountability

methods that will be used to improve implementation of the CAP.

DAMP Item I.2.2: Develop and distribute an expectations document to reinforce

the requirements of NOP-LP-2001 and the behaviors necessary for successful

implementation of the CAP. This is similar to DB [Davis-Besse] expectations

document DBBP-PI-2000 CR Process Expectations.

Enclosure

11

DAMP Item I.2.3: Implement a plan to routinely perform cross-functional

walkdowns of risk-significant systems. These walkdowns should include

management supervision, system engineering and craft performing a joint

walkdown with a focus on improving expectations and standards for identification

of problems. Schedule walkdowns monthly.

To accomplish these reviews, the team reviewed selected documentation such as

condition reports, corrective action program closure documentation, original and revised

procedures, training plans and training attendance records, system walkdown

schedules, and documentation regarding walkdown observations. In addition, the team

conducted interviews of cognizant licensee personnel to determine whether actions had

been accomplished. For example, in some cases the team interviewed licensee

personnel on licensee training attendance sheets to determine whether these personnel

had received the subject training.

4.1

DAMP Item I.2.1

a.

Inspection Scope

The team reviewed DAMP Item I.2.1: Train site personnel to the expectations and

accountability methods that will be used to improve implementation of the CAP.

To determine whether this DAMP item had been adequately implemented, the team

reviewed condition reports, corrective action program closure documentation, original

and revised procedures, training plans, and training attendance records. In addition, the

team conducted interviews of cognizant licensee personnel to determine whether

actions had been accomplished. In particular, the team interviewed licensee personnel

whose names appeared on training attendance sheets to determine whether these

personnel had received the subject training and to determine whether the personnel

were knowledgeable of the training material. In addition, the team reviewed

PYBP-SITE-0046, Corrective Action Program Implementation Expectations; training

course CAPC-200501_PY, Corrective Action Program Implementation Improvement;

and Condition Report (CR) 05-08057, Disposition/Tracking of Personnel Not Trained

Per CAPC-200501_PY.

b.

Observations and Findings

No findings of significance were identified and the team concluded that the licensees

actions adequately implemented DAMP Item I.2.1.

As was discussed in DAMP Item I.1.1, the team reviewed the training material and

concluded that it was adequate. In particular, the material addressed the role of the

corrective action program in a learning organization, FENOC and Perry management

expectations for the corrective action program in improving performance, and individual

responsibilities in the implementation of the corrective action program. The training was

initially provided to managers and supervisors, prior to being provided to all site

personnel. Typical training sessions were 1 to 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br /> in length. Attendance lists were

Enclosure

12

generated and individuals who were unable to attend due to extenuating circumstances

were identified. Condition Report 05-08057 was generated to identify individuals who

were initially offsite and unavailable for the training to ensure that they received the

training when they returned to the site. At the end of the inspection, licensee personnel

stated that the list would be reviewed after about 3 months and 6 months to identify if

any individuals still required the training.

The team noted that the licensee combined DAMP Item l.1.1 and DAMP Item l.2.1, and

provided the same training to all required site personnel.

4.2

DAMP Item I.2.2

a.

Inspection Scope

The team reviewed DAMP Item I.2.2: Develop and distribute an expectations

document to reinforce the requirements of NOP-LP-2001 and the behaviors necessary

for successful implementation of the CAP. This is similar to DB [Davis-Besse]

expectations document DBBP-PI-2000 CR Process Expectations.

To determine whether this DAMP item had been adequately implemented, the team

reviewed condition reports and corrective action program closure documentation. In

particular, the team reviewed CR 05-02725, Substantive Cross-Cutting Issue, Problem

Identification and Resolution; CR 05-03986, Nuclear Oversight Audit PY-C-05-01; and

PYBP-SITE-0046, Corrective Action Program Implementation Expectations. The team

also reviewed handout, FENOC CR Initiation Guidance, that the licensee developed to

provide additional guidance concerning issues that should be documented in a condition

report, specifically identify procedures related to the condition reporting process, and

discuss condition reporting documentation timeliness goals.

b.

Observations and Findings

No findings of significance were identified and the team concluded that the licensees

actions adequately implemented DAMP Item I.2.2.

The team determined that the documents reviewed adequately reinforced NOP-LP-2001

and prescribed the behaviors necessary for the successful implementation of the

corrective action program. However, the team determined that due to a lack of quality

and attention to detail, during the DAMP item review and closure process, licensee

personnel failed to address whether PYBP-SITE-0046 and a handout entitled FENOC

CR Initiation Guidance, had been distributed to the staff. The team independently

determined that these documents were appropriately made available to licensee

personnel both electronically and during training. Licensee personnel generated

CR 06-00576, DAMP Item I.2.2. Did Not Provide Complete Closure Documentation, to

enter this issue into the corrective action program.

Enclosure

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4.3

DAMP Item I.2.3

a.

Inspection Scope

The team reviewed DAMP Item I.2.3: Implement a plan to routinely perform

cross-functional walkdowns of risk-significant systems. These walkdowns should

include management supervision, system engineering and craft performing a joint

walkdown with a focus on improving expectations and standards for identification of

problems. Schedule walkdowns monthly.

To determine whether this DAMP item had been adequately implemented, the team

reviewed condition reports, corrective action program closure documentation, and

original and revised procedures. In addition, the team conducted interviews of cognizant

licensee personnel to determine whether actions had been accomplished. Specifically,

the team reviewed procedures and guidance for system walkdowns including refresher

training ESPC-SYS0503_PY, System Walkdown Refresher Training; and Plant

Engineering Section Policy (PESP) 9, System Walkdowns. In addition, to assess the

quality of the walkdowns, the team reviewed a sample of supervisory Observation Cards

completed during system walkdowns and observed a system walkdown of the Main

Generator and Exciter system. The team also reviewed PYBP-POS-1-11, Operations

Section System Ownership.

b.

Observations and Findings

No findings of significance were identified and the team concluded that the licensees

actions adequately implemented DAMP Item I.2.3.

Although the team concluded that DAMP Item l.2.3 had been adequately implemented,

the team identified that documents and training that addressed system walkdowns were

inconsistent and prescribed different types and frequencies of walkdowns. For example,

CR 05-02725, Substantive Cross-Cutting Issue, Problem Identification and Resolution,

stated that paired system walkdowns would be conducted once; PESP-09, System

Walkdowns, stated that walkdowns would be performed bi-weekly and quarterly; and

training provided to the system engineers prescribed monthly paired walkdowns. These

inconsistencies were discussed with a system engineer who stated that his instructions

regarding the paired walkdown program were to perform the walkdowns monthly.

Based on the teams observations, licensee personnel planned to revise PESP-09 to

clearly establish the requirements for monthly paired walkdowns.

The team concluded that due to a lack of quality and attention to detail, licensee

personnel failed to identify the inconsistencies described above during the item

resolution and closure process.

The team also noted that the practice of conducting a cross-functional walkdown as

reflected in the DAMP item was not adopted. Discussions with licensee personnel

confirmed that the change to the scope of the DAMP item had been reviewed and

approved in accordance with licensee procedures.

Enclosure

14

The team also identified that although supervisors evaluated system walkdown activities

on an Observation Card, most supervisors did not consistently evaluate all applicable

areas listed on the Observation Card during their observations. For example, most

observations conducted within the radiologically controlled area (RCA) did not include an

evaluation of the use of personal safety equipment, such as eye and hearing protection;

or the implementation of radiation safety practices, such as the obtaining of and use of

radiation dosimetry, although personal safety equipment and dosimetry were required

for entry into the RCA.

In addition to the specific engineering paired walkdowns, the team noted that

PYBP-POS-1-11, Operations Section System Ownership, encouraged operations

personnel to take individual responsibility for equipment operation and reliability.

Non-licensed operators were assigned ownership for individual systems to foster

increased equipment reliability. The operation system owners participated in outage

scope, design change evaluations, system health input, and walkdowns. The team

concluded that this positive initiative had the potential to improve system reliability.

5.0

Focus on Prioritization of Problems Identified in the Corrective Action Program

The following action items in the Focus on Prioritization of Problems Identified in the

Corrective Action Program area of PYBP-PII-002, Performance Improvement Initiative

Detailed Action and Monitoring Plan (DAMP), Revision 5, were reviewed:

DAMP Item I.3.1: Revise procedure NOP-LP-2001, Corrective Action

Program, to provide guidance for initiation of a significant root cause evaluation

at a lower threshold (i.e. issues that may not be significant but are considered to

be a negative trend, repeat issues, and adverse trend).

DAMP Item I.3.2: Implement a two-step screening process in accordance with

PYBP-SITE-0045, Initial Screening Committee to improve objectivity,

consistency, and cognitive trending of new condition reports. Also include

assignment of due dates based on the significance of issues.

DAMP Item I.3.3: Adopt controls to assure proper thresholds are set for human

and organizational performance issues and prevent splitting and relegating these

issues to lower classification.

DAMP Item I.3.4: Determine the appropriate number and select appropriate

individuals to obtain RCE [root cause evaluation] and/or ACE [apparent cause

evaluation] qualification.

DAMP Item I.3.5: Revise procedure NOBP-LP-2007, Condition Report Process

Effectiveness Review, to include specific guidance for performing early

effectiveness reviews (i.e. based on negative trends) and to include

requirements for evaluation when actions taken were determined to be

ineffective.

Enclosure

15

To accomplish these reviews, the team reviewed selected documentation such as

condition reports, corrective action program closure documentation, original and revised

procedures, and meeting schedules and minutes. In addition, the team conducted

interviews of cognizant licensee personnel to determine whether actions had been

accomplished.

5.1

DAMP Item I.3.1

a.

Inspection Scope

The team reviewed DAMP Item I.3.1: Revise procedure NOP-LP-2001, Corrective

Action Program, to provide guidance for initiation of a significant root cause evaluation

at a lower threshold (i.e. issues that may not be significant but are considered to be a

negative trend, repeat issues, and adverse trend).

To determine whether this DAMP item had been adequately implemented, the team

reviewed condition reports, corrective action program closure documentation, and

original and revised procedures. In particular, the team reviewed NOP-LP-2001,

Corrective Action Program; and NOBP-LP-2019, Corrective Action Program

Supplemental Expectations and Guidance.

b.

Observations and Findings

No findings of significance were identified and the team concluded that the licensees

actions adequately implemented DAMP Item I.3.1.

Overall, the procedures contained appropriate guidance and prescribed an adequate,

lower threshold for conducting root cause evaluations. However, during the review the

team identified a discrepancy in NOBP-LP-2019, Corrective Action Program

Supplemental Expectations and Guidance. In the Other category of NOBP-LP-2019,

the identification of organizational-based adverse trends was restricted to those that had

an actual impact on safety, rather than those that had impacted or could impact safety

as specified in other sections of NOBP-LP-2019. Licensee personnel generated

CR 06-00636, DAMP Item I.3.1 Inadvertent Omission from Attachment 1 of

NOBP-LP-2019, to enter this issue into the corrective action program.

The team concluded that due to a lack of quality and attention to detail, licensee

personnel failed to identify this error during the item resolution and closure process.

5.2

DAMP Item I.3.2

a.

Inspection Scope

The team reviewed DAMP Item I.3.2: Implement a two-step screening process in

accordance with PYBP-SITE-0045, Initial Screening Committee to improve objectivity,

consistency, and cognitive trending of new condition reports. Also include assignment

of due dates based on the significance of issues.

Enclosure

16

To determine whether this DAMP item had been adequately implemented, the team

reviewed condition reports, corrective action program closure documentation, and

original and revised procedures. In particular, the team reviewed PYBP-SITE-0045,

Initial Screening Committee, and attended an initial screening meeting and a

Management Review Board (MRB) meeting conducted on February 7, 2006.

b.

Observations and Findings

No findings of significance were identified and the team concluded that the licensees

actions adequately implemented DAMP Item I.3.2.

By direct observation, the team determined that the licensee had implemented a

two-step screening process that improved the objectivity, consistency, and cognitive

trending of new condition reports; and assigned due dates based on the significance of

issues. Through this process, a condition report was sent to the Initial Screening

Committee (ISC) for review and discussion, and then to the Management Review Board

(MRB) for final approval. Subsequently, the MRB ensured that the condition report was

appropriately screened for Category, Assigned Group, and Due Date. The MRB

also discussed complicated and/or significant condition reports. The ISC was instituted

by procedure, with required training for its members, and was accountable to the MRB.

Although not directly associated with the accomplishment of this DAMP item, the team

noted that the licensee did not compare initial and final Category determinations

between the ISC and MRB. The team concluded that this was a missed opportunity to

monitor the alignment between supervisors and managers. Licensee personnel

generated CR 06-00589, No Indicators to Track Deltas from Condition Report

Categorizations, to enter this issue into the corrective action program.

5.3

DAMP Item I.3.3

a.

Inspection Scope

The team reviewed DAMP Item I.3.3: Adopt controls to assure proper thresholds are

set for human and organizational performance issues and prevent splitting and

relegating these issues to lower classification.

To determine whether this DAMP item had been adequately implemented, the team

reviewed condition reports, corrective action program closure documentation, and

original and revised procedures. In particular, the team reviewed NOBP-LP-2011,

FENOC Cause Analysis; and NOBP-LP-2019, Attachment 1, Condition Report

Category and Activity Tracking Descriptions, and Attachment 2, Condition Report

Evaluation Methods.

b.

Observations and Findings

No findings of significance were identified and the team concluded that the licensees

actions adequately implemented DAMP Item I.3.3.

Enclosure

17

The team identified that the closure documentation had not credited the revision to

NOBP-LP-2011, which was necessary for closure of the DAMP item. However, through

discussions with licensee personnel, the team determined that Revision 3 to

NOBP-LP-2011, FENOC Cause Analysis, specifically addressed the DAMP item.

Licensee personnel generated CR 06-0604, DAMP Item I.3.3 Did Not Provide

Complete Closure Documentation, to enter this issue into the corrective action

program.

The team concluded that due to a lack of quality and attention to detail, licensee

personnel failed to identify that the item closure documentation associated with this

DAMP item was not adequate to close the item during the item closure process.

5.4

DAMP Item I.3.4

a.

Inspection Scope

The team reviewed DAMP Item I.3.4: Determine the appropriate number and select

appropriate individuals to obtain RCE and/or ACE qualification.

To determine whether this DAMP item had been adequately implemented, the team

reviewed condition reports, corrective action program closure documentation, and

original and revised procedures. In particular, the team reviewed CA 05-01043-7, which

prescribed the assessment of resource needs for root cause and apparent cause

evaluators and CR analysts, followed by the assignment of individuals to fill those

positions.

b.

Observations and Findings

No findings of significance were identified and the team concluded that the licensees

actions adequately implemented DAMP Item I.3.4.

The subject DAMP item prescribed that for each department, licensee personnel identify

and select the appropriate number of evaluators needed to support root cause and

apparent cause evaluations. Corrective Action 05-01043-7, which implemented this

DAMP item, prescribed that in addition to the identification and selection of root cause

and apparent cause evaluators, that additional necessary personnel to support the

CR Analyst position also be identified and selected.

During the review of CA 05-01043-7, the inspectors determined that the licensees

actions adequately implemented the DAMP item. However, the team also identified that

licensee personnel had not identified or selected the individuals to support the

CR Analyst position, although CA 05-01043-7 had been closed.

To address this issue, licensee personnel generated CR 06-00697, DAMP Item I.3.4

Closed Correctly However, Reference CA Not Complete, to enter this issue into the

corrective action program. Subsequently, licensee personnel identified the number of

CR analysts needed. The team verified that the appropriate number of CR analysts

Enclosure

18

were either trained or scheduled to attend training to meet necessary CR analyst

staffing levels.

The team concluded that the closure of CA 05-01043-7 was premature since all

CR Analyst positions had not been filled as required by CA 05-01043-7. However, since

the issue was associated with the staffing levels of CR analysts, and there had been no

identified impact on the facility during the period the issue existed, the issue was of only

minor significance.

5.5

DAMP Item I.3.5

a.

Inspection Scope

The team reviewed DAMP Item I.3.5: Revise procedure NOBP-LP-2007, Condition

Report Process Effectiveness Review, to include specific guidance for performing early

effectiveness reviews (i.e. based on negative trends) and to include requirements for

evaluation when actions taken were determined to be ineffective.

To determine whether this DAMP item had been adequately implemented, the team

reviewed condition reports, corrective action program closure documentation, and

original and revised procedures. In particular, the team reviewed NOBP-LP-2007,

Condition Report Process Effectiveness Review, and CA 05-07233-7.

b.

Observations and Findings

No findings of significance were identified; however, the team concluded that the

licensees actions had not adequately implemented DAMP Item I.3.5.

The team reviewed NOBP-LP-2007, Condition Report Process Effectiveness Review,

and confirmed that it eliminated the nominal 6 month guideline for performing

effectiveness reviews and added the evaluation of corrective action effectiveness at the

earliest practical opportunity. In addition, the process incorporated a corrective action

effectiveness review following a challenge to a system, component, or process,

sufficient to evaluate whether the corrective actions were effective.

However, the team identified that the procedure failed to address the performance of

early effectiveness reviews based on, for example, negative trends. Licensee personnel

generated CR 06-0080, DAMP Items I.3.5 and I.8.4 Incomplete, to enter this issue into

the corrective action program.

The team concluded that the licensees actions had not adequately implemented

DAMP Item I.3.5. The team also concluded that due to a lack of quality and attention to

detail, licensee personnel failed to identify that this DAMP item had not been adequately

implemented during the DAMP item review and closure process. However, since the

inadequate closure of DAMP Item I.3.5 had no actual impact on the facility, the issue

was of only minor significance.

Enclosure

19

6.0

Improve Quality of Evaluations and Corrective Actions

The following action items in the Improve Quality of Evaluations and Corrective Actions

area of PYBP-PII-002, Performance Improvement Initiative Detailed Action and

Monitoring Plan (DAMP), Revision 5, were reviewed:

DAMP Item I.4.2: Strengthen the root cause investigators training plan and

qualification requirements (JFG) [Job Familiarization Guidelines].

DAMP Item I.4.4: Improve implementation of FENOC NOBP-LP-2007,

Condition Report Effectiveness Review, to improve challenging of the adequacy

of the actions taken. Utilize periodic effectiveness reviews rather than a single

review at the end of completing all CAs.

DAMP Item I.4.5: Manager pre-job brief all apparent cause evaluations and

establish scope, expected resource investment, analytical techniques and

guidance for evaluation of generic implications. Ensure evaluator(s) have

appropriate skill set. Identify where mentoring is required to improve critical

thinking. The desired outcome is improvement in technical rigor.

To accomplish these reviews, the team reviewed selected documentation such as

condition reports, corrective action program closure documentation, original and revised

procedures, pre-job briefing records, and qualification records. In addition, the team

conducted interviews of cognizant licensee personnel to determine whether actions had

been accomplished.

6.1

DAMP Item I.4.2

a.

Inspection Scope

The team reviewed DAMP Item I.4.2: Strengthen the root cause investigators training

plan and qualification requirements (JFG).

To determine whether this DAMP item had been adequately implemented, the team

reviewed condition reports, corrective action program closure documentation, original

and revised procedures, training plans, and training attendance records. In particular,

the team reviewed NOBP-TR-1111-01, Corrective Action Program (CAP) Training

Program; Training Plan 9903, Root Cause Evaluator; Training Plan 9908, Corrective

Action Review Board (CARB) Member; and the training requirements specified in

CAP-RCA_FEN, FENOC Root Cause Evaluation Basic Training; CAP-RCT_FEN,

FENOC Root Cause Evaluation Advanced Training; and CAP-JFGRCE_FEN, Root

Cause Evaluator Job Familiarization Guide. In addition, the team interviewed Perry and

FENOC training management personnel.

Enclosure

20

b.

Observations and Findings

No findings of significance were identified; however, the team concluded that the

licensees actions had not adequately implemented DAMP Item I.4.2.

To strengthen the root cause evaluator training plan and qualification requirements,

licensee personnel modified the training and certification program to require a 5 day root

cause methodology-specific training course, removed the previous 2 day training course

as an acceptable method for certification, and added a generic root cause training

course. The generic training course also prescribed that the expectations for performing

root cause evaluations be discussed.

In reviewing these changes, the team determined that the training was managed by

FENOC corporate office personnel. In addition, the team determined that the generic

root cause training course had not been fully developed and that the only action that had

been implemented was to place a non-specific course description in the training plan.

The team also determined that this revised training and certification program had been

approved and implemented in December 2005.

Based on the above information, the team inquired about the controls in place to prevent

the corporate office from inadvertently revising the training requirements or the content

of lesson plans in a manner that would nullify the outcomes prescribed by the DAMP

item. Further, because the training program required a course for which no lesson plan

existed and no waivers had been granted, the team questioned the certification of

individuals currently performing root cause evaluations and the certification of Corrective

Action Review Board (CARB) members for root cause training.

During followup discussions, the team identified that although FENOC corporate office

personnel had issued the proposed training and certification program revision to the site

for review, the training organization, responsible for tracking certifications, had not been

provided a copy for review. Further, no mechanism existed to ensure that the results of

the implementation of DAMP items were not inadvertently nullified through the issuance

of a revised business practice. This team concluded that the licensees coordination

effort did not appropriately ensure that organizations were provided the opportunity to

review the changes prior to their implementation. Licensee personnel generated

CR 06-00630, No Process Exists to Prevent Inadvertent Changes to Closed PII

Actions, to enter this issue into the corrective action program.

While addressing the teams question regarding individual certifications, site and

FENOC corporate training personnel realized they had not adhered to site procedures or

the change management plan when implementing the revised training and certification

program. In an attempt to correct the situation, FENOC corporate office personnel

issued a memorandum dated February 10, 2006, which stated that all individuals

remained certified. However, the team identified that the memorandum was not

consistent with site procedures since the granting of a waiver required the evaluation of

an individuals qualification against the original and revised lesson plans and, as

Enclosure

21

previously stated, no revised lesson plan existed for the generic root cause training

course.

On February 17, 2006, licensee personnel informed the team that they planned to

re-implement the previous training and certification program that existed prior to the

revisions. Licensee personnel also generated CR 06-00784, Issues With

Implementation of Revised CAP Training, to review the condition and review individual

certifications while the revised program was in effect.

The team also noted that DAMP l.4.2 prescribed that the generic root cause training

course would include FENOC specific expectations for conduct of a root cause

evaluation. However, the team identified that the course description did not specify

what would be included in the training course.

The team further noted that although completion of only one of the four 5 day

methodology-specific training course was required for certification as a root cause

evaluator, the root cause evaluator training course description listed all four

methodology-specific 5 day training courses as prerequisites for root cause evaluator

certification.

The team also noted that NOBP-LP-2011, Section 4.5.3, stated, Appropriate

methodologies should be selected by the investigators and used appropriately.

However, the practice did not require that the individual(s) making the determination of

which method to use be qualified in the selected method.

The team concluded that DAMP Item I.4.2 had not been adequately implemented since

the actions taken by licensee personnel had not strengthened the root cause

investigators training plan and qualification requirements. The team also concluded that

due to a lack of quality and attention to detail, licensee personnel failed to identify that

this DAMP item had not been adequately implemented during the DAMP item review

and closure process. However, because the inadequate closure of DAMP Item I.4.2

had no actual impact on the facility, the issue was of only minor significance.

6.2

DAMP Item I.4.4

a.

Inspection Scope

The team reviewed DAMP Item I.4.4: Improve implementation of FENOC NOBP-LP-

2007, Condition Report Effectiveness Review, to improve challenging of the adequacy

of the actions taken. Utilize periodic effectiveness reviews rather than a single review at

the end of completing all CAs.

To determine whether this DAMP item had been adequately implemented, the team

reviewed condition reports, corrective action program closure documentation, original

and revised procedures, and attended a CARB meeting. In particular, the team

reviewed CA 05-07223-11 and NOBP-LP-2007, Condition Report Process

Effectiveness Review. In addition, team members attended a February 10, 2006

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22

CARB meeting and observed the discussion of effectiveness reviews associated with

CR 05-05260, Closed Cooling Chemistry Out of Admin Specification.

b.

Observations and Findings

No findings of significance were identified and the team concluded that the licensees

actions adequately implemented DAMP Item I.4.4.

The team determined that through completion of CA 05-07223-11, NOBP-LP-2007,

Condition Report Process Effectiveness Review, had been revised to prescribe interim

effectiveness reviews to improve the challenging of the adequacy of actions taken. The

effectiveness reviews as described in NOBP-LP-2007 prescribed an appropriate scope

and were required to be completed prior to closing the subject condition report. The

team also noted that condition reports that prescribed apparent cause and root cause

evaluations also received a final effectiveness review. In addition, team members

observed, during the February 10, 2006 CARB meeting, that managers exhibited many

of the behaviors the licensee had described in its expectations for successful

implementation of the corrective action program. The team also noted that the MRB

reviewed the CR list weekly to identify candidates for early effectiveness reviews.

6.3

DAMP Item I.4.5

a.

Inspection Scope

The team reviewed DAMP Item I.4.5: Manager pre-job brief all apparent cause

evaluations and establish scope, expected resource investment, analytical techniques

and guidance for evaluation of generic implications. Ensure evaluator(s) have

appropriate skill set. Identify where mentoring is required to improve critical thinking.

The desired outcome is improvement in technical rigor.

To determine whether this DAMP item had been adequately implemented, the team

reviewed condition reports, corrective action program closure documentation, and

original and revised procedures. In addition, the team conducted interviews of cognizant

licensee personnel to determine whether actions had been accomplished. In particular,

the team reviewed PYBP-SITE-0046, Corrective Action Program Implementation

Expectations, and the Apparent Cause Expectation brochure.

b.

Observations and Findings

No findings of significance were identified and the team concluded that the licensees

actions adequately implemented DAMP Item I.4.5.

The team noted that the licensee had developed a guidance document for pre-job

briefings. In reviewing the document, the team identified that the licensee had

exceeded the actions prescribed in DAMP l.4.5.

Enclosure

23

During the pre-job briefing process review, the team determined that the guidance

addressed when a pre-job briefing was to be conducted, and how to document the

briefing for root cause evaluations; however, no written guidance existed for pre-job

briefings for apparent cause evaluations. During followup discussions with licensee

personnel, the team verified that pre-job briefings were being conducted for apparent

cause evaluations; however, without written guidance, the long-term ability to sustain the

effort was questionable.

The team also identified a discrepancy in the Closure Documentation Summary for

DAMP Item 4.5. The documentation stated, ...each day at the MRB, the MRB

Chairperson discusses the need for the pre-job brief with each Manager and refers them

to the Apparent Cause Expectation brochure to be used in the Apparent Cause

investigation pre-job brief. During followup discussions, the team was informed that the

actual expectation was that the MRB Chairperson would discuss the need for a pre-job

briefing on Tuesdays and any time a new apparent cause evaluation was brought before

the MRB.

The team also identified that although the DAMP item stated, Identify where mentoring

is required to improve critical thinking, there was no documentation that required this to

be accomplished or evidence that it had been accomplished. The team also identified

that the closure package review did not identify this deficiency.

The team concluded that notwithstanding the omission of actions to address mentoring

to improve critical thinking, the licensees completed actions were sufficient to consider

this DAMP item, overall, to have been adequately implemented.

The team also concluded that due to a lack of quality and attention to detail, licensee

personnel failed to identify that some aspects of this DAMP item had not been

implemented during the DAMP item resolution and closure process.

7.0

Improve Ability to Correct Problems Early Before They Become Significant Issues

The following action items in the Improve Ability to Correct Problems Early Before They

Become Significant Issues area of PYBP-PII-002, Performance Improvement Initiative

Detailed Action and Monitoring Plan (DAMP), Revision 5, were reviewed:

DAMP Item I.5.1: Perform a focused self-assessment of the results of

Integrated Performance Assessment Trending to provide feedback on quality

and to identify site-wide trends.

DAMP Item I.5.4: Develop guidance and implement a CAP focus day to identify

and eliminate lower tier CAP open items.

To accomplish these reviews, the team reviewed selected documentation such as

condition reports, corrective action program closure documentation, self-assessment

reports, original and revised procedures, training plans and training attendance records,

Enclosure

24

and meeting schedules and minutes. In addition, the team conducted interviews of

cognizant licensee personnel to determine whether actions had been accomplished.

7.1

DAMP Item I.5.1

a.

Inspection Scope

The team reviewed DAMP Item I.5.1: Perform a focused self-assessment of the results

of Integrated Performance Assessment Trending to provide feedback on quality and to

identify site-wide trends.

To determine whether this DAMP item had been adequately implemented, the team

reviewed condition reports, corrective action program closure documentation, and

self-assessment reports. In addition, the team conducted interviews of cognizant

licensee personnel to determine whether actions had been accomplished. In particular,

the team reviewed self-assessment FL-SA-05-05, Self-Assessment of Integrated

Performance Assessment Trending, dated December 14, 2005, and CA 05-07223-13.

b.

Observations and Findings

No findings of significance were identified and the team concluded that the licensees

actions adequately implemented DAMP Item I.5.1.

The licensees self-assessment identified that the overall implementation of trending

activities was marginally effective and statistical trending of condition reporting data was

ineffective. The self-assessment appeared to be thorough and comprehensive.

Condition reports were generated to enter the issues identified in the assessment into

the licensees corrective action program.

7.2

DAMP Item I.5.4

a.

Inspection Scope

The team reviewed DAMP Item I.5.4: Develop guidance and implement a CAP focus

day to identify and eliminate lower tier CAP open items.

To determine whether this DAMP item had been adequately implemented, the team

reviewed condition reports, corrective action program closure documentation, and

meeting schedules and minutes. In addition, the team conducted interviews of

cognizant licensee personnel to determine whether actions had been accomplished.

Specifically, the team reviewed a document entitled Criteria for CAP Focus Day, and

CARB meeting minutes for a CARB meeting conducted on October 27, 2005. In

addition, team members attended the February 13, 2006 CAP Focus Day meeting.

Enclosure

25

b.

Observations and Findings

No findings of significance were identified and the team concluded that the licensees

actions adequately implemented DAMP Item I.5.4.

The CAP Focus Day was developed to review, and evaluate for elimination, any

corrective actions that had not been implemented, or actions that had been assigned for

implementation with a due date of greater than 360 days. The criteria developed for the

CAP Focus Day was implemented at the first CAP Focus Day meeting held on

October 25, 2005. Based upon the observation of the February 13, 2006, CAP Focus

Day meeting, the team concluded that the licensee had established an adequate

method to eliminate lower tier CAP open items through a CAP Focus Day.

8.0

Focus on Improving Quality of Closure Documentation

The following action items in the Focus on Improving Quality of Closure

Documentation area of PYBP-PII-002, Performance Improvement Initiative Detailed

Action and Monitoring Plan (DAMP), Revision 5, were reviewed:

DAMP Item I.6.1: Establish the Corrective Action Closure Board (CACB) as

having review authority for apparent cause evaluations. Establish a quorum that

requires one CARB member.

DAMP Item I.6.2: Provide feedback on CACB determinations to CR analysts,

CARB, and managers.

To accomplish these reviews, the team reviewed selected documentation such as

condition reports, corrective action program closure documentation, original and revised

procedures, feedback forms, and meeting schedules and minutes. In addition, the team

conducted interviews of cognizant licensee personnel to determine whether actions had

been accomplished.

8.1

DAMP Item I.6.1

a.

Inspection Scope

The team reviewed DAMP Item I.6.1: Establish the Corrective Action Closure Board

(CACB) as having review authority for apparent cause evaluations. Establish a quorum

that requires one CARB member.

To determine whether this DAMP item had been adequately implemented, the team

reviewed condition reports, corrective action program closure documentation, original

and revised procedures, and meeting schedules and minutes. In addition, the team

conducted interviews of cognizant licensee personnel to determine whether actions had

been accomplished. Specifically, the team reviewed PYBP-SITE-0042, Corrective

Action Closure Board Charter; and the October 20, 2005 CACB meeting agenda.

Enclosure

26

b.

Observations and Findings

No findings of significance were identified and the team concluded that the licensees

actions adequately implemented DAMP Item I.6.1.

The team identified that the CACB had been established, and had been provided the

authority to review apparent cause evaluations through the implementation of

PYBP-SITE-0042, Corrective Action Closure Board Charter. The CACB had

performed this function through December 2005 when the CACB was suspended due to

the unavailability of resources. Although the licensee planned to reinstate the CACB,

the backlog of CAs and CRs requiring review continued to increase. At the end of the

inspection, there were about 700 CAs and 270 CRs that required CACB review. In

addition, there were a number of apparent cause and root cause evaluations in progress

that would also require CACB review.

Although the team concluded that the DAMP item had been adequately implemented at

the time the DAMP item was closed, the decision to suspend the CACB activities

affected the effectiveness of the actions.

8.2

DAMP Item I.6.2

a.

Inspection Scope

The team reviewed DAMP Item I.6.2: Provide feedback on CACB determinations to

CR analysts, CARB, and managers.

To determine whether this DAMP item had been adequately implemented, the team

reviewed condition reports, corrective action program closure documentation, and

meeting schedules and minutes. In addition, the team conducted interviews of

cognizant licensee personnel to determine whether actions had been accomplished. In

particular, the team reviewed CACB meeting minutes and discussed CACB activities

with board members and CR analysts.

b.

Observations and Findings

No findings of significance were identified and the team concluded that the licensees

actions adequately implemented DAMP Item I.6.2.

The team reviewed information related to feedback provided by CACB. In

September 2005, feedback from CACB determinations was provided to CR analysts,

CARB, and managers through CACB meeting minutes. Subsequently, CR analyst

meeting minutes were provided as feedback. In November 2005, feedback was

provided both verbally at CR analyst meetings as well as through e-mail

correspondence. Through discussions with CR analysts, the team determined that

written feedback alone frequently did not provide sufficient detail for the CR analysts to

understand the basis for CACB determinations. To improve their understanding of

CACB determinations, CR analysts proactively attended CACB meetings.

Enclosure

27

The team noted that the CACB review and feedback process had not been formalized.

The team concluded that the lack of a formal process to provide feedback on CACB

determinations to CR analysts, CARB, and managers could impact the long-term

effectiveness of the actions.

9.0

Improve Oversight of the Corrective Action Program

The following commitment and action items in the Improve Oversight of the Corrective

Action Program area of PYBP-PII-002, Performance Improvement Initiative Detailed

Action and Monitoring Plan (DAMP), Revision 5, were reviewed:

Commitment 2.c/DAMP Item I.7.1: Establish a management review process

that routinely monitors the sites and section level CAP performance. Take

action to improve performance when expectations are not met and hold the

organization accountable for overall CAP effectiveness.

DAMP Item I.7.2: Focus CARB review on rigor of cause analysis and effective

cause/action resolution. Ensure that actions are smart and will fix the problem.

Use the FENOC fleet RCA [Root Cause Analysis] scoring sheet to drive

improved performance.

DAMP Item I.7.3: Qualify additional managers in FENOC CARB JFG to

improve ability to routinely establish quorums and hold CARB meetings as

scheduled.

DAMP Item I.7.4: Improve the CARB/CACB feedback process to ensure

lessons learned are getting to site personnel to promote continuous

improvement in the CAP area.

DAMP Item I.7.6: Qualify additional managers in root cause to enable meeting

quorum requirements.

To accomplish these reviews, the team reviewed selected documentation such as

condition reports, corrective action program closure documentation, original and revised

procedures, and qualification records. In addition, the team conducted interviews of

cognizant licensee personnel to determine whether actions had been accomplished.

9.1

Commitment 2.c/DAMP Item I.7.1

a.

Inspection Scope

The team reviewed Commitment 2.c/DAMP Item I.7.1: Establish a management review

process that routinely monitors the sites and section level CAP performance. Take

action to improve performance when expectations are not met and hold the organization

accountable for overall CAP effectiveness.

Enclosure

28

To determine whether this commitment and DAMP item had been adequately

implemented, the team reviewed condition reports, corrective action program closure

documentation, original and revised procedures, and meeting schedules and minutes.

In addition, the team conducted interviews of cognizant licensee personnel to determine

whether actions had been accomplished. In particular, the team observed and reviewed

meeting minutes associated with CARB meetings, CACB meetings, Management

Review Committee (MRC) meetings, CR Screening meetings, Senior Leadership Team

(SLT) meetings, and Monthly Performance Review (MPR) meetings. In addition, the

team reviewed the Key Performance Indicators (KPIs) developed to monitor corrective

action program implementation. The team also reviewed NOP-LP-2001, Corrective

Action Program; NOBP-LP-2008, Corrective Action Review Board; and

PYBP-SITE-0046, Corrective Action Program Implementation Expectations.

b.

Observations and Findings

No findings of significance were identified and the team concluded that the licensees

actions adequately implemented Commitment 2.c and DAMP Item I.7.1.

The team determined that the licensee had implemented appropriate review processes

to routinely monitor corrective action program performance. In addition, corrective

action program key performance indicators (KPIs) had been developed with color-coded

thresholds to monitor performance. In some cases, condition reports were generated to

document red and yellow KPIs and to track development and implementation of

corrective actions when expectations were not met.

The team determined that some actions had been implemented to improve corrective

action program performance when program performance expectations were not met.

Management feedback to corrective action owners, the appointment of management

sponsors for corrective action program products, and the analysis and development of a

closure plan to address KPI performance gaps were all examples of actions that the

licensee had implemented to address corrective action program performance issues.

However, a formal mechanism to address KPI issues within the licensees corrective

action program did not exist. In particular, licensee personnel had not developed written

guidance that prescribed the generation of a condition report to address declining KPIs,

performance gaps between actual and expected performance, the development of

action plans to reduce the gap between actual and expected performance, or the

tracking of the success of action plans to address identified performance deficiencies.

Although specific guidance did not exist, the team did not identify any declining KPIs for

which appropriate corrective actions had not been implemented.

The team concluded that the lack of a formal process to address KPI issues could

impact the long-term effectiveness of the actions. Licensee personnel generated

CR 06-00787, Inconsistencies With GAP Closure plans for Red/Yellow CAP KPIs, to

enter this issue into the corrective action program.

Enclosure

29

9.2

DAMP Item I.7.2

a.

Inspection Scope

The team reviewed DAMP Item I.7.2: Focus CARB review on rigor of cause analysis

and effective cause/action resolution. Ensure that actions are smart and will fix the

problem. Use the FENOC fleet RCA scoring sheet to drive improved performance.

To determine whether this DAMP item had been adequately implemented, the team

reviewed condition reports, corrective action program closure documentation, original

and revised procedures, and meeting schedules and minutes. In addition, the team

conducted interviews of cognizant licensee personnel to determine whether actions had

been accomplished. Specifically, the team reviewed NOBP-LP-2008, FENOC

Corrective Action Review Board, to address this DAMP item including

NOBP-LP-2008-01 that contained the Root Cause Review Summary. Team members

also attended a February 8, 2006, CARB meeting.

b.

Observations and Findings

No findings of significance were identified and the team concluded that the licensees

actions adequately implemented DAMP Item I.7.2.

The team noted that NOBP-LP-2008 assigned CARB the responsibility for reviewing all

root cause evaluation reports, selected apparent cause evaluation reports, and the

associated corrective actions. Further, the team noted that the standing CARB agenda

defined that one purpose of CARB was to ensure that causes were coupled to problem

statements. Team members observed that CARB meeting packages used the

FENOC-wide Root Cause Review summary sheets and Apparent Cause Quality sheets,

which aided in the alignment of corrective actions to root causes. In addition, the team

noted that CARB assigned one of its members to interface with the organization

presenting the RCE or ACE to ensure that feedback from CARB was understood.

9.3

DAMP Item I.7.3

a.

Inspection Scope

The team reviewed DAMP Item I.7.3: Qualify additional managers in FENOC CARB

JFG to improve ability to routinely establish quorums and hold CARB meetings as

scheduled.

To determine whether this DAMP item had been adequately implemented, the team

reviewed condition reports, corrective action program closure documentation, original

and revised procedures, and qualification records. In addition, the team conducted

interviews of cognizant licensee personnel to determine whether actions had been

accomplished. In particular, the team reviewed the FENOC Integrated Training System

(FITS) Qualification Matrices associated with root cause evaluators and CARB

Enclosure

30

members, for specific individuals who were added to the CARB roster. The team also

reviewed CA 05-07223-18.

b.

Observations and Findings

No findings of significance were identified and the team concluded that the licensees

actions adequately implemented DAMP Item I.7.3.

The team verified that two additional managers had been certified as CARB members,

which improved the licensees ability to meet CARB quorum requirements. However,

the team determined that a process had not been established to maintain a specific

number of qualified CARB members after this DAMP item was closed.

The team concluded that the lack of a formal process to maintain a specific number of

qualified CARB members could impact the long-term effectiveness of the actions.

9.4

DAMP Item I.7.4

a.

Inspection Scope

The team reviewed DAMP Item I.7.4: Improve the CARB/CACB feedback process to

ensure lessons learned are getting to site personnel to promote continuous

improvement in the CAP area.

To determine whether this DAMP item had been adequately implemented, the team

reviewed condition reports, corrective action program closure documentation, original

and revised procedures, and meeting schedules and minutes. In addition, the team

conducted interviews of cognizant licensee personnel to determine whether actions had

been accomplished. In particular, the team reviewed NOBP-LP-2008, Corrective Action

Review Board; the CARB review package dated November 4, 2005; CACB minutes for

September and October 2005; the CACB and CARB overview from the Supervisor Brief

on October 31, 2005; NOBP-SITE-0046, Corrective Action Program Implementation

Expectations; and the Condition Report Analyst Meeting Agenda for November 3, 2005.

b.

Observations and Findings

No findings of significance were identified and the team concluded that the licensees

actions adequately implemented DAMP Item I.7.4.

The team noted that CARB/CACB feedback was routinely provided during monthly

CR analyst meetings and in certain cases, CARB/CACB meeting notes were

electronically distributed to select site personnel. At times, CR analysts personally

attended CARB meetings to receive feedback. The team did not identify a specific

feedback process by which lessons learned were disseminated to general site

personnel so that the corrective action program could be continuously improved.

Enclosure

31

Similar to DAMP l.6.2, the team concluded that the lack of a formal CARB/CACB

feedback process could impact the long-term effectiveness of the actions.

9.5

DAMP Item I.7.6

a.

Inspection Scope

The team reviewed DAMP Item I.7.6: Qualify additional managers in root cause to

enable meeting quorum requirements. (Note, this item is similar to, but not the same

as DAMP 7.3)

To determine whether this DAMP item had been adequately implemented, the team

reviewed condition reports, corrective action program closure documentation, original

and revised procedures, and qualification records. In addition, the team conducted

interviews of cognizant licensee personnel to determine whether actions had been

accomplished. Specifically, the team reviewed the FITS Qualification Matrices

associated with the Root Cause Evaluator position for recently certified CARB members,

and CA 05-07223-21.

b.

Observations and Findings

No findings of significance were identified and the team concluded that the licensees

actions adequately implemented DAMP Item I.7.6.

The team reviewed information related to the number of root cause qualified CARB

members necessary for the CARB to meet minimum quorum requirements. During the

review, the team noted that three additional managers had been credited for root cause

training, which provided an increased ability to meet CARB quorum requirements. The

team also noted that no process was in place to maintain a specific number of root

cause-trained CARB members after this DAMP item had been closed.

The team concluded that the lack of a formal process to maintain a specific number of

root cause-trained CARB members could impact the long-term effectiveness of the

actions.

10.0

PII Phase 1 Carry Over Activities

The following Action Items in the PII Phase 1 Carry Over Activities area of

PYBP-PII-002, Performance Improvement Initiative Detailed Action and Monitoring Plan

(DAMP), Revision 5, were reviewed:

DAMP Item D.8.1: Fully Implement the Station Operating Experience (OE)

coordinator and Section OE coordinator role at Perry, as established in

NOP-LP-2100, by ensuring the Job Familiarization Guides (JFGs) are completed

for all sections.

Enclosure

32

DAMP Item D.8.3: Communication will be provided to PIU/Analysts with the

formality determined by the SAP conversion change management plan to

understand and apply coding.

DAMP Item D.8.4: A method to improve the timeliness of effectiveness reviews

will be established and implemented.

To accomplish these reviews, the team reviewed selected documentation such as

condition reports, corrective action program closure documentation, original and revised

procedures, and training plans and training attendance records. In addition, the team

conducted interviews of cognizant licensee personnel to determine whether actions had

been accomplished.

10.1

DAMP Item 8.1

a.

Inspection Scope

The team reviewed DAMP Item 8.1: Fully Implement the Station Operating Experience

(OE) coordinator and Section OE coordinator role at Perry, as established in

NOP-LP-2100, by ensuring the Job Familiarization Guides (JFGs) are completed for all

sections.

To determine whether this DAMP item had been adequately implemented, the team

reviewed condition reports, corrective action program closure documentation, original

and revised procedures, training plans and training attendance records, and qualification

records. In addition, the team conducted interviews of cognizant licensee personnel to

determine whether actions had been accomplished. In particular, the team reviewed

CA 04-02404-08; the FITS Qualification Matrix for Section OE Coordinators; Job

Familiarization Guide (JFG) GEN_JFGSOEC_FEN-01, Section Operating Experience

Coordinator Job Familiarization Guideline; and NOP-LP-2100, Operating Experience

Program. In addition, the team interviewed selected OE personnel.

b.

Observations and Findings

No findings of significance were identified and the team concluded that the licensees

actions adequately implemented DAMP Item I.8.1.

The team noted that although completion of the JFG was not a prerequisite for the

Section OE Coordinator position, it was considered by the licensee as an enhancement

necessary to fully implement the station OE program. The team verified that at the time

the DAMP item was closed, all original Section OE Coordinators had received the JFG

training.

However, the team identified that although three replacement Section OE Coordinators

had been designated since the DAMP item had been closed, these newly assigned

Section OE Coordinators had not completed the JFG training. In addition, the team

Enclosure

33

identified that a process had not been established to ensure newly assigned Section OE

Coordinators completed the JFG training.

The team concluded that the lack of a formal process to qualify Section OE

Coordinators could impact the long-term effectiveness of the licensees actions.

10.2

DAMP Item 8.3

a.

Inspection Scope

The team reviewed DAMP Item D.8.3: Communication will be provided to PIU/Analysts

with the formality determined by the SAP conversion change management plan to

understand and apply coding.

b.

Observations and Findings

Licensee personnel reviewed and approved the removal of this DAMP item from

PYBP-PII-002, Performance Improvement Initiative Detailed Action and Monitoring Plan

(DAMP), Revision 5 prior to the inspection. As a result, the team was unable to review

corrective actions implemented to address this DAMP item.

The team noted that the closure documentation associated with this DAMP item did not

explicitly include a discussion of the licensees actions to remove this item from

Revision 5 of PYBP-PII-002.

10.3

DAMP Item 8.4

a.

Inspection Scope

The team reviewed DAMP Item 8.4: A method to improve the timeliness of

effectiveness reviews will be established and implemented.

To determine whether this DAMP item had been adequately implemented, the team

reviewed condition reports, corrective action program closure documentation, and

original and revised procedures. In addition, the team conducted interviews of cognizant

licensee personnel to determine whether actions had been accomplished. In particular,

the team reviewed NOBP-LP-2007, Condition Report Effectiveness Review, and

CA 05-07233-07.

b.

Observations and Findings

No findings of significance were identified and the team concluded that the licensees

actions adequately implemented DAMP Item 8.4.

As discussed in DAMP Item 3.5 of this report, the team noted that NOBP-LP-2007,

Condition Report Process Effectiveness Review, had been revised to evaluate

effectiveness at the earliest opportunity. This revision eliminated a 6 month guideline for

Enclosure

34

performance of effectiveness reviews and provided guidance on when to initiate an

effectiveness review.

11.0

Validated/Closed Perry Phase 1 Action Items

The following validated and closed Perry Phase 1 DAMP Action Items were reviewed:

DAMP Item D.1.6: Perform an external assessment of the Corrective Action

Program (CAP) (04-02468-46).

DAMP Item D.9.2: Develop a method to assign clear, single point ownership of

root cause CRs, from CR investigation through CA implementation/effectiveness

review completion for each root cause CR (04-02468-69).

DAMP Item D.11.1: A two-step screening process is being implemented to

improve timeliness of issue entry into CAP and more accurate prioritization

(04-02468-66).

To accomplish these reviews, the team reviewed selected documentation such as

condition reports, corrective action program closure documentation, original and revised

procedures, and training plans and training attendance records. In addition, the team

conducted interviews of cognizant licensee personnel to determine whether actions had

been accomplished.

11.1

DAMP Item D.1.6

a.

Inspection Scope

The team reviewed DAMP Item D.1.6: Perform an external assessment of the

Corrective Action Program (CAP) (04-02468-46).

To determine whether this DAMP item had been adequately implemented, the team

reviewed condition reports, corrective action program closure documentation, and

self-assessment records. In addition, the team conducted interviewed cognizant

licensee personnel to determine whether actions had been accomplished. In particular,

the team reviewed Self-Assessment SA 761 PYRC-2005 Perry Corrective Action

Program Self-Assessment.

b.

Observations and Findings

No findings of significance were identified and the team concluded that the licensees

actions adequately implemented DAMP Item D.1.6.

The team reviewed SA 761 PYRC-205, Perry Corrective Action Program

Self-Assessment, and determined that it provided a thorough assessment of the

corrective action program.

Enclosure

35

However, the team could not determine whether the assessment could be considered as

having been performed externally since two of the five self-assessment auditors were

licensee staff members and the licensee had not defined the requirements for a

self-assessment to be considered externally conducted. Licensee personnel generated

CR 06-00613 NRC Definition of External is Different Than What They Observed, to

enter this issue into the corrective action program.

In addition to documentation associated with this DAMP item, the team reviewed the

results of two licensee audits and a Corrective Action Program Summit meeting that

were conducted to identify additional areas for improvement in the corrective action

program. The audit results identified many of the same issues identified by the team. In

some cases, corrective actions were planned, but had not been implemented prior to

this inspection. Although the licensees corrective actions to address the issues had not

been implemented, these actions represented additional licensee efforts to improve the

implementation of the corrective action program.

11.2

DAMP Item D.9.2

a.

Inspection Scope

The team reviewed DAMP Item D.9.2: Develop a method to assign clear,

single point ownership of root cause CRs, from CR investigation through

CA implementation/effectiveness review completion for each root cause

CR (04-02468-69).

To determine whether this DAMP item had been adequately implemented, the

team reviewed condition reports and corrective action program closure documentation.

In addition, the team conducted interviews of cognizant licensee personnel to

determine whether actions had been accomplished. In particular, the team reviewed

CA 04-02468-69 and discussed its contents with the Performance Improvement

Unit (PIU) supervisor, and reviewed NOP-LP-2001, Condition Report Process.

b.

Observations and Findings

No findings of significance were identified; however, the team concluded that the

licensees actions had not adequately implemented DAMP Item D.9.2.

Corrective Action 04-02468-69 was generated to implement DAMP 9.2 and stated that

the corrective action was to develop a method to assign clear, single point ownership of

root cause CRs... The team determined that CR 04-02468 had been closed as an

intervention action and a method to assign clear, single point ownership had not been

developed.

The PIU supervisor informed the team that the issue of ownership had been discussed

with the CARB and the MRB. The subject condition report assigned the responsibility

for completing the associated corrective action to CARB and identified that this item had

been added to the agenda as a standing item for the 1st Thursday of each month. The

Enclosure

36

PIU supervisor also stated the action was not proceduralized as it was an intervention

action. In addition, the individual who closed CR 04-02468 stated that the issue was

only applicable to a limited number of CRs and was not intended to be a long-term

corrective action.

The team determined that Section 4.7.1 of NOP-LP-2001 required that the MRB validate

or establish a CR condition owner. Further, if a root cause evaluation was determined to

be warranted to review the issue(s) identified in the CR, the MRB was required to

ensure a director level individual was designated as root cause sponsor.

The team identified that although Step 4.4.3.5 of NOP-LP-2001 prescribed the selection

of a Condition Owner, the owners responsibilities were not defined. In addition, the

team was unable to identify in NOP-LP-2001 or other documents where one individual

was identified with the responsibilities as prescribed by the DAMP item. In particular,

the team was unable to identify any documentation that defined an individual as being a

single point owner of root cause CRs, from CR investigation through CA

implementation and effectiveness review completion for each root cause CR. Licensee

personnel generated CR 06-00767, Corrective Action Alternately Closed Without

Proper Approval, to enter this issue into the corrective action program.

The team concluded that due to a lack of quality and attention to detail, licensee

personnel failed to identify that this DAMP item had not been adequately implemented

during the DAMP item review and closure process. However, because the inadequate

closure of DAMP Item D.9.2 had no actual impact on the facility, the issue was of only

minor significance.

11.3

DAMP Item D.11.1

a.

Inspection Scope

The team reviewed DAMP Item D.11.1: A two-step screening process is being

implemented to improve timeliness of issue entry into CAP and more accurate

prioritization (04-02468-66).

To determine whether this DAMP item had been adequately implemented, the team

reviewed condition reports, corrective action program closure documentation, original

and revised procedures, and meeting schedules and minutes. In addition, the team

conducted interviews of cognizant licensee personnel to determine whether actions had

been accomplished. In particular, the team reviewed PYBP-SITE-0045, Initial

Screening Committee, and attended a MRB meeting on February 7, 2006.

b.

Observations and Findings

No findings of significance were identified and the team concluded that the licensees

actions adequately implemented DAMP Item D.11.1.

Enclosure

37

By direct observation, the team determined that the licensee had implemented a

two-step screening process for condition reports that improved the timeliness of issue

entry and resulted in more accurate prioritization. Through this process, a condition

report was sent to the Initial Screening Committee (ISC) for review and discussion, and

then to the Management Review Board (MRB) for final approval. Subsequently, the

MRB ensured that the condition report was appropriately screened for Category,

Assigned Group, and Due Date. The MRB also discussed complicated and/or

significant condition reports. The ISC was instituted by procedure, with required training

for its members, and was accountable to the MRB.

12.0

Key Performance Indicators (KPIs)

a.

Inspection Scope

The team reviewed existing corrective action program performance indicators to

evaluate the quality of the indicators, the licensees use of the corrective action program

when indicators suggested a decline in corrective action program performance, and the

overall performance of the corrective action program based upon the licensees KPI

data.

b.

Observations and Findings

No findings of significance were identified.

The team verified that KPIs for the corrective action program had been developed and

were adequately maintained. The KPIs defined thresholds for acceptable performance

for specific corrective action program functions and tracked actual numbers or

percentages against the pre-defined thresholds. The performance level for each KPI

were color-coded (green, white, yellow, red) to facilitate performance monitoring. Based

on a review of the most recently issued KPIs, in general, the KPIs reflected an improving

performance trend.

The licensees expectation for yellow or red KPIs was that a condition report should be

generated and corrective actions should be implemented to address the issue. The

team reviewed a number of condition reports that had been generated to document red

and yellow KPIs. The corrective action program was used to track the development and

implementation of corrective actions to improve performance. The team also noted a

number of actions had been implemented to improve corrective action program

performance when program performance expectations were not met. Management

feedback to corrective action owners, the appointment of management sponsors for

corrective action program products, and the analysis and development of a closure plan

to address KPI performance gaps were all examples of actions implemented to address

corrective action program performance issues. However, a formal mechanism to

address KPI issues within the licensees corrective action program did not exist. In

particular, licensee personnel had not developed written guidance that prescribed the

generation of a condition report to address declining KPIs, performance gaps between

actual and expected performance, the development of action plans to reduce the gap

Enclosure

38

between actual and expected performance, or the tracking of the success of action

plans to address identified performance deficiencies. Although specific guidance did not

exist, the team did not identify any declining KPIs for which appropriate corrective

actions had not been implemented.

The team concluded that the lack of a formal process to address KPI issues could

impact the long-term effectiveness of the actions. Licensee personnel generated

CR 06-00787, Inconsistencies With GAP Closure plans for Red/Yellow CAP KPIs, to

enter this issue into the corrective action program.

13.0

Exit Meeting

On March 14, 2006, the team presented the inspection results to Mr. L. Pearce, Vice

President, and other members of his staff, who acknowledged the findings and

observations.

The team asked the licensee whether any materials examined during the inspection

should be considered proprietary. No proprietary information was identified.

Attachments: 1. Supplemental Information

2. Perry Performance Background

3. Perry IP 95003 Inspection Results

4. Summary of Phase 2 PII Initiatives

Attachment 1

1

SUPPLEMENTAL INFORMATION

KEY POINTS OF CONTACT

Licensee

G. Leidich, Chief Nuclear Office, FENOC

D. Pace, Senior Vice President, Fleet Engineering and Services, FENOC

J. Hagan, Chief Operating Officer, FENOC

J. Rinckel, Vice President, Oversight, FENOC

L. Pearce, Vice President, Perry

F. von Ahn, Plant Manager, Perry

F. Cayia, Director, Performance Improvement, Perry

T. Lentz, Director, Performance Improvement Initiative, Perry

J. Shaw, Director, Engineering, Perry

M. Wayland, Director, Maintenance, Perry

K. Howard, Manager, Design, Perry

J. Lausberg, Manager, Regulatory Compliance, Perry

J. Messina, Manager, Operations, Perry

LIST OF ITEMS OPENED, CLOSED, AND DISCUSSED

None.

Attachment 1

2

LIST OF DOCUMENTS REVIEWED

The following is a list of documents reviewed during the inspection. Inclusion on this list does

not imply that the NRC inspectors reviewed the documents in their entirety rather, that selected

sections or portions of the documents were evaluated as part of the overall inspection effort.

Inclusion of a document on this list does not imply NRC acceptance of the document or any part

of it, unless this is stated in the body of the inspection report.

Perry Business Practices:

PYBP-PII-0006, Process Improvement Initiative Process

PYBP-POS-1-11, Operations Section System Ownership

PYBP-SITE-0042, Corrective Action Closure Board Charter

PYBP-SITE-0045, Initial Screening Committee

PYBP-SITE-0046, Corrective Action Program Implementation Expectations

Nuclear Operating Business Practices:

NOBP-LP-2007, Condition Report Process Effectiveness Review

NOBP-LP-2008, Corrective Action Review Board

NOBP-LP-2008-01, Root Cause Review Summary

NOBP-LP-2011, FENOC Cause Analysis

NOBP-LP-2019, Corrective Action Program Supplemental Expectations and Guidance

NOBP-LP-2019, Attachment 1, (Condition Report Category and Activity Tracking Descriptions),

and Attachment 2, (Condition Report Evaluation Methods).

NOBP-TR-1111-01, Corrective Action program (CAP) Training Program

NOBP-SITE-0046, Corrective Action Program Implementation Expectations;

Nuclear Operating Procedures:

NOP-LP-2001, Corrective Action Program

NOP-LP-2100, Operating Experience Program

Condition Reports:

CR 05-02725, Substantive Cross-Cutting Issue, Problem Identification and Resolution

CR 05-03986, Nuclear Oversight Audit PY-C-05-01"

CR 05-08057, Disposition/Tracking of Personnel Not Trained Per CAPC-200501_PY

CR 06-00080, DAMP Items I.3.5 & I.8.4 Incomplete

CR 06-00576, DAMP Item I.2.2 Did Not Provide Complete Closure Documentation

CR 06-00589, No Indicators to Track Deltas From Condition Report Categorizations

CR 06-00604, DAMP Item I.3.3 Did Not Provide Complete Closure Documentation

CR 06-00613, NRCs Definition of External is Different Than What They Observed

CR 06-00630, No Process Exists to Prevent Inadvertent Changes to Closed PII Action

CR 06-00636, DAMP Item I.3.1 Inadvertent Omission from Attachment 1 of NOBP-LP-2019

CR 06-00697, DAMP Item I.3.4 Closed Correctly However, Reference CA Not Complete

CR 06-00767, Corrective Action Alternately Closed Without Proper Approval

CR 06-00784, Issues With Implementation of Revised CAP Training

CR 06-00787, Inconsistencies With GAP Closure Plans for Red/Yellow CAP KPIs

Attachment 1

3

Corrective Actions:

CA 04-02404-08

CA 04-02468-69

CA 05-07223-13

CA 05-07233-07

CA 05-07223-21

Self-Assessments:

Snapshot Assessment 810PII2005, Perry Nuclear Power Plant Performance Improvement

Initiative - Corrective Action Program Implementation Effectiveness,

Self-Assessment FL-SA-05-05, Self-Assessment of Integrated Performance Assessment

Trending, dated December 14, 2005

Self-Assessment SA 761 PYRC-2005 Perry Corrective Action Program Self-Assessment

Training Documents:

SSC-200502_PY-01, Supervisory Continuing Training

Training Plan 9903, Root Cause Evaluator

Training Plan 9908, Corrective Action Review Board (CARB) Member

Training Requirements CAP RCA_FEN, FENOC Root Cause Evaluation Basic Training

Training Requirements CAP-RCT_FEN, FENOC Root Cause Evaluation Advanced Training

Training Requirements CAP-JFGRCE_FEN, Root Cause Evaluator Job Familiarization Guide

ESPC-SYS0503_PY, System Walkdown Refresher Training

FITS Qualification Matrices associated with Root Cause Evaluators and CARB Members

Job Familiarization Guide (JFG) GEN_JFGSOEC_FEN-01, Section Operating Experience

Coordinator Job Familiarization Guideline

Other Documents:

FENOC Performance Appraisal Elements

CAPC-200501-PY, Corrective Action Program Implementation Improvement

CAP Improvement Plan: Communications Roadmap

FENOC CR Initiation Guidance

PESP-9, System Walkdowns

Apparent Cause Expectation brochure

Criteria for CAP Focus Day

CARB meeting minutes, dated September 2005 and October 2005

CACB meeting agenda, dated October 20, 2005

CARB review package, dated November 4, 2005

CACB and CARB overview, dated October 31, 2005

Condition Report Analyst Meeting Agenda, dated November 3, 2005

Attachment 1

4

LIST OF ACRONYMS USED

ACE

Apparent Cause Evaluation

CA

Corrective Action

CACB

Corrective Action Closure Board

CAL

Confirmatory Action Letter

CAP

Corrective Action Program

CARB

Corrective Action Review Board

CFR

Code of Federal Regulations

CR

Condition Report

DAMP

Detailed Action and Monitoring Plan

DB

Davis-Besse

ESW

Emergency Service Water

FENOC

FirstEnergy Nuclear Operating Company

FITS

FENOC Integrated Training System

HPCS

High Pressure Core Spray

IMC

Inspection Manual Chapter

INPO

Institute for Nuclear Power Operation

IP

Inspection Procedure

IR

Inspection Report

ISC

Initial Screening Committee

JFG

Job Familiarization Guidelines

KPI

Key Performance Indicators

LPCS

Low Pressure Core Spray

MPR

Monthly Performance Review

MRB

Management Review Board

MRC

Management Review Committee

NOBP

Nuclear Operating Business Practice

NOP

Nuclear Operating Procedure

NRC

Nuclear Regulatory Commission

OE

Operating Experience

PARS

Publicly Available Records

PESP

Plant Engineering Section Policy

PI

Performance Indicator

PII

Performance Improvement Initiative

PIU

Performance Improvement Unit

PNPP

Perry Nuclear Power Plant

PYBP

Perry Business Practice

RCA

Root Cause Analysis

RCE

Root Cause Evaluation

RHR

Residual Heat Removal

SCAQ

Significant Condition Adverse to Quality

SLT

Senior Leadership Team

TS

Technical Specification

1

PERRY PERFORMANCE BACKGROUND

As discussed in the Perry Annual Assessment Letter dated March 4, 2004, plant performance

was categorized within the Degraded Cornerstone column of the NRCs Action Matrix based on

two White findings in the Mitigating Systems cornerstone. An additional White finding in the

Mitigating Systems cornerstone was subsequently identified and documented by letter dated

March 12, 2004.

The first finding involved the failure of the high pressure core spray (HPCS) pump to start

during routine surveillance testing on October 23, 2002. An apparent violation of Technical Specification (TS) 5.4 for an inadequate breaker maintenance procedure was identified in

IR 05000440/2003008. This performance issue was characterized as White in the NRC's

final significance determination letter dated March 4, 2003. A supplemental inspection was

performed in accordance with IP 95001 for the White finding and significant deficiencies

were identified with regard to the licensee's extent of condition evaluation. Inspection

Procedure 95001 was re-performed and the results of that inspection were documented in

IR 05000440/2003012, which determined that the extent of condition reviews were adequate.

The second finding involved air-binding of the low pressure core spray(LPCS)/residual heat

removal (RHR) 'A' waterleg pump on August 14, 2003. A special inspection was performed for

this issue and the results were documented in IR 05000440/2003009. An apparent violation of

TS 5.4 for an inadequate venting procedure was identified in IR 05000440/2003010. This

performance issue was characterized as White in the NRC's final significance determination

letter dated March 12, 2004.

The third finding involved the failure of the 'A' Emergency Service Water (ESW) pump, caused

by an inadequate maintenance procedure for assembling the pump coupling that contributed to

the failure of the pump on September 1, 2003. An apparent violation of TS 5.4 was

documented in IR 05000440/2003006. This performance issue was characterized as White in

the NRC's final significance determination letter dated January 28, 2004.

As documented in IP 95002 Supplemental Inspection Report 05000440/2004008, dated

August 5, 2004, which reviewed the licensees actions to address these issues, the NRC

concluded that the corrective actions to prevent recurrence of a significant condition adverse to

quality (SCAQ) were inadequate. Specifically, the same ESW pump coupling that failed on

September 1, 2003, failed again on May 21, 2004. This resulted in the ESW pump White

finding remaining open.

As a result, Perry entered the Multiple/Repetitive Degraded Cornerstone column for Mitigating

Systems in the Reactor Safety strategic performance area for having two White inputs for five

consecutive quarters. Specifically, for the third quarter of 2004, the waterleg pump finding

remained open a fourth quarter while the ESW pump finding was carried open into a fifth

quarter as a result of the findings of the IP 95002 supplemental inspection.

Attachment 2

1The NRCs Action Matrix is described in Inspection Manual Chapter 0305, Operating

Reactor Assessment Program.

1

PERRY IP 95003 INSPECTION RESULTS

As a result of poor performance, the Nuclear Regulatory Commission (NRC) designated the

Perry Nuclear Power Plant (PNPP), owned and operated by FirstEnergy Nuclear Operating

Company, as a Multiple/Repetitive Degraded Cornerstone Column facility in the NRCs Action

Matrix1 in August 2004. Accordingly, a supplemental inspection was performed in accordance

with the guidance in NRC Inspection Manual Chapter (IMC) 0305 and Inspection Procedure (IP) 95003, Supplemental Inspection for Repetitive Degraded Cornerstones, Multiple Degraded

Cornerstones, Multiple Yellow Inputs, or One Red Input.

In addition, the scope of the IP 95003 inspection included the review of licensee actions to

address deficiencies identified during a previous IP 95002 inspection. In particular, the NRC

reviewed the licensees root cause and corrective actions to address the areas of procedure

adequacy, procedure adherence, and training deficiencies identified in the previous IP 95002

inspection; as well as the problem identification, root cause review, and corrective actions to

address repetitive emergency service water (ESW) pump coupling failures.

By letter dated September 30, 2004, FirstEnergy advised the NRC that actions were underway

to improve plant performance. To facilitate these performance improvements, FirstEnergy

developed the Perry Performance Improvement Initiative (PII). As part of the NRC's IP 95003

inspection, the team conducted a detailed review of the PII.

As documented in IP 95003 Supplemental Inspection Report 50-440/2005003, the NRC

determined Perry was being operated safely. The NRC also determined that the programs and

processes to identify, evaluate, and correct problems, as well as other programs and processes

in the Reactor Safety strategic performance area were adequate. Notwithstanding these overall

conclusions, the NRC determined that the performance deficiencies that occurred prior to and

during the inspection were often the result of inadequate implementation of the corrective action

program (CAP) and human performance errors.

The team identified that a number of factors contributed to CAP problems. A lack of rigor in the

evaluation of problems was a major contributor to the ineffective corrective actions. For

example, in the engineering area, when problems were identified, a lack of technical rigor in the

evaluation of those problems at times resulted in an incorrect conclusion, which in turn affected

the ability to establish appropriate corrective actions. The team also determined that corrective

actions often were narrowly focused. In many cases a single barrier was established to prevent

a problem from recurring. However, other barriers were also available that, if identified and

implemented, would have provided a defense-in-depth against the recurrence of problems. The

team also identified that problems were not always appropriately prioritized, which led to the

untimely implementation of corrective actions. A number of programmatic issues were

identified that have resulted in the observed CAP weaknesses. For example, the team

identified a relatively high threshold for classifying deficiencies for root cause analysis. As a

result, few issues were reviewed in detail. In addition, for the problems that were identified that

Attachment 3

2

required a root cause evaluation, the team found that the qualification requirements for root

cause evaluators were limited and multi-disciplinary assessment teams were not required. The

team also identified that a lack of independence of evaluators existed. This resulted in the

same individuals repeatedly reviewing the same issues without independent and separate

review. In addition, the team identified weaknesses in the trending of problems, which has

hindered the ability to correct problems at an early stage before they become more significant

issues. Finally, the team determined that a lack of adequate effectiveness reviews was a

barrier to the identification of problems with corrective actions that had been implemented.

Overall, the NRC concluded that while some limited improvements may have been realized,

there has been no substantial improvement in the licensees implementation of the corrective

action program since Perry entered the Multiple/Repetitive Degraded Cornerstone column of

the NRCs Action Matrix.

In the area of human performance, the team determined that a number of self-revealed

findings relating to procedure adherence occurred that had a strong human performance

contribution. These findings emanated from events that have resulted in an unplanned

engineered safety feature actuation, a loss of shutdown cooling, an unplanned partial drain

down of the suppression pool, inadvertent operation of a control rod (a reactivity event), and

other configuration control errors. The team reviewed the events that occurred during the

inspection and identified that the procedure adherence problems had a number of common

characteristics. In a number of cases, personnel failed to properly focus on the task at hand.

Although pre-job briefings were held prior to many events, and procedures were adequate to

accomplish the intended activity, personnel failed to sufficiently focus on the individual

procedure step being accomplished and performed an action outside of that prescribed by the

procedure. In some cases, the team determined that a lack of a questioning attitude

contributed to the procedure problems that occurred. Although information was available to

personnel that, if fully considered, could have prevented the procedure adherence issues that

occurred, that information was not sought out or was not questioned. The presence of

supervisors with the necessary standards to foster good procedure adherence could have acted

as a significant barrier to prevent some of the problems that occurred. However, adequate

supervisory oversight was not always available or used. Further, the team identified that

available tools for assessing human and organizational performance had not been effectively

used. Overall, the NRC concluded that while some limited improvements may have been

realized, there has been no substantial improvement in human performance since Perry

entered the Multiple/Repetitive Degraded Cornerstone column of the NRCs Action Matrix.

In the area of design, the IP 95003 inspection team concluded that the systems, as designed,

built, and modified, were operable and that the design and licensing basis of the systems were

sufficiently understood. Notwithstanding the overall acceptability of performance in the

engineering area, the team identified common characteristics in a number of problems

identified during the inspection. These characteristics included a lack of technical rigor in

engineering products that resulted in an incorrect conclusion. Also, there appeared to be a lack

of questioning by the licensee staff of some off-normal conditions. Finally, weaknesses in the

communications between engineering and other organizations such as operations and

maintenance sometimes hindered the resolution of problems.

Attachment 3

3

In the area of procedure adequacy, the team determined that the licensees procedures to

safely control the design, maintenance, and operation of the plant were adequate, but

warranted continued management focus and resource support. In particular, process-related

vulnerabilities in areas such as periodic plant procedure reviews, procedure revisions, and use

classifications were identified by the team.

In the area of equipment performance, the team acknowledged that the licensee had completed

numerous recent plant modifications to improve equipment performance. In addition, improved

engineering support and management oversight of equipment performance were noted.

Notwithstanding the above, the team identified numerous examples that indicated that the

resolution of degraded equipment problems and implementation of the CAP continued to be a

challenge to the organization.

In the area of configuration control, the team identified numerous examples that indicated the

resolution of configuration control issues and implementation of the CAP continued to be a

challenge to the organization. The team agreed with the licensees assessment that continuing

configuration control problems were primarily the result of inappropriate implementation of

procedural requirements rather than the result of configuration management procedural

shortcomings. However, given the on-going errors associated with equipment alignment, as

well as multiple errors associated with maintenance configuration control such as scaffolding

erection, the team concluded that adequate evaluations of the root causes of configuration

control errors had not been performed. The team also concluded that the licensee lacked rigor

in its efforts to resolve latent configuration control issues. Several licensee-identified issues

have not been corrected, and contributed to configuration control shortcomings.

In addition, in the area of emergency preparedness, the team determined that there were some

performance deficiencies associated with the licensees implementation of the Emergency Plan.

A number of findings were identified in which changes to the Emergency Plan or Emergency

Action Levels were made without required prior NRC approval. In addition, the results of the

augmentation drill where personnel were called to report to the facility for a simulated

emergency were unsatisfactory.

With regard to the NRC's review of issues associated with the previous IP 95002 inspection, the

NRC determined that actions to address procedure adequacy and ESW pump failures was still

in progress at the end of the IP 95003 inspection. In particular, the team identified that one of

the licensees corrective actions to address the verification of the quality of ESW pump work

was inadequate. In addition, in light of the continuing problems in human performance and the

impact on procedure adherence, the team concluded that actions to address procedure

adherence had not been fully effective. Finally, actions to address training were also still in

progress at the end of the inspection. In this case, the licensees corrective actions to address

this issue had not been timely and at the conclusion of the IP 95003 inspection, had not yet

been implemented. As a result, the NRC concluded that the open White findings associated

with the IP 95002 inspection would continue to remain open pending additional licensee actions

and the NRCs review of those actions.

In the assessment of the licensees performance improvements planned and implemented

through the Perry PII, the team determined that the Perry PII had a broad scope and addressed

Attachment 3

4

many important performance areas. The IP 95003 inspection team also observed that,

although substantially completed, the PII had not resulted in significant improvement in plant

performance in several areas. There were a number of reasons identified as why this occurred,

one being that the PII was largely a discovery activity, and as such, many elements of the PII

did not directly support improving plant performance. Instead, the problems identified through

the PII reviews were entered into the CAP and the proper resolution of these problems

depended upon the proper implementation of the CAP. During the IP 95003 inspection, the

NRC identified that in some cases the CAP had not been implemented adequately to address

the concerns identified during PII reviews. The team identified that although many PII actions

have been completed, some of the more significant assessments, such as in the area of human

performance, were still in progress at the end of the inspection.

Overall, based on the factors discussed above, the NRC was unable to draw any definitive

conclusions regarding the overall effectiveness of the Perry PII. As a result, further reviews

were deemed to be necessary to determine whether the PII was sufficient to address and

resolve the specific issues identified.

Attachment 3

1

SUMMARY OF PHASE 2 PII INITIATIVES

To correct the identified declining trends in performance at Perry, the Perry Phase 2 PII was

structured around the following six key improvement initiatives:

Corrective Action Program Implementation Improvement

As described in the Phase 2 PII, the Corrective Action Program Implementation Improvement

initiative was designed to drive ownership and accountability for the corrective action program

(CAP) deep into the PNPP organization. The initiative was aimed at driving behavior changes

to increase ownership and accountability of the corrective action program to solve plant issues.

Key objectives of this initiative included improvement in the following areas:

ownership and station focus,

management and oversight of the corrective action program,

prioritization of issues and resolution activities,

trending capability,

backlog management,

quality of corrective actions and documentation,

individual accountability, and

corrective action work assignment and resource utilization.

Excellence in Human Performance

As described in the Phase 2 PII, the Excellence in Human Performance initiative was designed

to clarify standards and expectations for human performance, establish line ownership,

alignment, and integration of the Institute for Nuclear Power Operation (INPO) Performance

Model, and strengthen line accountability for human performance. Key objectives of this

initiative included improvement in the following areas:

performance expectations,

line ownership, alignment, and integration, and

line accountability of results.

Training to Improve Performance

As described in the Phase 2 PII, the Training to Improve Performance initiative was targeted at

improving both PNPP Skills Training and Operator Training Programs to improve plant and

personnel performance. Key objectives of this initiative included the following:

establish training as a dominant tool to improve station performance, and

develop a comprehensive plan to help line and training managers return the

performance of Perry's training programs to a level consistent with current industry

standards.

Attachment 4

2

Effective Work Management

As described in the Phase 2 PII, the Effective Work Management initiative was designed to

provide a site-wide systematic and focused effort to drive improvements in work management.

The initiative was intended to implement improvements in the selection, preparation, and

execution of work to achieve excellence in work management. Key objectives of this initiative

included the following:

a long range plan for equipment performance,

contingency planning guidance and execution,

strong use of operating experience in work packages,

improvement in outage preparation and execution, and

control of contract workers.

Employee Engagement and Job Satisfaction

As described in the Phase 2 PII, the Employee Engagement and Job Satisfaction Initiative was

designed to increase employee contribution to PNPP success by creating and environment in

which all employees can make a meaningful contribution and feel pride and a sense of

accomplishment in their work. Key objectives of this initiative included the following:

employee involvement in Phase 2 PII activities,

leadership behaviors and performance management,

leadership assessment and development, and

use of overtime.

Operational Focused Organization

As described in the Phase 2 PII, the Operational Focused Organization initiative was designed

to improve the operational focus of the PNPP organization to achieve a higher order of safe and

reliable operation. Key objectives of this initiative included the following:

fundamental skills and behaviors required for safe and reliable operation,

operations-led organization,

alignment of goals and priorities,

strong craft ownership and engineering presence, and

operations resources replenishment planning.

Attachment 4