IR 05000293/2012009
| ML12348A459 | |
| Person / Time | |
|---|---|
| Site: | Pilgrim |
| Issue date: | 12/13/2012 |
| From: | Bellamy R R NRC/RGN-I/DRP/PB5 |
| To: | Smith R G Entergy Nuclear Operations |
| References | |
| FOIA/PA-2013-0250 IR-12-009 | |
| Download: ML12348A459 (18) | |
Text
-ffi SUBJEGT: PILGRIM NUCLEAR POWER STATION - NRC SUPPLEMENTAL INSPECTIONREPORT O5OO293I2O12OO9 AND ASSESSMENT FOLLOW-UP LETTER
Dear Mr. Smith:
On November 15, 2012, the U.S. Nuclear Regulatory Commission (NRC) completed asupplemental inspection pursuant to Inspection Procedure (lP) 95001, "lnspection for One orTwo White Inputs in a Strategic Performance Area," at your Pilgrim Nuclear Power Station. Theenclosed inspection report (lR) documents the inspection results, which were discussed onNovember 15,2012, with you and members of your staff.As required by the NRC Reactor Oversight Process Action Matrix, this supplemental inspectionwas conducted because a finding of low to moderate safety significance (White) was identifiedin the third quarter of 2011, and involved the failure of Pilgrim Nuclear Power Station personnelto carry out their assigned roles and responsibilities and to adequately implement conduct ofoperations and reactivity controlstandards and procedures during a reactorstartup on May 10,2011, which resulted in a reactor scram. Entergy responded by letter dated October 3, 2011.After considering the statements in Entergy's response letter, the results were conveyed to youin a letterdated November 21,2011,'FINAL SIGNIFICANCE DETERMINATION FORAWHITEFINDING, WITH ASSESSMENT FOLLOWUP; NOTICE OF VIOLATION, NRC INSPECTIONREPORT NO.05000293t2011013 - PILGRIM POWER STATION' (ML112440100). The NRCstaff was informed on September 5, 2012 of your staff's readiness for this supplementalinspection.The objectives of this supplemental inspection were to provide assurance that: (1) the rootcauses and the contributing causes for the risk-significant issues were understood; (2) theextent of condition and extent of cause of risk significant performance issues were identified;and (3) corrective actions for risk significant performance issues are sufficient to address theroot and contributing causes and prevent recurrence. The inspection consisted of examinationof activities conducted under your license as they related to safety, compliance with theCommission's rules and regulations, and the conditions of your operating license. The NRCconcluded that, overall, the inspection objectives were met. However, some observationsregarding the root cause and the extent and quality of Entergy's corrective actions were noted.Taken collectively, these observations were not considered significant weaknesses in that they did not represent a substantial inadequacy in Entergy's evaluation of the causes of theperformance issue, determination of the extent of the performance issue, or actions taken orplanned to correct it.Based on the guidance in lnspection Manual Chapter (lMC) 0305, "Operating ReactorAssessment Program," and the results of the inspection, the White finding will be closed andPilgrim will transition from the Regulatory Response Column of the NRC's Action Matrix to theLicensee Response Column as of the date of this letter.In accordance with 10 CFR 2.930 of the NRC's "Rules of Practice," a copy of this letter, itsenclosure, and your response (if any) will be available for public inspection in the NRC PublicDocument Room or from the Publically Available Records System (PARS) component of theNRC's Agency,vide Documents Access and Management System (ADAMS), accessible fromthe NRC web site at http://www.nrc.gov/reading-rm/adams.html (the Public Electronic ReadingRoom).
Sincerely,We-qRonald R. Bellamy, Chief -\Projects Branch 5Division of Reactor ProjectsDocket No: 50-293License No: DPR-35Enclosure;lnspection Report 05000293/201 2009
w/Attachment:
Supplementary lnformationcc w/encl: Distribution via ListServ did not represent a substantial inadequacy in Entergy's evaluation of the causes of theperformance issue, determination of the extent of the performance issue, or actions taken orplanned to correct it.Based on the guidance in lnspection Manual Chapter (lMC) 0305, "Operating ReactorAssessment Program," and the results of the inspection, the White finding will be closed andPilgrim will transition from the Regulatory Response Column of the NRC's Action Matrix to theLicensee Response Column as of the date of this letter.ln accordance with 10 CFR 2.930 of the NRC's "Rules of Practice," a copy of this letter, itsenclosure, and your response (if any) will be available for public inspection in the NRC PublicDocument Room or from the Publically Available Records System (PARS) component of theNRC's Agencyruide Documents Access and Management System (ADAMS), accessible fromthe NRC web site at http://www.nrc.gov/reading-rm/adams.html (the Public Electronic ReadingRoom).
Sincerely,/RNRonald R. Bellamy, ChiefProjects Branch 5Division of Reactor ProjectsDocket No: 50-293License No: DPR-35
Enclosure:
I nspection Report 05000293/201 2009
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Supplementary lnformationcc w/encl: Distribution via ListServ23484459DOCUMENT NAME; G:\DRS\Operations Branch\DAntonio\Pilgrim 95001\Pil95001 2012-009 redone.docxADAMS ACCESSION NUMBbR: MLg suNstReviewV Non-Sensitive! Sensitiveg!Publicly AvailableNon-Publicly AvailableOFFICERI/DRS/OBRI/DRPRIiDRPNAMEJDAntonio*BSmith.RBellamyDATE12t11t1212t12t1212113112IAL RECORD COPYsee previous concurrence Distribution wlencl:W. Dean, RA (RIORAMAIL RESOURCE)D. Lew, DRA (RIORAMAIL RESOURCE)D. Roberts, DRP (RIDRPMAIL RESOURCE)P. Wilson, DRP (RIDRPMAIL RESROUCE)C. Miller, DRS (RIDRSMAIL RESOURCE)J. Clifford, DRS (RIDRSMAIL RESOURCE)C. Santos, Rl OEDOR. Bellamy, DRPT. Setzer, DRPE. Keighley, DRPJ. DeBoer, DRPM. Schneider, DRP, SRIB. Smith, DRP, RlS. Campbell, Resident AARidsNrrPMPilgrim ResourceRidsNrrDorlLPLl -1 ResourceROPReports ResourceJ. D'Antonio, DRSD. Jackson, DRSD. Bearde, DRS ENCLOSUREU.S. NUCLEAR REGULATORY COMMISSIONREGION IDocket No.: 50-293License No.: DPR-35ReportNo.: 05000293/2012009Licensee: Entergy Nuclear Operations, lnc.Facility: Pilgrim Nuclear Power StationLocation: 600 Rocky Hill RoadPlymouth, MA 02360-5528Dates: November 12,2012 through November 15,2012Inspectors: JosephD'Antonio,SeniorOperationsEngineerJustin Heinley, Resident InspectorApproved by: Ronald R. Bellamy, ChiefReactor Projects Branch 5Division of Reactor ProjectsEnclosure Summarv of FindinqslR 0500029312012009; 1111212012 - 1111512012; Pilgrim Nuclear Power Station;Supplemental lnspection - Inspection Procedure (lP) 95001.A Region I senior operations inspector and the resident inspector from Three Mile lslandperformed this inspection.NRC-ldentified and Self-Revealed FindinqsCornerstone: Initiating EventsThe NRC staff performed this supplemental inspection in accordance with lP 95001, "lnspectionfor One or Two White Inputs in a Strategic Performance Area," to assess Entergy's root causeevaluation and corrective actions taken in response to a reactor scram during a reactor startupand heatup on May 10,2011. The NRC staff previously characterized this issue as having lowto moderate safety significance (White), as documented in NRC Inspection Report05000293/2011012 (ML1 12440100). The significance determination was finalized in aNovember 21,2011 letter from the NRC to Mr. Robert Smith, Site Vice President of PilgrimNuclear Power Station, 'FINAL SIGNIFICANCE DETERMINATION FOR A WHITE FINDING,WITH ASSESSMENT FOLLOW-UP; NOTICE OF VIOLATION, NRC INSPECTION REPORTNO. O5OOO29312011O13 _ PILGRIM NUCLEAR POWER STATION.Entergy identified the root cause of the issue as: "The root cause of this event was thefailure to adhere to established standards and expectations due to a lack of consistentsupervisory and management enforcement."As documented in NRC Inspection Report 0500029312011012 (M1112440100), the specialinspection team reviewed the root cause evaluation and concluded that the root causeevaluation was thorough and appeared to identify the underlying casual factors. In the periodbetween the completion of the special inspection in July 2011, and this supplemental inspectionin Novemb er 2012, Entergy has had no further reactivity mismanagement events. Based on theresults of this inspection, the inspectors concluded that, in general, Entergy had adequatelyperformed a root cause evaluation of the May,2Q11 event. Additionally, the inspectorsconcluded that the combined effect of the completed and planned corrective actions taken werereasonable to address the related performance issues. The inspectors also had severalobservations. These observations were not considered significant in that they did not representa substantial inadequacy in Entergy's evaluation of the causes of the performance issue,determination of the extent of the performance issue, or actions taken or planned.As a result of this supplemental inspection, in accordance with the guidance in IMC 0305,"Operating Reactor Assessment Program," the White finding associated with the May,2011event is closed and Entergy will transfer to the Licensee Response Column of the NRC's actionmatrix as of the date of the cover letter to this report.Enclosure Other FindinqsNo findings were identified.iiiEnclosure 4.4c.A4,01REPORT DETAILSOTHER ACTIVITIESSupplemental Inspection (95001 )Inspection ScopeThe NRC staff performed this supplemental inspection in accordance with lP 95001 toassess Entergy's evaluation of a White finding, which affected the Initiating Eventscornerstone in the Reactor Safety strategic performance area. The inspectionobjectives were:To provide assurance that the root causes and contributing causes of risk-significantperformance issues are understood;To provide assurance that the extent of conditions and extent of cause of risk-significantperformance issues are identified;To provide assurance that the licensee's corrective actions for risk-significantperformance issues are sufficient to address the root and contributing causes andprevent recurrence.On May 10, 2011, with reactor thermal power at approximately 1.7 percent, PilgrimStation experienced an intermediate range monitor (lRM) hi-hi flux reactor scram duringa reactor startup and heatup. In accordance with Inspection Manual Chapter 0309, aspecial inspection team was chartered on May 13,2011, to evaluate operatorperformance and organizational decision-making. Entergy entered this event into thecorrective action program as CR-PNP-2011-02475 and performed a root causeevaluation of the event. Entergy's root cause evaluation (RCE), "Root CauseEvaluation Report, Reactor Scram on IRM Hi-Hi Flux, CR-PNP-2A11-2475, Event Date:0O-10-2011" identified one root cause and four contributing causes. The RCE and theCR identified a total of 87 corrective actions.The special inspection took place from May 16,2011 through July 20, 2011 and theresutts were documented in lnspection Report 05000293/2011012 (ML112440100)' Aself-revealing finding with a preliminary low to moderate safety significance (preliminaryWhite) was identified. The finding was associated with the failure of Pilgrim personnel,including licensed Reactor Operators and Senior Reactor Operators, to implementconduct of operations and reactivity control standards and procedures during a reactorstartup, which contributed to an unrecognized subcriticality followed by an unrecognizedreturn to criticality and subsequent reactor scram. The finding was characterized ashaving low to moderate (White) safety significance based on the criteria contained inIMC 0609, Appendix M, "significance Determination Process Using Qualitative Criteria."Entergy responded by letter dated October 3,2011. After considering the statements inEntergy's response letter, the results were conveyed to Entergy in a letter datedNovember 21,2011, .FINAL SIGNIFICANCE DETERMINATION FOR A WHITEFINDING, WITH ASSESSMENT FOLLOWUP; NOTICE OF VIOLATION' NRCINSPECTION REPORT NO. O5OOO29312011013 - PILGRIM POWER STATION,"Enclosure 2(M1112440100). Additionally, Pilgrim Station entered the Regulatory Response Columnof the NRC's Action Matrix on November 21 , 2011 as a result of one inspection finding oflow to moderate (White) safety significance.Entergy performed a readiness review from April 16,2012 to July 20,2012 to assess thestation's readiness for a 95001 inspection for the May 10,2011 event. The results weredocumented in LO-PNPLO-201 2-2025, "Snapshot AssessmenUBenchmark ON: PNPS95001 Readiness" The review determined that the RCE was comprehensive andcorrective actions complete with some exceptions.Entergy staff informed the NRC staff on September 5, 2012 that they wereready for the supplemental inspection.The inspectors reviewed Entergy's root cause and condition report for the scram,reviewed applicable corrective action program documents, interviewed operations crewpersonnel, and observed a crew simulator evaluation and crew activities in the controlroom. The inspectors also held discussions with licensing, reactor engineering, training,and operations personnel to ensure that the root and contributing causes wereunderstood and corrective actions taken or in progress were appropriate to address theidentified causes and to prevent recurrence of the original issue. In addition, the leadinspector had performed control room observations from June 28 to July 2,2012,including a power maneuver and rod pattern adjustment..02 Evaluation of the Inspection Requirements02.01 Problem ldentificationa. tP 95001 requires that the inspection staff determine that the licensee's evaluation offhe issue documents who identified fhe issue (i.e., licensee-identified, self-revealing, orNRC-identified) and the conditions under which fhe issue was identified.The inspectors noted that while Entergy's root cause evaluation did not explicitlyidentify who identified the issue, it does provide sufficient detail on how the issuedeveloped to determine that the issue was self-revealing. NRC IMC 0612, paragraph3.17, defines self revealing and states, in-part:"Self revealing findings or violations are those developed from issues that becomeself-evident and require no active and deliberate observation by the licensee orNRC inspectors to determine whether a change in process or equipmentcapability or function has occurred. Self revealing issues become readilyapparent to either NRC or licensee personnel through a readily detectabledegradation in the material condition, capability, or functionality of equipment orplant operations and require minimal analysis to detect. Examples of selfrevealing findings and violations include those revealed through: reactor trips andsecondary plant transients., .."Enclosure 3Specifically, the "Event Narrative" of the root cause evaluation describes crew andindividual actions leading to the reactor scram.Overall, the inspectors determined that Entergy's root cause evaluation adequatelydocuments that this was a self-revealing issue.b. IP 95001 requires that the inspection staff determine that the licensee's evaluation offhe issue documents how long fhe issue exisfed and prior opportunities foridentification.Entergy does not explicitly state how long the issues leading to this event existed. Theroot cause evaluation documented a review of internal and external operatingexperience. The internal review identified numerous instances of failure to adhere tostandards and expectations or to follow procedures, none of which resulted in areactivity mismanagement. The external review did provide many examples of relevantoperating experience, including reactivity mismanagement events'Overall, the inspectors determined that Entergy's root cause evaluation effectivelydocumented that the issue of compliance with standards and expectations had existedfor several years and documented prior opportunities for identification from both site andindustry operating experience.c. tP 95001 requires that the inspection staff determine that the licensee's evaluationdocuments the ptant specific risk consequences, as applicable, and complianceconcerns associated with the issue(s).Entergy's root cause evaluation documented the safety consequences of this event.The licensee stated that ineffective adherence to standards and expectations andinability to carry out fundamental behaviors during a reactivity manipulation representa serious challenge to safe operation. However, this particular event did not challengesafety limits or fission product barriers and presented no radiological or industrialsafety challenges.Overall, the inspectors determined that Entergy's evaluation documented the plantspecific risk consequences and compliance concerns associated with the issue andwas consistent with the NRC's evaluation.d. FindinosNo findings were identified.02.Q2 Root Cause. Extent of Condition. and Extent of Cause Evaluationa. lP 95001 requires that the inspection staff determine that the licensee evaluated theissue usrng a systematic methodology to identify the root and contributing causes.Entergy used the following systematic methods to complete the root cause evaluation:Event Timeline, Barrier Analysis, Why Staircase, and an Organizational andEnclosure b.4Programmatic Weakness Evaluation. Entergy identified one root cause and fourcontributing causes. Entergy determined the root cause of the event to be:"The root cause of this event was the failure to adhere to established standardsand expectations due to a lack of consistent supervisory and managementenforcement."The inspectors determined that Entergy had evaluated the issue usingsystematic methodologies to identify root and contributing causes.lP 95001 requires that the inspection staff determine that the licensee's roof causeevaluation was conducted to a level of detail commensurate with the significance offhe lssue.Entergy's root cause evaluation included the use of a combination of root causeassessment methods that are complimentary. A collective review of the root andcontributing causes did not result in the identification of any additional fundamentalissues.The inspectors observed that, in one case, the "why staircase" and contributing causediscussion did not explicitly address a relevant factor. Specifically, contributing cause 2,"Weaknesses in Just-ln-Time Training" (JITT) states that not all personnel involved inthe startup had attended the JITT, and the content of JITT did not address the regime ofoperation where the trip occurred. The root cause does not identify that personnelmissed the JITT due to a schedule change which moved up the startup date and thatmeeting the new schedule prevented getting all personnel to training. In addition, thereactor was restarted after this event without correcting the inadequate JITT. Theresponsible manager for the RCE was interviewed and stated that there was arecognition of the time pressure resulting from moving up the startup date. Nonetheless,the inspectors consider the failure to specifically address the element of poororganizational response to time pressure in the RCE to be a weakness. The inspectorsnoted there are corrective actions to address these issues.Despite this observation, the inspectors determined that the licensees' root causeevaluation was generally conducted to a level of detail commensurate with thesignificance of the issue.lP 95001 requires that the inspection staff determine that the licensee's root causeevaluation inctuded a consideration of prior occurrences of the issue and knowledgeof Operating Experience.The root cause evaluation documented a review of internal and external operatingexperience, The internal review identified numerous instances of failure to adhere tostandards and expectations or to follow procedures, none of which resulted in areactivity mismanagement. The external review did provide many examples of relevantoperating experience, including reactivity mismanagement events.Enclosure 5Overall, the inspectors determined that Entergy's root cause evaluation included aconsideration of prior occurrences of the issue and knowledge of operating experience.d. lP 95001 requires that the inspection staff determine that the licensee's root causeevaluation addresses the extent of condition and extent of cause of the issue.Extent of condition. Entergy's root cause evaluation addressed the extent of conditionfor the event. The condition identified was:Root Cause:"The root cause of this event was the failure to adhere to established standards andexpectations due to a lack of consistent supervisory and managementenforcement."Contributing Causes:o Weakness in Monitoringo WeaknessinJust-ln-Time-Trainingo Procedural Guidance Not Optimume Weakness in TeamworkThe discussion of these causes determined that they were applicable to conduct ofoperations in general, not limited to one individual, one crew, or this particularevolution.Extent of Cause. The root cause evaluation team considered the extent of causeassociated with the root cause and determined that the issue of ineffectivereinforcement of standards and expectations was potentially applicable to other stationdepartments. Certain corrective actions address this concern beyond the twodepartments directly involved in this event.Overall, the inspectors determined that Entergy's root cause evaluation addressed theextent of cause of the issue.e. tP 95001 requires that the inspection staff determine that the licensee's root cause,extent of condition, and extent of cause evaluations appropriately considered the safetyculture componenfs as described in IMC 0305'Entergy performed a safety culture evaluation and considered the safety cultureaspects of Work Practices, and Continuous Learning to be applicable to this issue.Corrective actions have been completed taking into consideration the input of thesafety culture aspects.Enclosure 6The inspectors noted that the contributing cause of "Procedure Guidance Not Optimum"was not evaluated as applicable to the "Resources" component, and the impact of timepressure on the contributing cause "Weaknesses In Justln-Time-Training" was notevaluated as applicable to the "Safety Policies" component. Corrective actions for theseissues were identified as part of the main CR for this event. Overall, the inspectorsdetermined the root cause evaluation included a proper consideration of whether theroot cause, extent of condition, and extent of cause evaluations appropriately consideredthe safety culture components.f. FindinqsNo findings were identified.02.03 Corrective Actionsa. tP 95001 requires that the inspection staff determine that (1) the licensee specifiedappropriate corrective actions for each root and/or contributing cause, or (2) anevaluation fhaf sfafes no actions are necessary is adequate.The root cause evaluation and CR document corrective actions for the root cause,contributing causes and corrective actions for other issues. The inspectors reviewed allof the corrective actions to ensure that they addressed the identified causes. Theinspectors found the corrective actions to be extensive and thorough with regard toaddressing both the specific performance deficiencies identified with this event, and themanagement and supervisory deficiencies which allowed it to happen. Observations,reviews, and interviews performed by the inspectors indicate that the impact of thesecorrective actions has been pervasive throughout conduct of operations and training,The inspectors did note one inconsistency in corrective actions requiring training. Thelicensee's root cause evaluation identified the need to perform additional training andimplement oversight qualification programs as corrective actions to address the root andcontributing causes. The inspectors identified that the scheduled performancefrequency of the training was inconsistent between the root and contributing causescorrective actions. Specifically, the inspectors identified training evolutions forsupervisors and operations staff, which were directed as corrective actions for the rootcause, that were scheduled as a onetime occurrence. However, additional trainingused to correct contributing causes was scheduled to be performed on a continual basis.The licensee entered the inconsistency into their CAP as CR-PNP-2012-05305 forevaluation.Overall, the inspectors found that Entergy specified appropriate corrective actions forthe root cause, contributing causes, extent of condition, and extent of cause.Enclosure b.7lP 95001 requires that the inspection staff determine that the licensee prioritizedcorrective actions with consideration of risk significance and regulatory compliance.The inspectors reviewed the prioritization of the corrective actions and verified that theprioritization was based on appropriate consideration of risk significance and regulatorycompliance.Overall, the inspectors determined that Entergy had established an appropriateschedule for implementing and completing the corrective actions.tP 95001 requires that the inspection staff determine that the licensee established aschedule for implementing and completing the corrective actions.Entergy's corrective actions and proposed corrective action plan provided dates forcompletion of actions as described in the root cause evaluation. As of the issue date ofthis report, all corrective actions have been completed with the exception of one newCA number 88 has been open for the CR discussed in paragraph "a"'tP 95001 requires that the inspection staff determine that the licensee developedquantitative and/or qualitative rneasures of success for determining the effectivenessof the corrective actions to prevent recurrence.The inspectors determined that the root cause evaluation included an effectivenessreview plan for the corrective actions to prevent recurrence. This plan included fleetobservations of four scheduled reactor downpowers, internal and external observation of13 other power maneuvers, verification of changes to just-in-time training and verificationof satisfactory completion of simulator training related to the event.tP 95001 requires that the inspection staff determine that the licensee's planned or takencorrective actions adequatety address a Notice of Violation (NOV) that was the basis forthe supplemental inspection, if applicable.As required by the NRC Reactor Oversight Process Action Matrix, this supplementalinspection was conducted because a finding of low to moderate safety significance(White) was identified in the third quarter of 2Q11. This issue was documented in NRCSpecial Inspection Report 05000293/2011012, dated September 1,2011, and involvedthe failure of Pilgrim Nuclear Power Station personnel to carry out their assigned rolesand responsibilities and to adequately implement conduct of operations and reactivitycontrol standards and procedures during a reactor startup on May 10,2011, whichresulted in a reactor scram. Entergy responded by letter dated October 3,2A11. Afterconsidering the statements in Entergy's response letter, the results were conveyed toEntergy in a letter dated November 21,2011, 'FINAL SIGNIFICANCEDETERMINATION FOR A WHITE FINDING, WITH ASSESSMENT FOLLOWUP;NOTICE OF VIOLATION, NRC INSPECTION REPORT NO. O5OOO293I2O11O13 _PILGRIM POWER STATION" (ML1 1 2440100).d.Enclosure 8The letter concluded that information regarding: (1) the reason for the violations; (2) theactions planned or already taken to correct the violations and prevent recurrence; and(3) the date when full compliance was achieved, were already adequately addressed onthe docket in NRC Inspection Report 05000293/2011012 and in the Entergy responseletter dated October 3, 2011.The inspectors noted that the issue date of the RCE was prior to the issue date of theWhite finding, and that the White finding was not explicitly mentioned in the correctiveactions. At the request of the inspectors, the facility performed a review to ensure allelements of the White finding were addressed by the corrective actions. The results ofthis review were provided to the NRC on December 7,2012. The inspectors verifiedthat all elements of the White finding were appropriately addressed'f. FindinqsNo findings were identified.02.04 Evaluation of IMC 0305 Criteria for Treatment of Old Desiqn lssuesThis part of lP 95001 was not implemented as Entergy did not request credit for self-identification of an old design issue and the finding did not meet the requirements ofIMC 0305 paragraph 04.18 for consideration as an old design issue'4046 Exit MeetinqOn November 15, 2012, the inspectors presented the inspection results to Mr. R. Smith,Site Vice President, and other members of his staff, who acknowledged the results. Theinspection team confirmed that proprietary information reviewed during the inspectionwas returned to Entergy.ATTACHMENT: SUPPLEMENTAL INFORMATIONEnclosure A-1ATTACHMENTSUPPLEMENTAL IN FORMATIONKEY POINTS OF CONTACTLicensee PersonnelRobert Smith, Site Vice PresidentGary James, Reactor Engineering ManagerDave Noyes, Operations ManagerDave Mannai, Sr, Manager Nuclear Safety and LicensingJoe Lynch, Licensing ManagerJohn House, Supervisor of Initial Operator TrainingRandy Haislett, Assistant Operations Manager for TrainingMike Hettner, Shift ManagerKen Gracia, Shift ManagerMert Probasco, Shift MangerJohn Ohrenberger, Shift ManagerPaul Gallant, Shift managerTony Toman, RO, lnstructorNRC PersonnelJoseph M. D'Antonio, Senior Operations EngineerJustin Heinley, Resident Inspector, Three Mile lslandLIST OF ITEMS OPENED, CLOSED AND DISCUSSEDClosed05000293/2011012-01 NOV Failure to lmplement Conduct of Operations andReactivity Control Procedures during Reactor Startup.LIST OF DOCUMENTS REVIEWEDProceduresEN-OP-1 17 "Managers Guide for Operations Assessments/Obseryations," Rev. 3PNPS 1.3.34 "Operations Administrative Policies and Processes," Rev. 121"What lt Looks Like" sheet for management observations of briefingsEN-HU-102 "Human Performance Traps and Tools," Rev. 12EN-OP-103 Reactivity Management Program, Rev. 5PNPS 2.1.4 Approach to Critical and Plant Heatup, Rev. 28Attachment A-2EN-OP-116 "lnfrequently Performed Tests or Evolutions," Rev. 10PNPS 2.1.1 Startup from ShutdownPNPS 2.2.88 "Reactor Manual Control System," Rev. 30PNPS 2.4.11.1"CRD System Malfunctions," Rev. 22PNPS 1.3.63 "Conduct of Event Review Meetings," Rev. 25EN-HU-103 "Human Performance Error Reviews"EN-OP-115, Rev. 13EN-HU-103, Human Performance Error Reviews, Rev. 7EN-OP-1 16, Infrequently Performed Tests or Evolution, Rev. 10EN-OP-1 17, Operations Assessments, Rev. 3EN-RE-214, Conduct of Reactor Engineering, Rev. 0FSEM-SUPC-COACH2O1 0, Coaching, Rev. 0Fundamental Behavior Scorecard, June 2011 - September 2012PCBT-ADM-IPTE-OVRST, Senior Management Oversight for IPTE, Rev. 0O-RQ-04-01-145, Team Work Pre-Refueling Outage, Rev. 0O-RQ-04-01-137, Operations HU Tools and Fundamentals Reinforcement, Rev.01.3.37, Post Trip Reviews, Rev. 292.1.1, Startup from Shutdown, Rev. 1773.M.3-61.5, 'B' Diesel Generator Post Overhaul Testing, Rev. 44Condition ReportsCR-PNP-2011-02475 Reactor Scram on 5/1 012011 and associated Root Cause EvaluationReport for Reactor Scram on IRM Hi-Hi Flux 0710712011, Rev' 2CR-HQN-201 1-500 Significant Event Response TeamTrainino Materials and PresentationsSOER 10-2 Lessons Learned Presentation, 91512011Lesson Plan O-RQ-04-01-138 "May 2011 IRM Scram Event Review"Lesson Plan O-RQ-04-01-137 "Operations HU Tools and Fundamentals Reinforcement"Lesson Plan O-RO-01-02-08 "Reactor Operational Physics"Requal Module O-RQ-6-02-80 Scenario #10LORT Exam Scenario O-RQ-06-02-124LORT Exam Scenario SES-180Lesson Plan O-RQ-04-04-72 "Reactor Startup and Criticality Template,'1 Rev. 1Lesson Plan O-RO-03-02 "Reactor Plant Startup Certification," Rev, 11Lesson Plan O-RO-O1-01-04 "Reactivity Coefficients," Rev. 3Lesson Plan O-RO-02-07 -02 Intermediate Range MonitorsRE Coaching, May 2011 - Jan 2012Presentation Case Study Plant Restart Following IRM scramOperator Fundamentals Project documentAttachment A-3Self-AssessmentsLO-PNPLO-2011-136 Focused Self Assessment Training Effectiveness in Addressing OperatorFundamentals 81512011LO-PNPLO-2A11-0048 Focused Self Assessment PNPS Operator Fundamentals 8/1812011LO-PNPLO-2012-00025 Snapshot Assessment/Benchmark On: PNPS 95001 Readiness.Attachment