IR 05000313/2019014

NRC Confirmatory Order (EA 17 132 and EA 17-153) Follow-Up Inspection Report 05000416/2019012; Arkansas Nuclear One, Units 1 and 2-Nrc Confirmatory Order (EA 17 132 and Ea-17-153) Follow-Up Inspection Report 05000313/2019014

ML19094B867
Person / Time
Site:	Grand Gulf, Arkansas Nuclear, River Bend, Waterford
Issue date:	04/04/2019
From:	Anton Vegel NRC/RGN-IV/DRP
To:	Ventosa J Entergy Nuclear Operations
References
EA-17-132, EA-17-153 IR 2019012, IR 2019013, IR 2019014
Download: ML19094B867 (22)

Text

April 4, 2019 EA-17-132 EA-17-153 Mr. John Chief Operating Officer South Entergy Nuclear 1340 Echelon Parkway Mailstop Code: M-ECH-66 Jackson, MS 39213 SUBJECT: GRAND GULF NUCLEAR STATION - NRC CONFIRMATORY ORDER (EA-17-132 AND EA-17-153) FOLLOW-UP INSPECTION REPORT 05000416/2019012 ARKANSAS NUCLEAR ONE, UNITS 1 AND 2 - NRC CONFIRMATORY ORDER (EA-17-132 AND EA-17-153) FOLLOW-UP INSPECTION REPORT 05000313/2019014 AND 05000368/2019014 RIVER BEND STATION - NRC CONFIRMATORY ORDER (EA-17-132 AND EA-17-153) FOLLOW-UP INSPECTION REPORT 05000458/2019013 WATERFORD STEAM ELECTRIC STATION, UNIT 3 - NRC CONFIRMATORY ORDER (EA-17-132 AND EA-17-153) FOLLOW-UP INSPECTION REPORT 05000382/2019012

Dear Mr. Ventosa:

On January 10, 2019, the U.S. Nuclear Regulatory Commission (NRC) completed its onsite review of your progress in implementing the actions that were directed by a Confirmatory Order (CO), dated March 12, 2018 (NRCs Agencywide Documents Access and Management System (ADAMS) Accession No. ML18072A191) (EA-17-132 and EA-17-153). The team discussed the results of this inspection with you and other members of your staff on February 27, 2019. The team documented the results of this inspection in the enclosed inspection report.

The team reviewed Entergy Operations, Inc.s fleet-wide actions implementing the items directed by the CO, focusing on the actions that were required to be completed by December 31, 2018. The team used Inspection Procedure 92702, Follow-up on Traditional Enforcement Actions Including Violations, Deviations, Confirmatory Action Letters, Confirmatory Orders, and Alternative Dispute Resolution Confirmatory Orders. The inspection included a review of fleet-wide communications, root cause evaluations, corrective actions, and effectiveness reviews to address willful violations that have occurred across the Entergy Operations, Inc.s fleet and prevent similar willful violations in the future. The attached report documents observations related to those actions.

Since the CO defines actions that are to occur over a 3-year period, the NRC intends to monitor your development and implementation of actions to comply with the requirements in the CO, including any changes made in response to the observations in this report during future inspections. The team did not identify any findings or violations of more than minor significance.

In response to the NRCs inspection observations, Entergy Operations, Inc., submitted a letter, dated March 21, 2019 (ADAMS Accession No. ML19081A270), that delineated additional commitments to address issues of willful misconduct as stated in paragraph 4OA5.1.3 of the attached inspection report. If your understanding of these commitments differs from that of the NRC, please contact Jason Kozal at (817) 200-1144 at your earliest convenience.

This letter, its enclosure, and your response (if any) will be made available for public inspection and copying at http://www.nrc.gov/reading-rm/adams.html and at the NRC Public Document Room in accordance with 10 CFR 2.390, Public Inspections, Exemptions, Requests for Withholding.

Sincerely,

/RA Michael C. Hay Acting for/

Anton Vegel, Director Division of Reactor Projects Docket Nos. 05000313; 05000368; 05000382; 05000416; and 05000458 License Nos. DPR-51, NPF-6, NPF-29; NPF-47; NPF-38

Enclosure:

Inspection Reports 05000313/2019014, 05000368/2019014, 05000382/2019012, 05000416/2019012, and 05000458/2019013 w/ Attachments: Supplemental Information

REGION IV==

Docket Numbers: 05000313; 05000368; 05000382; 05000416; 05000458 License Numbers: DPR-51, NPF-6, NPF-29; NPF-47; NPF-38 Report Numbers: 05000313/2019014; 05000368/2019014; 05000382/2019012 05000416/2019012; 05000458/2019013 Enterprise Identifiers: I-2019-014-0000; I-2019-01-0008; I-2019-012-0007; I-2019-013-0003 Licensee: Entergy Operations, Inc.

Facility: Entergy Headquarters (Echelon)

Dates: January 7 through February 27, 2019 Team Lead: D. Proulx, Senior Project Engineer Inspector: J. Dixon, Senior Project Engineer Approved By: J. Kozal Chief, Project Branch C Division of Reactor Projects Enclosure

SUMMARY

The U.S. Nuclear Regulatory Commission (NRC) continued monitoring the licensees performance by conducting a follow-up inspection at the Entergy Operations, Inc., headquarters in Jackson, MS, in accordance with the Reactor Oversight Process. The Reactor Oversight Process is the NRCs program for overseeing the safe operation of commercial nuclear power reactors. Refer to https://www.nrc.gov/reactors/operating/oversight.html for more information.

The inspection activities described in this report were performed between January 7, 2019, and February 27, 2019, by inspectors from the NRCs Region IV office. The NRCs program for overseeing the safe operation of commercial nuclear power reactors is described in NUREG-1649, Reactor Oversight Process, dated July 2016.

The team reviewed the actions due to be completed by December 31, 2018, as required by the Confirmatory Order (EA-17-132 and EA-17-153). The team had several observations with respect to the fleet-wide implementation of the actions.

No findings were identified.

REPORT DETAILS

4OA5 Other Activities

Confirmatory Order Follow-up (IP 92702)a. Background In November 2017, the NRC proposed three traditional enforcement apparent violations involving deliberate misconduct, which were associated with general employee training examination proctoring and falsification of non-licensed operator rounds at Grand Gulf Nuclear Station. An alternative dispute resolution (ADR)mediation was conducted on February 6, 2018. A Confirmatory Order (CO)

(Agencywide Documents Access and Management System (ADAMS) Accession No. ML18072A191) (EA-17-132 and EA-17-153) was issued on March 12, 2018, which contained actions to be implemented fleet-wide by Entergy Operations, Inc.

(EOI) as agreed upon during ADR. These actions included commitments to conduct fleet-wide communications to employees at all Entergy sites, training, causal evaluations, and organizational health surveys.

Between January 7 and January 10, 2019, the NRC conducted an initial inspection using Inspection Procedure 92702 to assess the licensees actions to comply with the CO, with emphasis on actions due to be completed by December 31, 2018, and reviewing samples of actions implemented at Entergy South plants.

b. Confirmatory Order Items The team reviewed the following CO elements that were due for completion by December 31, 2018:

.1 Communications with Site Workers

Element A Within 1 month of the issuance date of the Confirmatory Order, a licensee senior executive at each Entergy site and the corporate nuclear headquarters will communicate with workers the circumstances leading to this Confirmatory Order, that willful violations will not be tolerated, and, as a result, Entergy will be undertaking efforts to confirm whether others are engaging in such conduct at any of its sites. The communication will stress the importance of procedural adherence, ensuring that documents are complete and accurate, and of potential consequences for engaging in willful violations. This message will be balanced with the recognition that people do make mistakes and when that happens, it is Entergys expectation that its employees and contractors will identify and document issues accordingly.

Element B Within 6 months of the completion of Element A, Entergy will conduct semiannual communications with workers in the Entergy fleet reemphasizing its intolerance of willful misconduct and updating the workforce on the status of compliance with this Confirmatory Order until December 31, 2019. Starting in 2020, Entergy will conduct annual training emphasizing its intolerance of willful misconduct.

.1 Observations

Based on the CO issue date (March 12, 2018), the communications with site workers to meet Elements A and B were due on April 12 and October 12, 2018, respectively. By April 3 and September 27, 2018, respectively, all Entergy south sites and corporate headquarters completed actions intended to meet these requirements by issuing site-wide e-mails. The first set of e-mails included an attached video from the Chief Nuclear Officer (CNO).

• For Element A, each of the site vice presidents communicated to their respective sites via all employee e-mails in March of 2018 known as Nuclear Talk. The scope of these e-mails varied and did not always cover each of the specific topics listed in the CO. In communication e-mails for Arkansas Nuclear One and Grand Gulf, the discussion of willful actions was raised after several paragraphs that discussed general plant topics such as outage status. Attached to the e-mail was a link to a video by the CNO reiterating these points. The team noted that Entergy Operations, Inc. (EOI) had no method to verify if employees read the e-mail and had no planned actions to determine if the message was received and understood by EOI workers

• Entergy Operations, Inc., credited communicating the information by sending e-mails to meet the requirements of the CO. The team noted that this method of delivery of the intended information had the following limitations:

o None of the sites credited face-to-face communications in the form of all hands meetings or supervisor to worker briefings to meet this element, and EOI Corporate agreed that the e-mails were not a completely effective communication tool.

o The e-mails were sent to permanent EOI employees and long-term contractors. The team determined that many supplemental workers do not receive EOI e-mail, so a portion of the target population likely did not receive these e-mails.

o Entergy Operations, Inc., did not have a method to determine whether the e-mails were read and understood.

• The team noted that none of the Nuclear Talk e-mails issued for Element A discussed the need for workers and contractors to identify and document (i.e., write condition reports) willful issues, even though this was a required topic.

• For Element B, each of the licensees provided another all employee e-mail using Nuclear Talk to re-emphasize the unacceptability of willful actions.

A link was also provided to a CNO video that discussed the importance of integrity in EOI. The team noted the following:

o Three of the Nuclear Talk e-mails reviewed by the team were sent by the site vice-presidents. However, Grand Gulfs 6-month Nuclear Talk e-mail was sent by the Recovery Director rather than the senior site executive.

These e-mails included less detail than the initial e-mails. The CO required updating the workforce on the status of compliance with the CO. The team noted that the status provided was incomplete and lacked details. While the e-mail stated that the causal analyses were completed, it did not communicate that several corrective actions were already in place, procedure and process changes had been implemented, initial extent of condition audits to identity if any other willful actions occurred were complete and continuing audits had started. The CNO video also did not provide a detailed discussion of the current status of the CO.

Grand Gulfs 6-month Nuclear Talk e-mail started by discussing site recovery efforts for three paragraphs followed by a discussion of willful violations potentially diluting the intended message.

o River Bend Stations 6-month Nuclear Talk did not discuss the status of compliance with the CO.

o Subsequent to the onsite portion of this inspection, in response to these concerns, on January 21, 2019, EOI conducted a Tier 2 communication consisting of a face-to-face communication from supervisors to employees, that covered the items discussed in Element B of the CO. EOI did not maintain attendance records, so the team could not assess if a significant population of workers received the message.

• Entergy Operations, Inc., performed a fleet-wide Integrity Pulse Survey to gauge the value of its communications on willful misconduct. Entergy Operations, Inc. stated that it does not consider this to be an effectiveness review. The NRC was concerned that this survey did not appear to provide meaningful data, in that EOI sent the survey to 100 random employees at each Entergy site and Entergy Corporate, and received a very low response rate. It is unclear which site departments were represented, or whether or not the population included management, supervision, contractors, or outage workers. These responses were out of approximately 900-1000 employees at each site, not counting contractors.

Responses for Region IV Facilities:

ANO 31 Grand Gulf 81 River Bend 26 Waterford 25 Entergy Corporate 35 Of those who responded to the pulse survey, 86 percent said they knew there were integrity issues in EOI, 60 percent knew of the willful violations, and 20 percent knew that EOI had integrity issues in a general sense.

Only 12 percent of those responding said they had heard of integrity issues from the Nuclear Talk e-mails. Approximately 26 percent of the respondents said they watched the video from the CNO. Approximately 35 percent of the respondents knew of integrity issues because their supervisor discussed it with them. The remaining indicated that they had heard it from another employee in conversation. Based on these observations, Entergy Corporate personnel stated they would take additional actions to understand the results and improve the effectiveness of their communications, which is discussed below. As of the end of the on-site portion of this inspection, EOI did not have a plan to address this gap.

• Entergy Operations, Inc., plans to conduct the first effectiveness review of completed corrective actions in August 2019. The EOI end-of-year letter for 2018 stated no effectiveness reviews have been performed yet. At the time of this inspection, EOI did not have an effectiveness review planned for the communication aspects due to the various types and numbers of communication avenues that are being used to deliver the message.

Based on these observations and subsequent to the onsite portion of the inspection, the licensee stated that they would conduct early effectiveness reviews in May of 2019 to assess the effectiveness of the various communication methods.

.2 Conclusions

Based on the information available, the team was unable to conclude that the methods implemented by EOI to communicate the information and expectations delineated in this CO element were effectively delivered to a substantial majority of EOI workers. The method of delivery using e-mails did not appear to be effective to ensure the information was recognized and treated as important or were received and understood so they could reliably be expected to be acted upon. In some cases, the message was either not sent by a senior executive at the site or some of the required information was not included in the e-mails. Entergy Operations, Inc., provided the team with examples of additional communications, including all-hands meetings in which the subject of integrity and willful violations was discussed. Entergy Operations, Inc., did not document the attendance or the content of the meetings, so the value of these meetings could not be assessed.

Entergy Corporate initiated Condition Reports CR-HQN-2019-00039 and -00056 to address the teams observations.

.3 Entergy Response Letter

In response to these observations, EOI submitted letter CNRO-2091-00013, dated March 21, 2019, which made the following formal commitments:

(1) Entergy developed a plan to strengthen documentation of the two remaining required semi-annual integrity communications. Entergy will utilize the Tier 2 Communication process to ensure that the communications are delivered in a timely manner. Entergy will record the receipt and acknowledgement of these communications for future traceability. These communications will be conducted to meet the semiannual communications required of Element B of the CO in April and October 2019.

(2) Element D of the Confirmatory Order requires Entergy to identify specific criteria necessary to perform annual effectiveness reviews. As part of these effectiveness reviews, Entergy will conduct surveys to ensure the integrity messages have been received and understood. Entergy will modify its corrective actions, as needed, based on the results of the effectiveness reviews. This effectiveness review is scheduled for completion on December 31, 2019.

.2 Causal Evaluation of Previous Corrective Actions to Deter Willful Violations

A. Element C Within 6 months of the issuance date of the Confirmatory Order, Entergy will perform a causal evaluation, informed by site evaluations, to determine why prior fleet-wide corrective actions from Confirmatory Orders and other willful violations issued after January 1, 2009, were not fully successful in preventing or minimizing instances of willful misconduct across the fleet. The causal evaluation will include the following elements:

1. Problem identification 2. Root cause, extent of condition (including an assessment of work groups that perform NRC-regulated activities to determine whether those workers are engaging in willful misconduct), and extent of cause evaluation 3. Corrective actions, with time frame for their completion 4. Safety culture attributes

.1 Observations

Based on the CO issue date (March 12, 2018), the causal evaluation of previous corrective actions to deter willful violations was due on September 12, 2018. By August 28, 2018, Entergy completed actions intended to meet this combined fleet-wide action in the root cause analysis associated with Entergy Corporate Condition Reports CR-HQN-2017-1968 and CR-HQN-2018-1210.

• Entergy performed site root cause evaluations at Grand Gulf, River Bend, Waterford, and at the Entergy Corporate level. No causal evaluation was performed at Arkansas Nuclear One since no indications of wrongdoing were identified during Entergys review. Subsequently, Entergy Corporate performed two separate root causes: one for Fleet Integrity Events, updated based on the results of the site root causes, and one for Ineffective Actions on Willful Misconduct. The causal evaluations between the sites and Entergy Corporate were aligned and appeared adequate to identify the root and contributing causes. It is evident that the site causal evaluations informed the Entergy Corporate causal evaluations.

• The individual sites and Entergy Corporate root cause evaluations identified the same root cause: The fleet did not have adequate methods in place to prevent and detect deliberate misconduct from occurring during operator rounds and proctoring.

• Contributing causes from the individual sites and Entergy Corporate root cause evaluations were generally aligned but there were some differences which were unique to each site. The Waterford root cause evaluation included some insights related to contributing causes that were different than those identified in the Entergy Corporate root cause evaluation.

Specifically, the Waterford evaluation noted that fleet leadership failed to detect that significant integrity events that occurred between 2009 and 2014 were representative of a larger fleet concern rather than the result of individual actions alone. The Entergy Corporate root cause only considered events that had occurred since 2011.

• The Waterford root cause evaluation also identified a contributing cause that Waterford missed the opportunity to identify the willful misconduct associated with non-licensed operator rounds. The extent of condition review performed for the root cause evaluation for falsified fire watch rounds should have identified the non-licensed operators. The falsified fire watch rounds was the subject of a different Confirmatory Order (EA-15-100) (Accession No. ML16096A474) that was issued on April 6, 2016, and the letter documenting that the requirements of the CO were met was issued on September 7, 2018 (Accession No. ML18253A135).

• The team concluded that the extent of condition/cause evaluations reasonably identified organizations and specific activities where the conditions that could allow for falsification to exist but not be detected.

However, the team determined that the extent of condition review is not complete. Rather than complete the extent of condition review as part of the causal evaluations, the cause evaluations were completed, and a decision was made to perform audits at a future date. In addition, the initial screening was based on auditable activities, and it is unclear how EOI intends to use the information identified during audit activities because no process was developed. As a result, the team was unable to evaluate the actual extent of condition and whether or not the corrective actions are adequate. The results of future audits and how EOI incorporates the results into effectiveness reviews will be a focus of a future NRC inspection.

• Instead, EOI implemented audits to detect deliberate misconduct in those groups for those activities on a moving forward basis. The team noted a large variance in the procedure instructions on how to perform the quarterly audit between the organizations that were identified in the extent of condition/cause. This large variance raises concerns for being able to reliably identify anomalies to determine if willful misconduct has occurred, and calls into question the adequacy of the extent of condition determination. For example:

o The Security audit requires that one area be reviewed quarterly for one 24-hour period. Guidance specifically excludes areas from consideration where a badge access reader does not provide useful information.

o In contrast, the Operations audit requires that one day shift and one night shift NLO per crew (10 operators), and at least five areas where a badge access reader does not provide useful information (since this type of area is easier to avoid entering undetected), be reviewed quarterly.

While two sets of quarterly audits have been performed, it is not clear that the results have been evaluated and compared back to the causal evaluations. When the team asked for the audit results, it was apparent that the information had not been shared between the sites or Entergy Corporate and, therefore, it was not clear how the information is being used to assess the adequacy of the extent of condition review and the corrective actions. At the time of the inspection it appeared that the action was limited to gathering the raw data and EOI had yet to establish how the information would be used to conduct the effectiveness reviews.

• The Entergy Corporate root cause for Ineffective Actions on Willful Misconduct identified the root cause as: Entergy had the cultural perception that willful misconduct aspects of events should be addressed outside of the corrective action program. This was apparently driven by EOI investigating these events under a program used for ethics and disciplinary issues, and included a goal of ensuring individual privacy. This evaluation identified a contributing cause as a lack of sharing NRC violations as operating experience within the fleet, since 19 of 24 violations reviewed were not evaluated by the other stations in the fleet as internal operating experience. This prevented sharing information that would have allowed recognition that the willful misconduct issues existed in different parts of the fleet. As corrective action, EOI created a confidential corrective action program as a separate database to track and trend similar events while protecting privacy of individuals.

• Each site appears to have performed a one-time activity to have each NLO have a discussion with the shift manager, and the shift manager tour with the NLO as a knowledge check on log taking, management expectations, and mentoring. There was no reoccurring requirement to have supervisors tour with log takers. The only supervisor in the field requirement that was provided for review was contained in Procedure EN-HU-105, Human Performance - Managed Defenses, which requires one observation per week or 4 per month. However, the procedures guidance is general in nature and is focused on Excellence in Human Performance to reduce the error rate. It is not tailored to looking for or changing the behaviors that could lead to willful misconduct. There is also no specific guidance for what constitutes an observation or how the results of the observations are used; therefore, the team was not confident that this program will have the desired effect of changing behaviors related to willful misconduct. After additional questioning by the team, it was confirmed that Entergy Corporate did not implement a corrective action for a reoccurring requirement to observe operators, including tours and log taking as expected. Procedure EN-OP-117 was supposed to be revised to require each operating crew manager/supervisor to complete at least three observations of NLOs per month (CR-HQN-2017-00300, corrective action 33).

• One contributing cause that EOI identified was that the electronic log-taking device (eSOMS) has a feature that allows the user to accept all previous shifts readings at once. Entergy Operations, Inc., identified that this feature was used in multiple examples of log falsifications that were not initially detected because there was inadequate supervisory oversight.

The NRC noted that EOI has not yet changed this feature.

• The Corrective Actions to Prevent Recurrence (CAPRs) for the Entergy Corporate root cause evaluation were to proceduralize a quarterly audit of operator rounds to detect willful misconduct, to proceduralize a biannual assessment of proctoring activities to detect deliberate misconduct with proctoring exams, and to create computer-based training related to willful misconduct that requires annual renewal. The team noted that these CAPRs were primarily focused on detecting examples of misconduct after it has occurred by conducting quarterly small-sample audits. However, one of the Entergy Corporate causal evaluations concluded that cultural behavior deficiencies in the area of Leadership Safety Values and Actions was resulting in Continuous Learning and Problem Identification and Resolution adverse behaviors. This was, in part, because leaders assumed a level of integrity in each employee and were dependent upon the access authorization and behavioral observation program without considering the possibility for breaches in integrity. Based on the actions taken and proposed, the team concluded that Entergy is addressing the safety culture at each site through the ongoing communications, sharing of the quarterly audits, and effectiveness reviews and surveys to ensure that the integrity messages have been understood.

.2 Conclusions

The team concluded that the root cause evaluations identified appropriate root and contributing causes. The corrective actions from the root cause analysis for why prior fleet-wide corrective actions from other willful violations were not fully successful in preventing or minimizing instances of willful misconduct across the fleet emphasized process changes and detection rather than prevention. The prevention actions are expected to be realized through the procedure and process changes by communicating that instances of willful misconduct will not be tolerated, and the probability of detection is high and the consequences potentially high.

There are a large number of specific actions to address NLOs and examination proctors, which is appropriate. It is apparent, however, that other organizations are not receiving as much attention. This places significant importance on the audit results and EOIs ability to use the audit findings to identify whether additional corrective actions are needed for other groups. The results of the audits are required by the CO to be shared within the department, but in some instances the team was not provided with information to demonstrate that audit results were shared, or that audit results were reported to a central owner to assess for changes or enhancements.

Based on the teams questioning, it was determined that Entergy Corporate had not yet determined the process by which the audit results would be used to determine the effectiveness of the corrective actions.

The CAPRs focus on operations and examination proctors, but the CO is associated with willful misconduct fleet-wide. This shows a misalignment between the problem statements for the cause evaluations and the CO.

However, the team noted that the contributing causes were frequently better aligned with the CO.

Entergy Corporate initiated Condition Reports CR-HQN-2019-00051, -00052,

-00057, and -00184 to address the teams observations.

.3 Entergy Response Letter

In response to these observations, EOI submitted letter CNRO-2091-00013, dated March 21, 2019, which stated the following:

Entergy performed causal analyses related to gaps in meeting integrity standards, which included extent of condition reviews for work groups that perform NRC regulated activities, to determine if individuals from those work groups engaged in willful misconduct. This review did not identify additional instances of workers engaging in willful misconduct.

In addition, plans were developed to conduct quarterly audits of activities performed by these work groups.

B. Element E For the Grand Gulf Nuclear Station, the evaluation described in Element C will address the three violations that are the subject of this ADR mediation session (refer to the NRCs letter, dated November 20, 2017).

.1 Observations

Based on the CO issue date (March 12, 2018), the causal evaluation of the three Grand Gulf violations that led to the ADR mediation session was due on September 12, 2018. On August 28, 2018, Entergy completed actions intended to meet this requirement for the instance of a General Employee Training (GET) examination proctor providing answers, and two instances of non-licensed operators (NLOs), for a total of six individuals, falsifying operator rounds sheets. These actions were completed in the root cause evaluations associated with Condition Reports CR-GGN-2018-2767 and CR-GGN-2018-2768.

• The licensees root cause evaluation for the GET proctor providing examination answers provided a well-supported analysis of the causes.

The causal analysis specifically found that a lack of management/

supervisor oversite in the GET testing process led the GET proctor to believe that their actions were unmonitored and acceptable. The licensees extent of cause evaluation identified an additional instance of proctor impropriety associated with contractor-led GET classes conducted in the local union shop.

• The root cause evaluation for the NLOs falsifying logs at Grand Gulf stated that Grand Gulf did not have a systematic method to detect log falsification. However, EOI also identified that unqualified NLOs under instruction were allowed to do rounds alone, other NLOs were allowed to enter the room to take a reading and report it to the assigned operator, logs were allowed to be taken on scratch paper and transferred later, some NLOs were filling in all log entries at the end of shift, and there was no verification that the building operators were actually evaluating plant conditions. The team noted that these details were indicative of a lack of supervisory oversight and field presence. However, these were not identified as causal factors in the EOI evaluation.

• Corrective actions were focused on periodically issuing site-wide management e-mails, changing procedures, requiring audits of operator rounds and other plant process changes. Nonlicensed operators were also required to have face-to-face meetings with shift supervision at the end of every shift and certify that they had correctly completed their rounds, which was an action to address behavioral issues.

• The Grand Gulf root cause evaluation report included many contributing causes such as:

o a high work load for NLOs o the NLOs had the belief that rounds were not important o there was no specific time set aside to complete rounds o NLOs believed misconduct would not be detected or would not be addressed through termination

• The team reviewed Revisions 0 and 1 of the Grand Gulf root cause evaluation report to address the NLO falsification issues, and identified that many corrective actions were removed when Revision 1 was made.

Once the CO was issued, the root cause was revised to include only the more general corrective actions developed in other root cause evaluations for the fleet. This resulted in actions that appear to be less focused. As an example, in Revision 0, Grand Gulf planned to hold an all hands meeting led by the site vice president, and face-to-face communications with all first line supervisors and their employees on the unacceptability of willful misconduct. In Revision 1, these communications were removed and changed to take credit for the Nuclear Talk e-mails to meet Elements A and B of the CO, a less effective and unverifiable method of communication. In addition, Revision 0, of the Grand Gulf root cause evaluation had a corrective action to audit the system engineer walkdowns in the plant. Revision 1 reduced this action to reviewing mitigating systems performance indicator (MSPI) calculations. Since MSPIs only involve four systems vice the over 100 systems in the plant, the team was concerned that this corrective action may not be broad enough to adequately audit engineering activities.

.2 Conclusions

The licensees root cause evaluation for the GET proctor providing examination answers provided a well-supported analysis of the causes and appropriate corrective actions. The team concluded that the root cause evaluations for the specified issues of willful misconduct of NLOs at Grand Gulf identified details which were indicative of a lack of supervision and field presence, but these were not considered as causal factors. The Grand Gulf evaluation report was revised to match a fleet-level evaluation despite the requirement to have a site-specific evaluation for Grand Gulf, and the corrective actions were revised in a manner that appears to have potentially reduced their effectiveness.

Entergy Corporate initiated Condition Reports CR-HQN-2019-00051, -00052, and

-00057 to address the teams observations.

.3 Notifications to the NRC When Actions Are Completed

A. Element J Within 1 month of completion of Element C, Entergy will submit written notification to the appropriate Regional Administrators.

.1 Observations

Based on the completion date of Element C of August 28, 2018, the written notification to the Regional Administrators was due on September 28, 2018.

On September 27, 2018, Entergy submitted letters to the regional administrators documenting completing Element C of the CO.

.2 Conclusions

Entergy Operations, Inc., submitted a timely and complete letter to comply with Element J of the CO.

B. Element K By December 31 of each calendar year from 2018 through 2020, Entergy will provide in writing to the appropriate Regional Administrators a summary of the actions implemented across the fleet as a result of this Confirmatory Order and the results of any effectiveness reviews performed.

.1 Observations

On December 28, 2018, Entergy submitted letters to the NRC Regional Administrators summarizing the actions taken across the fleet and results of any effectiveness reviews performed during calendar year 2018.

• The letter discussed the e-mail communications with site workers, completion of root cause analyses, and listed some corrective actions.

• The EOI letter stated that no effectiveness reviews were completed, and did not discuss whether or not the communications were received or understood by site workers and contractors. The letter did not discuss the results of the Integrity Pulse Survey.

• Effectiveness reviews are planned, but are not scheduled until August through October 2019. Entergy Operations, Inc., scheduled the effectiveness reviews for this time frame to allow time for the corrective actions to take effect. However, some actions could have been reviewed for effectiveness. For example, the initial and first six month communications have occurred and the results of all the other communications in addition to the Integrity Pulse Survey could have been used together to determine effectiveness to date. In addition, the Extent of Condition/Cause to determine if other organizations have similar issues has already had two quarterly audits performed on each group, yet no overall assessment had been performed, which the team considered a missed opportunity to assess the results to date.

.2 Conclusions

The EOI letter to the regional administrators to discuss the fleet-wide actions was timely and provided a summary of the actions taken to address the CO.

Entergy Corporate initiated Condition Report CR-HQN-2019-00057 to address the teams observations.

4OA6 Meetings, Including Exit

Exit Meeting Summary

On February 27, 2019, the team presented the inspection results to Mr. John Ventosa, Chief Operating Officer South, and other members of the EOI staff. The licensee acknowledged the issues presented. The licensee confirmed that any proprietary information reviewed by the team had been returned or destroyed.

SUPPLEMENTAL INFORMATION

KEY POINTS OF CONTACT

Entergy Operations Inc. Personnel

R. Gaston, Director, Regulatory Assurance

J. Nadeau, Senior Staff Engineer - Regulatory Assurance

J. Hennen, Fleet Corrective Action Program and Operating Experience Specialist

NRC

M. Hay, Deputy Director, Division of Reactor Projects

J. Kozal, Chief, Reactor Project Branch C

N. OKeefe, Chief, Reactor Project Branch D

LIST OF CONFIRMATORY ORDER ELEMENTS DISCUSSED

Discussed

Communications with Site Workers

Element A (Section 4OA5.1)

Element B (Section 4OA5.1)

Causal Evaluation of Previous Corrective Actions to Deter Willful Violations

Element C (Section 4OA5.2.A)

Element E (Section 4OA5.2.B)

Notifications to the NRC When Actions Are Completed

Element J (Section 4OA5.3.A)

Element K (Section 4OA5.3.B)