November 21, 2011 

EA-11-174 

Mr. Robert G. Smith 

Site Vice President 

Entergy Nuclear Operations, Inc. 

Pilgrim Nuclear Power Station 

600 Rocky Hill Road 

Plymouth, MA 02360-5508 

SUBJECT: FINAL SIGNIFICANCE DETERMINATION OF WHITE FINDING, WITH 

ASSESSMENT FOLLOW-UP; NOTICE OF VIOLATION, NRC INSPECTION 

REPORT NO. 05000293/2011013, PILGRIM NUCLEAR POWER STATION 

Dear Mr. Smith: 

This letter provides you the final significance determination for the preliminary White finding 

discussed in the U.S. Nuclear Regulatory Commission (NRC) letter dated September 1, 2011 

(ML112440100) 1, as well as our assessment of the current performance of the Entergy Nuclear 

Operations, Inc. (Entergy) Pilgrim Nuclear Power Station (Pilgrim). This updated assessment of 

Pilgrim supplements, but does not supersede, our mid-cycle assessment letter issued on 

September 1, 2011 (ML112420017). 

In the preliminary determination letter dated September 1, 2011, the NRC described the finding, 

which was identified during an NRC special inspection conducted in response to the 

May 10, 2011, reactor scram event, and which was presented to you and your staff during a 

July 20, 2011, exit meeting. The finding involved the failure of Pilgrim personnel to adequately 

implement conduct of operations and reactivity control standards and procedures during a 

reactor startup, which resulted in a reactor scram. 

As described in NRC Inspection Report No. 05000293/2011012, issued on September 1, 2011, 

the NRC used a qualitative assessment tool (Inspection Manual Chapter (IMC) 0609, Appendix 

M) to assess the significance of this finding because the event was caused, in part, by multiple 

human performance failures which were not easily modeled using quantitative risk assessment 

methods. The Appendix M assessment involved analysis of several factors including: review of 

six specific attributes of the finding (such as the impact the issue had on defense-in-depth, 

whether there was a reduction in safety margin, and the extent of condition); and consideration 

of any additional applicable circumstances. The relative weight of each of these inputs was 

determined by NRC management review. 

The September 1, 2011, letter included an offer for Entergy to attend a regulatory conference or 

reply in writing to provide its position on the facts and assumptions the NRC used to arrive at 

 

1

 Designation in parentheses refers to an Agency-wide Documents Access and Management System 

(ADAMS) accession number. Documents referenced in this letter are publicly-available using the 

accession number in ADAMS. 
R. Smith 2 

the finding and its safety significance. In response, Entergy submitted a letter dated October 3, 

2011 (ML112970166), which stated that while Entergy agreed with the performance deficiency 

and root cause as articulated in the NRC inspection report, it had calculated a different, lower 

risk assessment of the event than the assessment used by the NRC to determine the need for 

NRC Region I to initiate a special inspection team in accordance with IMC 0309. In its letter, 

Entergy further requested that the NRC reassess the Appendix M factors involving how the 

performance deficiency affected plant equipment, and the length of time over which the 

performance deficiency existed. A detailed description of Entergy’s requests as articulated in its 

response letter and the NRC assessment are provided in the enclosed “Assessment of 

Entergy’s Written Response” (Enclosure 2). 

After considering the information developed during the inspection in addition to the statements 

presented in Entergy’s response letter, the NRC concluded that the inspection finding is of low 

to moderate safety significance, and is therefore appropriately characterized as White. The 

major considerations used by the NRC in reaching this conclusion include: (1) during the event, 

several operators failed to adequately control plant parameters involving reactivity. This led to 

the Reactor Protection System being relied upon to terminate the inadvertent power excursion, 

rather than operators proactively monitoring reactor conditions to ensure a controlled, safe 

startup of the reactor; (2) the performance issues demonstrated during the event involved 

multiple personnel, including operators, management, and reactor engineers; and, (3) operator 

performance and causal factors associated with the event existed for a considerable time in 

advance of the event, as stated in both the NRC’s inspection report, and the Entergy root cause 

assessment. 

Regarding the NRC’s decision to initiate the special inspection team in response to the event, 

this decision relied on a number of factors, including a risk assessment. Although the NRC’s 

risk assessment of the event, as described in the aforementioned inspection report, informed 

the decision to initiate the special inspection, it was only one factor amongst a number of more 

heavily-weighted qualitative factors, such as concerns with operational performance and 

possible adverse generic implications, per IMC 0309 deterministic factors. Of note is the fact 

that the NRC estimate of core damage probability was relatively close to Entergy’s assessment, 

as was discussed with Entergy staff at the time. 

The NRC recognizes that actuation of the Reactor Protection System, as occurred in this event, 

can occur for a multitude of reasons and is designed to place the plant in a safe condition. In 

many instances, other performance deficiencies at other sites have led to an automatic reactor 

shutdown, and the NRC has assessed those findings as having very low safety significance 

(Green). Green findings have also involved latent demonstrations of weaknesses which existed 

for a prior period of time. What the NRC found was differentiating in this case was the 

inadequate monitoring of important reactivity parameters by multiple levels of operators and 

supervision; parameters that operators should be monitoring and controlling very carefully, that 

eventually led to a reactor protective system actuation being used to ensure safety during a 

reactor startup. Also, the occurrence of this event at a time when reactivity management should 

have been the main focus of the operating crew revealed a number of underlying issues 

involving training and operator fundamentals that are more than anomalous. 

Additional details regarding the NRC’s review of Entergy’s response are included in 

Enclosure 2. 
R. Smith 3 

You have 30 calendar days from the date of this letter to appeal the staff’s determination of 

significance for the identified White finding. Such appeals will be considered to have merit only 

if they meet the criteria given in the IMC 0609, Attachment 2, “Process for Appealing NRC 

Characterization of Inspection Findings.” An appeal must be sent in writing to the Regional 

Administrator, Region I, 475 Allendale Rd., King of Prussia, PA 19406. You are not required to 

respond to this letter. However, if you choose to respond, you should follow the instructions 

specified in the enclosed Notice when preparing your response. 

As a result of our review of Pilgrim’s performance, specifically, this White finding in the Initiating 

Events Cornerstone, we have assessed Pilgrim to be in the Regulatory Response column of the 

NRC Action Matrix. Therefore, we plan to conduct a supplemental inspection using Inspection 

Procedure 95001, “Inspection for One or Two White Inputs in a Strategic Performance Area,” 

when Entergy staff notifies us of your readiness for this inspection. This inspection is conducted 

to provide assurance that the root cause and contributing causes of risk significant performance 

issues are understood, the extent of condition is identified, and the corrective actions are 

sufficient to prevent recurrence. 

In addition to the performance deficiency, the NRC has also determined that a violation of NRC 

regulations occurred, as cited in the enclosed Notice of Violation (Notice). The violation 

involves failures to conduct safety-related activities as described in written procedures related to 

administrative issues, general plant operations and start-up of safety-related boiling water 

reactor systems. In accordance with the NRC Enforcement Policy, the Notice is considered an 

escalated enforcement action because it is associated with a White finding. 

In its response letter, Entergy provided corrective actions it has taken, and has planned, in 

response to the issues. These actions include, in part: (1) revising the Just in Time Training 

program to ensure specific aspects of start up operations are understood by the operating crew; 

(2) having operations department management observe the control room activities, specifically, 

100% of the time during start-up activities; and, (3) coaching or re-training operations crews and 

reactor engineers on expectations of behavior during reactivity manipulations. The NRC 

believes these corrective actions are appropriately comprehensive. 

The NRC has concluded that information regarding: (1) the reason for the violation; (2) the 

actions planned or already taken to correct the violation and prevent recurrence; and, (3) the 

date when full compliance was achieved, is already adequately addressed on the docket in this 

letter, in NRC Inspection Report 05000293/2011012, and in the Entergy response letter dated 

October 3, 2011. Therefore, you are not required to respond to this letter and/or the Notice 

unless the descriptions in the aforementioned correspondence do not accurately reflect your 

position. In that case, or if you choose to provide additional information, you should follow the 

instructions specified in the enclosed Notice. 

 
R. Smith 4 

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

enclosure, and your response, if you choose to provide one, will be made available 

electronically for public inspection in the NRC Public Document Room located at NRC 

Headquarters in Rockville, MD, and from the NRC’s Agency-wide Documents Access and 

Management System (ADAMS), accessible from the NRC Web site at 

http://www.nrc.gov/reading-rm/adams.html. To the extent possible, your response, if you 

choose to provide one, should not include any personal privacy, proprietary, or safeguards 

information so that it can be made available to the Public without redaction. 

Sincerely, 

 /RA/ 

William M. Dean 

Regional Administrator 

Docket No. 50-293 

License No. DPR-35 

Enclosures: 

1. Notice of Violation 

2. Assessment of Entergy’s Written Response 

cc w/encl: Distribution via ListServ
R. Smith 4 

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

enclosure, and your response, if you choose to provide one, will be made available 

electronically for public inspection in the NRC Public Document Room located at NRC 

Headquarters in Rockville, MD, and from the NRC’s Agency-wide Documents Access and 

Management System (ADAMS), accessible from the NRC Web site at 

http://www.nrc.gov/reading-rm/adams.html. To the extent possible, your response, if you 

choose to provide one, should not include any personal privacy, proprietary, or safeguards 

information so that it can be made available to the Public without redaction. 

Sincerely, 

 /RA/ 

William M. Dean 

Regional Administrator 

Docket No. 50-293 

License No. DPR-35 

Enclosures: 

1. Notice of Violation 

2. Assessment of Entergy’s Written Response 

cc w/encl: Distribution via ListServ 

SUNSI Review Complete: AEP USNRC (Reviewer=s Initials) 

DOCUMENT NAME: BD CM Pilgrim Final White Finding NOV-Formatted.docxDocument1 

After declaring this document AAn Official Agency Record@ it will be released to the Public.ADAMS Accession No.: ML113220300 

To receive a copy of this document, indicate in the box: "C" = Copy without attachment/enclosure "E" = Copy with attachment/enclosure "N" = No copy 

OFFICE RI/ORA RI/DRS RI/DRP RI/DRP RI/DRS 

NAME ADeFrancisco DJackson RBellamy DRoberts DA for CMiller PW for 

DATE 10/31 /11 11 /01/11 11/01/11 11 / 03 /11 11 / 03 /11 

OFFICE RI/RC RI/ORA HQ/OE HQ/NRR RI/RA 

NAME KFarrar DHolody LCasey MAshley WDean 

DATE 11 /15 /11 11/08 /11 11/14 /11 11/10/11 11/18 /11 

 OFFICIAL RECORD COPY 
R. Smith 5 

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M. Ashley, OE 

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E. Leeds, NRR 

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RidsNrrPMPilgrim Resource 

RidsNrrDorlLPL1-1 Resource 

ROPReports.Resource 

Enforcement Coordinators RII, RIII, RIV 

 (C. Evans, S. Orth, H. Gepford) 

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Region I OE Files (with concurrences)
 NOTICE OF VIOLATION 

Entergy Nuclear Operations, Inc. Docket No. 50-293 

Pilgrim Nuclear Power Station License No. DPR-35 

 EA-11-174 

During an NRC inspection, for which an exit was conducted on July 20, 2011 a violation of NRC 

requirements was identified. In accordance with the NRC Enforcement Policy, the violation is 

listed below: 

Technical Specification 5.4, “Procedures,” states, in part, that written procedures shall be 

established, implemented, and maintained covering the applicable procedures 

recommended in Appendix “A” of Regulatory Guide (RG) 1.33, February, 1978. 

RG 1.33, Appendix “A,” requires the licensee to conduct safety-related activities as 

described in written procedures related to Paragraph 1 (“Administrative Procedures”); 

Paragraph 2 (“General Plant Operating Procedures”); and, Paragraph 4 (“Procedures for 

Start-up, Operation, and Shutdown of Safety-Related BWR Systems.”) 

Contrary to the above, prior to and during a reactor startup operation on May 10, 2011, 

safety-related activities were not conducted as described in written procedures, as 

demonstrated by the following examples: 

a. Entergy procedure EN-OP-115, “Conduct of Operations” Revision 10, Section 4.0, 

requires the Shift Manager (SM) to “provide oversight of activities supporting 

complex and infrequently performed plant evolutions such as plant heatup [and] 

startup.” Additionally, the SM is responsible for ensuring “conservative actions are 

taken during unusual conditions ... when dealing with reactivity control.” However, 

during reactor heatup, the SM did not properly oversee the activities in progress and 

was not present in the control room when the heatup rate was being corrected with 

control rod insertion. The SM did not ensure the actions taken to establish or adjust 

the reactor heatup rate were conservative. 

b. Pilgrim Nuclear Power Station (PNPS) procedure 1.3.34 “Operations Administrative 

Policies and Procedures” Revision 117, Section 6.10.1.1[4] requires that 

“Infrequently Performed Tests or Evolutions Briefings for the performance of 

procedures classified as “Infrequently Performed Tests or Evolutions” (IPTE)” be 

performed with Senior Line Manager oversight as specified in EN-OP-116, 

“Infrequently Performed Tests or Evolutions.” Entergy Procedure EN-OP-116, 

Revision 7, Attachment 9.1 identifies “Reactor Start Up” as an IPTE. In this case, an 

IPTE briefing package for the reactor start up had been prepared, approved, and the 

briefing had been scheduled; however, the IPTE briefing was never performed as 

required by the procedures described above. In addition, an IPTE brief was also not 

performed for the startup following the reactor scram. 

c. Entergy procedure EN-OP-115, “Conduct of Operations” Revision 10, Section 5.2, 

requires Control Room operators to “develop and implement a plan that includes 

contingencies and compensatory measures;” and when implementing such a plan, 

the crew is required to “continuously evaluate the plan for changing conditions” and 

use “Human Performance (HU) tools (...peer/cross-checking, oversight, questioning 
Notice of Violation 2 

attitude, etc.)” In addition, “When the Control Room team is faced with a time critical 

decision,” the team is required to “Use all available resources,” without proceeding 

“in the face of uncertainty...” However, in this case, the control room operators failed 

to develop contingency plans or compensatory measures for adjusting reactor 

heatup rate or addressing higher than expected reactor heatup rates, and did not 

develop or implement contingencies for control rods which were difficult to physically 

move when they were at low reactor power. Additionally, the use of HU tools was 

ineffective in addressing the actions or conditions that led to the unexpected reactor 

heatup rate or the mispositioning of control rod 30-11. Specifically, poor use of peer 

checking and a failure to adequately question the conditions that led to the 

unexpected reactor heatup rate directly contributed to the mispositioned control rod 

and the reactor scram. Lastly, the Control Room team did not use all available 

resources by failing to involve Reactor Engineering staff in its decision-making, and 

proceeded in the face of uncertainty by inadequately considering the consequences 

of the reactivity changes. 

d. Entergy procedure EN-OP-115, “Conduct of Operations” Revision 10, Section 5.4 

requires that reactor operators perform reactivity manipulations “in a deliberate, 

carefully controlled manner while the reactor is monitored to ensure the desired 

result is obtained;” and, to shutdown the reactor “whenever the status of reactor 

criticality or approach to criticality becomes unknown.” In this case, the reactor 

operators did not perform reactivity manipulations in a deliberate, carefully controlled 

manner and adequately monitor the conditions of the reactor while attempting to 

establish and adjust the reactor heatup rate. Although the reactor operators were 

watching the response of both the IRMs and the computer point displaying a five 

minute average reactor heatup, they were moving control rods faster than the plant 

could respond and therefore taking actions to continue control rod movement before 

the desired result of their manipulations could be assessed. Additionally, after 

inserting control rods to adjust the reactor heatup rate, the operators had sufficient 

indications that the reactor was significantly subcritical as evidenced by the required 

ranging down of IRMs, the drop in SRM count rates, and the negative reactor period. 

Notwithstanding those indications of subcriticality, the operators did not take the 

required action to either shut down the reactor or re-establish a controlled return to 

criticality. This subsequently led to an unrecognized approach to criticality and 

eventual reactor scram. 

e. PNPS procedure 1.3.34 “Operations Administrative Policies and Procedures,” 

Revision 117, Section 6.7.5 requires that “Any relief occurring during the shift (either 

short-term or for the remainder of the shift) will be recorded in the CRS log.” It further 

requires the operators to conduct “a verbal discussion of plant status and off-normal 

conditions...” However, several people in watch standing positions changed from the 

start of the shift, and none of those changes were entered into the control room log. 

In addition, when the Assistant Control Room Supervisor (ACRS) was turning over to 

the Control Room Supervisor, there was no discussion of the mispositioning of 

control rod 30-11, which occurred approximately 15 minutes prior to the turnover. 
Notice of Violation 3 

f. PNPS Procedure 2.4.11, “Control Rod Positioning Malfunctions,” Revision 35, 

Section 5.4 defines a mispositioned control rod as “a control rod found to be left in a 

position other than the intended position or a control rod that moves more than one 

notch beyond its intended position.” Attachment 4 Step 3 of this procedure requires 

that upon discovery of a control rod which is mispositioned greater than one notch, 

Reactor Engineering is to be contacted for an assessment of core conditions. 

Further, the procedure, in Step 5, requires that “If the control rod is determined to be 

mispositioned, then record the event as a condition report.” However, Reactor 

Engineering was not contacted for an assessment of core conditions after a rod 

inadvertently became mispositioned by greater than one notch. In addition, the 

event was not recorded as a condition report. 

g. PNPS Procedure 2.1.1, “Startup from Shutdown” Revision 173, Page 53, Caution 2 

requires that if “the reactor goes subcritical after achieving initial criticality” operators 

must “return to step [53] and re-perform the steps to restore the Reactor to a critical 

condition.” In addition, PNSP Procedure 2.1.4, “Approach to Critical” Revision 26, 

Section 5.0 requires that “In the event the reactor goes subcritical after achieving 

initial criticality” operators must, “with Reactor Engineering guidance, re-perform 

Section 7.0 Steps [6] and [7] to restore the Reactor to a critical condition.” However, 

the operators did not recognize that the reactor had become subcritical and did not 

re-perform the procedural steps mentioned above to restore the reactor to a critical 

condition in a controlled manner under the guidance of Reactor Engineering, even 

though there was sufficient information available to identify that the reactor had 

become subcritical. Reactor Engineers were available in the control room, but they 

were not consulted. 

This violation is associated with a White Significance Determination Process finding. 

The NRC has concluded that information regarding: (1) the reason for the violation; (2) the 

actions planned or already taken to correct the violation and prevent recurrence; and, (3) the 

date when full compliance was achieved, is already adequately addressed on the docket in 

NRC Inspection Report 05000293/2011012, in the Entergy response letter dated October 3, 

2011, and in the letter enclosing this Notice of Violation (Notice). However, you are required to 

submit a written statement or explanation pursuant to 10 CFR 2.201 if the description therein 

does not accurately reflect your corrective actions or your position. In that case, or if you 

choose to respond, clearly mark your response as a "Reply to a Notice of Violation, EA-11-174,” 

and send it to the U.S. Nuclear Regulatory Commission, ATTN: Document Control Desk, 

Washington, DC 20555-0001 with a copy to the Regional Administrator, Region I, and a copy to 

the NRC Resident Inspector at Pilgrim, within 30 days of the date of the letter transmitting this 

Notice. 

If you choose to respond, your response will be made available electronically for public 

inspection in the NRC Public Document Room or from the NRC’s document system (ADAMS), 

accessible from the NRC Web site at http://www.nrc.gov/reading-rm/adams.html. Therefore, to 

the extent possible, the response should not include any personal privacy, proprietary, or 

safeguards information so that it can be made available to the Public without redaction. 
Notice of Violation 4 

In accordance with 10 CFR 19.11, you may be required to post this Notice within two working 

days of receipt. 

Dated this 21st day of November 2011 
Enclosure 2: Assessment of Entergy’s Written Response

In its October 3, 2011, written response to the preliminary White finding issued on September 1, 

2011, the licensee agreed with the primary cause of the event (a lack of consistent supervisory 

and management enforcement of administrative procedure requirements and management 

expectations for command and control, roles and responsibilities, reactivity manipulations, clear 

communications, proper briefings and proper turnovers) and the cross cutting aspect assigned 

as documented in the Special Inspection Report (Human Performance, Work Practices), and did 

not present any new information. However, the letter documents three specific points regarding 

the risk assessment of the finding that Entergy requests the NRC consider. 

Entergy Written Response Consideration 1 

Entergy challenged the NRC’s calculation of Conditional Core Damage Probability 

(CCDP) documented in the special inspection team (SIT) Report that was utilized in the 

IMC 0309 evaluation that led to the decision to conduct a Special Inspection. Entergy 

stated that its risk analysts developed a high E-7 range CCDP while the NRC 

determined CCDP at or near low E-6. 

NRC Response 

The difference between the NRC’s and Entergy’s calculation of the CCDP is small, and 

was discussed with Entergy staff at the early stages of the NRC’s review of the event. It 

is recognized that the Inspection Manual Chapter (IMC) 0309 decision making for 

initiating a reactive inspection is “risk informed,” and other deterministic criteria were also 

considered. Additionally, the NRC did not include the numerous human performance 

errors that were observed by the control room staff at Pilgrim in its CCDP calculation. 

The CCDP is quite sensitive to assumptions of negative licensed operator performance 

and would have further supported the decision to conduct a Special Inspection to better 

understand the facts surrounding the event, had these observations been incorporated. 

The NRC maintains its decision to have conducted the SIT based on information that 

was known at the time. In addition, the results of the inspection, specifically, 

identification of a performance deficiency that was determined to have low to moderate 

safety significance, was determined independently of the risk considerations used in the 

decision to initiate an SIT. 

Entergy Written Response Consideration 2 

Entergy challenged the IMC 0609 Appendix M section relating to “the extent of the 

performance deficiency affecting other equipment,” stating: (1) the performance 

deficiency did not degrade plant equipment or challenge any fission product barriers; (2) 

it is speculative to conclude that the operator performance observed during the event 

had the potential to adversely affect other plant equipment; and, (3) during the event, no 

operator went outside of his assigned roles or responsibilities. 

NRC Response 

Weaknesses in operator human performance fundamentals exhibited during this event 

were observed throughout the operations organization, as discussed in the Entergy root 
Enclosure 2 2 

cause assessment of the event. The broad nature of this performance deficiency (as 

opposed to one which was isolated to a specific crew) demonstrates an increased 

probability of error that could manifest itself in any number of operational situations. 

Although automatic initiation of equipment terminated the transient during this event, it 

was the operators themselves who were directly manipulating reactivity during startup. 

Operator performance is as important to nuclear safety, and to the maintenance of 

defense-in-depth protection, as is the performance of safety-related equipment. In this 

case, the performance of the individual operators and the crew negatively impacted 

nuclear safety. Given the additional information contained in Entergy’s root cause 

assessment and the NRC’s inspection results, the scope of issues extended to other 

operators and crews, as well. 

Entergy Written Response Consideration 3 

Entergy challenged the Appendix M section relating to the “period of time effect on the 

performance deficiency,” stating: (1) its self assessment and corrective action reviews 

identified “gaps to excellence,” that were observed previous to the May event and were 

causal factors associated with the May event; (2) its ROP performance had not indicated 

any negative trends in operator performance in advance of the event; and, (3) the event 

was not preceded by a degradation of operator performance. 

NRC Response 

Entergy’s root-cause evaluation determined that causal factors associated with the event 

had existed for a considerable period of time in advance of the event, and referenced a 

number of condition reports and self assessments to support this conclusion. The NRC 

does not view a lack of procedure compliance as merely a “gap to excellence,” but rather 

a failure to meet a license requirement. 

In summary, Entergy did not present any new facts or arguments in its written response that 

would change the NRC’s determination that the performance deficiency is appropriately 

characterized as having low to moderate safety significance (White).