UNITED STATES

NUCLEAR REGULATORY COMMISSION 

REGION I 

2100 RENAISSANCE BLVD., SUITE 100 

KING OF PRUSSIA, PA 19406-2713 

January 26, 2015 

EA 14-229 

Mr. John Dent 

Site Vice President 

Entergy Nuclear Operations, Inc. 

Pilgrim Nuclear Power Station 

600 Rocky Hill Road 

Plymouth, MA 02360-5508 

SUBJECT: PILGRIM NUCLEAR POWER STATION - NRC 95002 SUPPLEMENTAL 

INSPECTION REPORT 05000293/2014008 AND ASSIGNMENT OF TWO 

PARALLEL WHITE PERFORMANCE INDICATOR INSPECTION FINDINGS 

Dear Mr. Dent: 

On December 2, 2014, the U.S. Nuclear Regulatory Commission (NRC) completed a 

supplemental inspection in accordance with Inspection Procedure (IP) 95002 at Pilgrim Nuclear 

Power Station (Pilgrim). The enclosed report documents the inspection results, which were 

discussed on December 12, 2014, with you and other members of your staff. The inspection 

was performed because Pilgrim experienced four scrams in 2013 which resulted in two 

performance indicators (PI) in the Initiating Events cornerstone, Unplanned Scrams per 7000 

Critical Hours and Unplanned Scrams with Complications, crossing the threshold from Green to 

White. Entergy Nuclear Operations, Inc. (Entergy) performed four root cause evaluations for the 

individual scram events. Additionally, Entergy performed a root cause evaluation to assess the 

commonalities between the four scram events and a common cause analysis to assess if any 

safety culture aspects caused or significantly contributed to the events. 

The NRC performed this supplemental inspection to determine if: (1) the root and contributing 

causes of individual and collective risk-significant performance issues were understood; (2) the 

extent of condition and extent of cause for the individual and collective risk-significant 

performance issues were understood; and (3) your completed or planned corrective actions for 

the risk-significant performance issues are sufficient to address the root and contributing causes 

and prevent recurrence. The NRC also conducted an independent review of the extent of 

condition and extent of cause for the two white PIs and an assessment of whether any safety 

culture component caused or significantly contributed to the performance issues. 

Overall, the NRC has determined that your actions have not provided the assurance level to 

fully meet all of the inspection objectives and have correspondingly determined that Pilgrim will 

remain in the Degraded Cornerstone of the Action Matrix by the assignment of two parallel 

White PI inspection findings. Although inspectors determined that, in general, Entergy’s 

problem identification, cause evaluation, and corrective action plans for the White PIs were 

adequate, they identified deficiencies regarding Entergy’s execution of corrective actions 
J. Dent 2

documented in the corrective action plans, as well as Entergy’s understanding of some of the 

causes of the issues. Specifically, inspectors identified several examples where corrective 

actions were not completed as intended or were closed prematurely. Additionally, for one of the 

root cause evaluations, inspectors determined that Entergy failed to investigate a deficient 

condition in accordance with corrective action program (CAP) requirements to ensure they fully 

understood all of the causes of one of the scram events. 

 

With respect to the safety culture review, inspectors determined that Entergy’s evaluations 

appropriately identified the safety culture aspects that caused or significantly contributed to the 

performance issues. In particular, Entergy identified that implementation of the station’s CAP 

has not been effective in ensuring adequate corrective actions are taken to address issues in a 

timely manner. Inspectors determined that the specific deficiencies in execution of corrective 

actions and causal analysis were indicative of the CAP implementation weakness identified in 

the safety culture review. Correspondingly, inspectors determined that corrective actions 

identified to improve performance in this area have not been effective. Ultimately, inspectors 

determined that your actions in total did not provide the assurance level required to meet 

inspection objectives and represent a significant weakness. In accordance with IP 95002 and 

Inspection Manual Chapter 0305, if the licensee did not (1) adequately evaluate the causes or 

(2) take or plan adequate corrective actions for a safety-significant PI, then a parallel PI 

inspection finding will be opened and given the same color as the PI. As such, based on the 

significant weakness identified above, the NRC is assigning two parallel White PI inspection 

findings in this report. 

Accordingly, Pilgrim will remain in the Degraded Cornerstone Column of the Action Matrix until 

the NRC verifies, through the successful completion of a supplemental inspection, that Entergy 

has taken actions to address the deficiencies identified in evaluation or correction of the 

individual performance issues discussed above. Specifically, the inspection will verify that 

Entergy has taken action to: (1) address the specific deficiencies in execution of corrective 

actions; (2) address the deficient cause evaluation; and (3) understand why corrective actions 

intended to address the identified CAP implementation weakness were not effective at ensuring 

the inspection objectives were satisfied. You or your staff should contact the NRC for a followup inspection when sufficient corrective actions have been completed or planned to address 

these weaknesses. Additionally, the NRC will continue to assess the effectiveness and 

sustainability of your efforts to address challenges in CAP implementation during the next 

biennial problem identification and resolution inspection, scheduled for August 2015. 

In addition to the two parallel White PI inspection findings, this report documents two findings of 

very low safety significance (Green). One of these findings was determined to involve a 

violation of NRC requirements. However, because of the very low safety significance, and 

because it is entered into your CAP, the NRC is treating this finding as a non-cited violation, 

consistent with Section 2.3.2.a of the NRC Enforcement Policy. If you contest the non-cited 

violation in this report, you should provide a response within 30 days of the date of this 

inspection report, with the basis for your denial, to the Nuclear Regulatory Commission, ATTN: 

Document Control Desk, Washington, DC 20555-0001; with copies to the Regional 

Administrator, Region I; the Director, Office of Enforcement, United States Nuclear Regulatory 

Commission, Washington, DC 20555-0001; and the NRC Resident Inspector at Pilgrim. In 

addition, if you disagree with the cross-cutting aspect assigned to any finding, or a finding not 

associated with a regulatory requirement in this report, you should provide a response within 30 
J. Dent 3

days of the date of this inspection report, with the basis for your disagreement, to the Regional 

Administrator, Region I, and the NRC Resident Inspector at Pilgrim. 

In accordance with Title 10 of the Code of Federal Regulations (10 CFR) 2.390, “Public 

Inspections, Exemptions, Requests for Withholding,” of the NRC's "Rules of Practice," a copy of 

this letter, its enclosure, and your response (if any) will be available electronically for public 

inspection in the NRC’s Public Document Room or from the Publicly Available Records 

component of the NRC's Agencywide Documents Access and Management System (ADAMS). 

ADAMS is accessible from the NRC Web site at http://www.nrc.gov/reading-rm/adams.html (the 

Public Electronic Reading Room). 

Sincerely, 

 /RA/ 

Ho K. Nieh, Director 

Division of Reactor Projects 

Docket No. 50-293 

License No. DPR-35 

Enclosure: Inspection Report No. 05000293/2014008 

 w/ Attachment: Supplemental Information 

cc w/encl: Distribution via ListServ 
J. Dent 3 

days of the date of this inspection report, with the basis for your disagreement, to the Regional 

Administrator, Region I, and the NRC Resident Inspector at Pilgrim. 

In accordance with Title 10 of the Code of Federal Regulations (10 CFR) 2.390, “Public 

Inspections, Exemptions, Requests for Withholding,” of the NRC's "Rules of Practice," a copy of 

this letter, its enclosure, and your response (if any) will be available electronically for public 

inspection in the NRC’s Public Document Room or from the Publicly Available Records 

component of the NRC's Agencywide Documents Access and Management System (ADAMS). 

ADAMS is accessible from the NRC Web site at http://www.nrc.gov/reading-rm/adams.html (the 

Public Electronic Reading Room). 

Sincerely, 

 /RA/ 

Ho K. Nieh, Director 

Division of Reactor Projects 

Docket No. 50-293 

License No. DPR-35 

Enclosure: Inspection Report No. 05000293/2014008 

 w/ Attachment: Supplemental Information 

cc w/encl: Distribution via ListServ 

Distribution w/encl: (via email) 

D. Dorman, RA 

D. Lew, DRA 

H. Nieh, DRP 

M. Scott, DRP 

R. Lorson, DRS 

J. Trapp, DRS 

R. Powell, DRP 

R. McKinley, DRP 

S. Shaffer, DRP 

J. DeBoer, DRP 

J. Greives, DRP, SRI 

E. Carfang, DRP, SRI 

B. Scrabeck, DRP, RI 

K. Butler-Morgan, RI OEDO 

N. McNamara, RI, SLO 

D. Tifft, RI, SLO 

D. Screnci, RI, PAO 

N. Sheehan, RI, PAO 

RidsNrrPMPilgrim Resource 

ROPReports Resource 

RidsNrrDorlLpl1-1 Resource 

ROPAssessment Resource

DOCUMENT NAME: G:\DRP\BRANCH5\2-PG\PG 95002 - Nov 2014\Inspection Report Documentation\2014-008 PG 95002 final.docx 

ADAMS ACCESSION NUMBER: ML15026A069 

 SUNSI Review  Non-Sensitive 

 Sensitive 

 Publicly Available 

 Non-Publicly Available 

OFFICE RI/DRP RI/DRP RI/ORA NRR/DIRS RI/DRP 

NAME JGreives/RRM for RMcKinley/RRM BBickett/BB SMorris/SM HNieh/HKN 

DATE 1/14/15 1/14/15 1/20/15 1/23/15 1/26/15 

OFFICIAL RECORD COPY 
1 

 Enclosure 

U.S. NUCLEAR REGULATORY COMMISSION 

REGION I 

Docket No. 50-293 

License No. DPR-35 

Report No. 05000293/2014008 

Licensee: Entergy Nuclear Operations, Inc. (Entergy) 

Facility: Pilgrim Nuclear Power Station 

Location: Plymouth, Massachusetts 

Dates: November 3, 2014 through December 12, 2014 

Inspectors: J. Greives, Senior Resident Inspector, Lead Inspector 

C. Bickett, Senior Project Engineer 

S. Rich, Resident Inspector 

J. Patel, Reactor Inspector 

M. Keefe, Human Factors Specialist, Safety Culture Lead 

S. Morrow, Human Factors Engineer 

A. Keim, Reactor Operations Engineer 

B. Smith, Resident Inspector 

Approved by: Raymond R. McKinley, Chief 

Reactor Projects Branch 5 

Division of Reactor Projects 

 
Enclosure 

2

TABLE OF CONTENTS 

SUMMARY OF FINDINGS ........................................................................................................... 3

REPORT DETAILS ....................................................................................................................... 8

4. OTHER ACTIVITES .............................................................................................................. 8

4OA4 Supplemental Inspection (95002) ..................................................................................... 8

01 Inspection Scope ............................................................................................................... 8

02 Evaluation of the Inspection Requirements ....................................................................... 9

02.01 Problem Identification. ....................................................................................................... 9

02.02 Root Cause, Extent of Condition, and Extent of Cause Evaluation. ................................ 14

02.03 Corrective Actions ........................................................................................................... 25

02.04 Independent Assessment of Extent of Condition and Extent of Cause. .......................... 42

02.05 Safety Culture Consideration .......................................................................................... 46

02.06 Evaluation of IMC 0305 Criteria for Treatment of Old Design Issues.............................. 48

ATTACHMENT: SUPPLEMENTAL INFORMATION.................................................................. 49

SUPPLEMENTAL INFORMATION ........................................................................................... A-1

KEY POINTS OF CONTACT .................................................................................................... A-1

LIST OF ITEMS OPENED, CLOSED, AND DISCUSSED ........................................................ A-1

LIST OF DOCUMENTS REVIEWED ........................................................................................ A-2

LIST OF ACRONYMS ............................................................................................................... A-6
3 

Enclosure 

SUMMARY OF FINDINGS 

Inspection Report (IR) 05000293/2014008; 11/3/2014 – 12/12/2014; Pilgrim Nuclear Power 

Station (Pilgrim); Supplemental Inspection – Inspection Procedure (IP) 95002. 

A senior resident inspector, senior project engineer, two resident inspectors, one reactor 

inspector, one human factors specialist, one human factors engineer, and one reactor 

operations engineer performed this inspection. The inspectors assigned two White parallel 

Performance Indicator (PI) inspection findings. Additionally, inspectors identified two findings of 

very low safety significance (Green), one of which was determined to be a non-cited violation 

(NCV). The significance of most findings is indicated by their color (i.e., greater than Green, or 

Green, White, Yellow, Red) and determined using Inspection Manual Chapter (IMC) 0609, 

“Significance Determination Process (SDP),” dated June 2, 2011. Cross-cutting aspects are 

determined using IMC 0310, “Aspects Within the Cross-Cutting Areas,” dated December 4, 

2014. All violations of NRC requirements are dispositioned in accordance with the NRC’s 

Enforcement Policy, dated July 9, 2013. The NRC’s program for overseeing the safe operation 

of commercial nuclear power reactors is described in NUREG-1649, “Reactor Oversight 

Process,” Revision 5, February 2014. 

Cornerstone: Initiating Events

The NRC staff performed this supplemental inspection in accordance with IP 95002, 

“Supplemental Inspection for One Degraded Cornerstone or Any Three White Inputs in a 

Strategic Performance Area,” dated February 9, 2011, to assess Entergy’s root and common 

cause evaluations associated with Pilgrim’s entry into the Degraded Cornerstone Column of the 

Reactor Oversight Program (ROP) Action matrix due to two White PIs in the Initiating Events 

cornerstone. Pilgrim experienced four scrams in 2013 which resulted in the Unplanned Scrams 

per 7000 Critical Hours and Unplanned Scrams with Complications PIs crossing the threshold 

from Green to White. 

Entergy performed a root cause evaluation (RCE) for each of the unplanned scram events. 

Additionally, Entergy performed a RCE upon entry into the Degraded Cornerstone Column to 

identify weaknesses which led to the degraded cornerstone and to document a collective causal 

evaluation. Entergy also conducted a common cause analysis (CCA) to perform a review of the 

site safety culture and determine if any aspects of safety culture contributed to the four scram 

events. For each of the evaluations, Entergy identified corrective actions to address the 

identified causes. In performance of these reviews, Entergy identified challenges in corrective 

action program (CAP) implementation in that Entergy has not taken corrective actions to 

address identified issues and causes in a timely manner. Entergy’s CCA documented that this 

was the leading driver behind challenges in nuclear safety culture behaviors at Pilgrim. 

Additionally, Entergy identified that individuals did not always understand the importance of 

adhering to nuclear standards and that station leaders have not consistently exhibited behaviors 

that set the appropriate standards. 

Although, the inspectors determined that, in general, Entergy’s problem identification, cause 

evaluation, and corrective action plans for the two White Initiating Events PIs were adequate, 

they identified deficiencies regarding Entergy’s execution of corrective actions documented in 

the corrective action plans, as well as Entergy’s understanding of some of the causes of the 

issues. 
4 

Enclosure 

Inspectors identified that Entergy had not completed several corrective actions adequately or in 

a timely manner as specified in the RCEs and as required by their CAP. Specifically, for the 

scram which occurred on February 8, 2013, during a winter storm, Entergy did not complete an 

action to send a faulted component for failure analysis in accordance with CAP procedure 

requirements. This prevented the inspectors from verifying that Entergy understood the material 

condition of the main switchyard transformer insulators and that the material condition and 

supporting preventative maintenance tasks were sufficient. The intent of this testing is to assist 

in determining a replacement strategy for insulators and is used to determine the condition of 

the insulator exterior glazing which is effective against contamination from coastal salt, fog, 

and/or mist conditions. Additionally, inspectors identified that Entergy had failed to complete 

one of the effectiveness reviews for this RCE in accordance with their CAP requirements 

Inspectors also determined that implementation of several corrective actions was inadequate to 

provide assurance that the corrective action plan for a loss of reactor recirculation flow which 

resulted in a reactor scram on January 10, 2013, was sufficient to address the root and 

contributing causes, including the extent of those causes. The corrective action plan included 

actions to review surveillance procedures and ensure they did not have similar deficiencies 

(e.g., physical work complete prior to system restoration, critical steps identified). Training was 

conducted with personnel to reinforce human performance standards and enhanced oversight 

of field activities by managers and supervisors was specified to reinforce human performance 

standards in the field. Entergy conducted assessments of the RCE prior to this inspection and 

self-identified that many of these actions had either not been completed as intended or lacked 

sufficient evidence to support closure. Despite additional actions being specified to correct the 

licensee-identified deficiencies, the inspectors identified that many of the human performance 

related actions were either cancelled or closed. As an example, a maintenance standing order 

was created and signed by maintenance supervisors in September 2014 which directed interim 

actions for enhanced supervisor oversight and procedure review in preparation for maintenance. 

This was an interim action until a long-term procedure upgrade project for maintenance was 

complete. Despite this, inspectors identified that the maintenance standing order was not being 

implemented at the time of the on-site inspection. Inspector’s observation of maintenance 

execution and review of recently completed maintenance did not support closure or cancellation 

of corrective actions identified in the RCE. 

For the scram that occurred on August 22, 2013, an electrical transient on a non-safety-related 

bus resulted in the loss of all reactor feedwater. Inspectors determined that Entergy’s RCE 

adequately investigated a modification that created the single point vulnerability (SPV) to a loss 

of all reactor feed. However, inspectors determined that Entergy did not investigate the cause 

of the electrical transient in accordance with station CAP requirements sufficiently to ensure all 

the causes were understood. The electrical transient was directly caused by a failed cable 

splice; however, Entergy did not investigate this failure mechanism sufficiently to determine the 

specific cause such that the extent of cause could be understood and appropriate corrective 

actions could be taken. 

Inspectors noted that both the common cause evaluation and safety culture review performed 

by Entergy appropriately identified that implementation of the station’s CAP had not been 

effective in ensuring adequate corrective actions were taken to address issues in a timely 

manner, and Entergy identified corrective actions to improve performance in this area. 

Inspectors also identified examples where corrective actions identified to address challenges in 

CAP implementation were not being completed as required. Specifically, two actions 

(departmental performance improvement coordinator mentoring and corrective action closure 

training with the condition review group (CRG)) were cancelled without being completed. 
5 

Enclosure 

Inspectors’ discussion with Entergy personnel revealed that the performance improvement 

department determined that these actions were not producing the desired results, and they 

decided to implement training instead. However, Entergy staff did not receive Corrective Action 

Review Board (CARB) approval of the changes as required by CAP procedures. 

Inspectors determined that the specific deficiencies in execution of corrective actions and causal 

analysis were indicative of the CAP implementation weakness identified in the safety culture 

review and correspondingly determined that corrective actions specified in the common cause 

and safety culture evaluations were ineffective. As such, these issues represent a significant 

weakness because they did not provide assurance that you (1) understood the causes and (2) 

had taken or planned adequate corrective actions to address the safety-significant PIs. 

Therefore, in accordance with IP 95002 and IMC 0305, the NRC staff is assigning two parallel 

White PI inspection findings which will remain in effect until a follow-up supplemental inspection 

has been satisfactorily completed. In addition, the NRC staff identified two performance 

deficiencies during the inspectors’ review of Entergy’s evaluations and corrective actions. The 

follow-up inspection will verify that Entergy has: (1) assessed the independent failure analysis of 

the faulted insulator for potential impact to the RCE and revised as appropriate; (2) revised the 

RCE for the winter storm scram to include additional action for the incomplete effectiveness 

review; (3) demonstrated effectiveness of additional human performance related corrective 

actions implemented during the inspection through in-progress and completed work; and (4) 

completed the evaluation of the cause(s) for the failed splice and revised the RCE to include 

additional corrective actions, if appropriate. Additionally, the follow-up inspection will verify that 

Entergy has considered the revisions to the RCEs for potential revision to the overall common 

cause evaluation, which should include taking action to understand why corrective actions 

intended to address the identified CAP implementation weakness was not effective at ensuring 

the inspection objectives were satisfied. 

 White. The NRC assigned two parallel White PI inspection findings involving a significant 

weakness identified in Entergy's causal evaluation and corrective actions for the White 

Unplanned Scrams per 7000 Critical Hours and White Unplanned Scrams with 

Complications PIs. 

In accordance with IP 95002 and NRC IMC 0305, "Operating Reactor Assessment 

Program," parallel PI inspection findings are assigned the same safety significance as the 

initiating PIs. These two parallel PI inspection findings provide for additional NRC review of 

Entergy's actions to address the weaknesses identified in this report. These findings take 

the color (White) of the PIs. (Section 4AO4 02.03.f.2) 

 Green. Inspectors identified a Green finding because Entergy did not fully derive the causes 

of the manual scram on August 22, 2013, following a loss of all feedwater. Specifically 

Entergy did not investigate the causes of a failed cable splice which directly caused an 

electrical transient that resulted in the automatic tripping of all three reactor feed pumps 

(RFPs) in accordance with the standards in Entergy procedures EN-LI-118, “Cause 

Evaluation Process,” and EN-LI-118-01, “Event and Causal Factor Charting.” Entergy 

entered the issue into the CAP as condition report (CR)-PNP-2014-5796 and initiated 

additional causal analysis to determine why the splice was improperly fabricated. 

This performance deficiency affects the equipment performance attribute of the Initiating 

Events cornerstone, because the failure to fully derive the causes of the failed splice 

prevented them from taking appropriate actions to evaluate and correct those causes. This 

impacts the cornerstone objective to limit the likelihood of events that upset plant stability 
6 

Enclosure 

and challenge critical safety functions during shutdown as well as power operations because 

unidentified deficiencies could lead to similar electrical transients which could cause similar 

plant transients and scrams. The inspectors determined the significance of the finding using 

IMC 0609, Appendix A, “The Significance Determination Process for Findings At-Power.” 

The finding was determined to be of very low safety significance (Green) because the 

finding was a transient initiator and, although the event being evaluated for causal factors 

caused a reactor scram and loss of mitigation equipment, the failure to identify all the 

causes of the event and plan appropriate corrective actions has not resulted in a 

subsequent reactor scram or loss of mitigating equipment. This finding had a cross-cutting 

aspect in the area of Problem Identification and Resolution, Evaluation, because Entergy did 

not thoroughly evaluate the issue of the manual scram to ensure that resolutions address 

causes and extent of conditions commensurate with their safety significance. Specifically, 

Entergy focused on the causes related to the modification of the feed pump trips and did not 

fully evaluate the causes related to the failed splice. [P.2] (Section 4OA4 02.02.e) 

 Green. The inspectors identified a Green finding for Entergy's failure to identify and correct 

conditions adverse to quality by implementing adequate and timely actions to address 

similar conditions. Specifically, inspectors identified multiple examples of failure to 

implement the corrective actions in accordance with CAP requirements which resulted in 

failing to identify and correct several conditions adverse to quality. Two of the finding 

examples also involved a NCV of Title 10 of the Code of Federal Regulations (10 CFR) Part 

50, Appendix B, Criterion XVI, "Corrective Action." Entergy’s immediate corrective actions 

included entering the issues into their CAP as CR-PNP-2014-5909, CR-PNP-2014-5976; 

CR-PNP-2014-5977, CR-PNP-2014-5682, CR-PNP-2014-5625, CR-PNP-2014-5826, CRPNP-2014-5735, and CR-PNP-2014-06067. Additionally, Entergy took action to address the 

conditions adverse to quality by revising procedures and specifying additional procedure 

reviews to identify and correct other conditions adverse to quality. 

The failure to implement CAP procedural requirements with respect to corrective action 

response and documentation was a performance deficiency. This finding was determined to 

be more than minor because it was similar to IMC 0612, "Power Reactor Inspection 

Reports," Appendix E, "Examples of Minor Issues," example 3.j in that it represents a 

significant programmatic deficiency that could lead to worse errors if uncorrected. 

Specifically, if left uncorrected this issue would have the potential to lead to a more 

significant safety concern because not following an established process for completing 

corrective actions could result in a failure to identify and correct conditions adverse to quality 

or other adverse conditions. Additionally, this performance deficiency affects the procedure 

quality, equipment performance, and human performance attributes of the Initiating Events 

cornerstone, and impacts the objective to limit the likelihood of events that upset plant 

stability and challenge critical safety functions during shutdown as well as power operations. 

Specifically, a severe weather procedure did not prescribe sufficient actions that would limit 

the likelihood of ice bridging or place the plant in a condition that it could respond to a loss of 

offsite power (LOOP) without potentially upsetting plant stability, and the failure to conduct 

insulator testing prevented the station from assessing its replacement strategy. Additionally, 

several surveillance procedures did not provide sufficient barriers (e.g. critical step 

annotation, test equipment verification, etc.) in accordance with the station programs to limit 

the likelihood of scrams and other transients during testing. 

The inspectors determined the significance of the finding using IMC 0609, Appendix A, “The 

Significance Determination Process for Findings At-Power.” The finding was determined to 

be of very low safety significance (Green) because the failure to implement corrective 
7 

Enclosure 

actions has not resulted in a subsequent reactor scram or loss of mitigating equipment. This 

finding had a cross-cutting aspect in the area of Problem Identification and Resolution, 

Resolution, because Entergy did not take effective corrective actions to address issues in a 

timely manner commensurate with their safety significance. Specifically, corrective actions 

were not completed in accordance with Entergy’s CAP and, in some cases, after 

identification of unsatisfactory closure by Entergy, follow-up actions were inadequate to 

resolve the deficiencies. [P.3] (Section 4OA4 02.03.f) 
8 

Enclosure 

REPORT DETAILS 

4. OTHER ACTIVITES 

4OA4 Supplemental Inspection (95002) 

 01 Inspection Scope 

The NRC staff performed this supplemental inspection in accordance with IP 95002 to 

assess Entergy’s evaluation associated with two White PIs which affected the Initiating 

Events cornerstone in the reactor safety strategic performance area. The objectives of 

the 95002 inspection were to: 

 

 provide assurance that the root and contributing causes of individual and collective 

risk-significant performance issues were understood; 

 provide assurance that the extent of condition and extent of cause of risk-significant 

issues were identified and to independently assess the extent of condition and extent 

of cause of individual and collective risk-significant issues; 

 independently determine if safety culture components caused or significantly 

contributed to the performance issues; and 

 provide assurance that the licensee’s corrective actions for risk-significant issues 

were or will be sufficient to address the root and contributing causes and to preclude 

repetition.

Pilgrim entered the Regulatory Response Column of the NRC’s ROP Action Matrix 

because one PI was of low to moderate safety significance (White) in the Initiating 

Events cornerstone. Specifically, the “Unplanned Scrams with Complications” PI 

crossed the Green to White threshold value in the 3rd quarter of 2013. In response to 

this ROP Action Matrix input, Pilgrim was transitioned to the Regulatory Response 

Column of the Action Matrix as documented in an assessment follow-up letter dated 

November 6, 2013 (ML13310A318). Subsequently, a second PI was reported of low to 

moderate safety significance (White) in the Initiating Events cornerstone. Specifically, 

the “Unplanned Scrams per 7000 Critical Hours” PI for Pilgrim crossed the threshold 

from Green to White in the 4th quarter of 2013. In response to these two ROP Action 

Matrix inputs, Pilgrim was transitioned to the Degraded Cornerstone Column of the 

Action Matrix as documented in an assessment letter dated March 4, 2014 

(ML14063A316). The NRC informed Entergy of the intent to perform a supplemental 

inspection in accordance with IP 95002 in this letter. 

Entergy informed the NRC on September 25, 2014, that they were ready for the 

supplemental inspection. In preparation for the inspection, Entergy performed a RCE for 

each of the unplanned scram events on January 10, 2013, February 8, 2013, August 22, 

2013, and October 14, 2013. Additionally, Entergy performed a RCE upon entry into the 

Degraded Cornerstone Column to identify weaknesses that existed in the site 

organization. This RCE was conducted to identify weaknesses which led to the 

degraded cornerstone, and to document a collective causal evaluation. Entergy also 

conducted a CCA to perform a review of the site safety culture and determine if any 

aspects of safety culture contributed to the four scram events. 
9 

Enclosure 

Entergy documented their assessments and evaluations associated with the events that 

are the focus of this inspection in the following CRs: 

 

 CR-PNP-2013-0147 – RCE for Inadvertent Trip of Both Reactor Recirculation 

Pumps (RRPs) on January 10, 2013 

 CR-PNP-2013-0798 – RCE for Loss of Offsite Power on February 8, 2013 

 CR-PNP-2013-5949 – RCE for Manual Scram due to Trip of All Three RFPs on 

August 22, 2013 

 CR-PNP-2013-6944 – RCE for Loss of Offsite Power and Subsequent Reactor 

Scram on October 14, 2013 

 CR-PNP-2013-7830 – RCE for Degraded Initiating Events Cornerstone 

 CR-PNP-2014-1669 – Safety Culture Aspect CCA 

For clarity and ease of reading, the individual CR numbers will not be repeated in the 

body of this IR. The report is broken up into sections for each event. The reference to 

RCE or CCA in each section will be specific to the applicable CR above for the event 

being discussed. 

The inspectors reviewed Entergy’s causal evaluation for each issue in addition to other 

evaluations conducted in support of and as a result of the identified causes. The 

inspectors reviewed corrective actions that were taken or planned to address the 

identified causes. The inspectors also held discussions with Entergy personnel to ensure 

that the root and contributing causes and the contribution of safety culture components 

were understood and corrective actions taken or planned were appropriate to address 

the causes and preclude repetition. The inspectors also independently assessed the 

extent of condition and extent of cause of the identified issues. In addition, the 

inspectors performed an assessment of whether any safety culture components caused 

or significantly contributed to the issues.

 

02 Evaluation of the Inspection Requirements 

02.01 Problem Identification. 

a. IP 95002 requires that the inspection staff determine that the licensee’s evaluation of the 

issue documents who identified the issue (i.e., licensee-identified, self-revealing, or 

NRC-identified) and the conditions under which the issue was identified. 

.1 Reactor Scram due to Inadvertent Trip of Both RRPs on January 10, 2013 

On January 10, 2013, both RRPs tripped unexpectedly while Pilgrim was operating at 

100 percent power. The operators responded by inserting a manual scram. The pumps 

tripped when Entergy staff reset the residual heat removal break detection logic with a 

relay inadvertently sealed in following surveillance testing. The relay sealed in when the 

relay cover jarred the relay while it was being installed by instrumentation and control 

(I&C) technicians. This was a self-revealing event, caused by the failure of I&C 

department personnel to ensure adequate barriers were in place to mitigate the potential 

adverse consequences of the error while performing the surveillance procedure. 

Additionally, inadequate application of human performance tools and overconfidence 

and complacency among the members of the I&C department contributed to this event. 
10 

Enclosure 

The inspectors determined that Entergy’s RCE appropriately documented the 

identification of the issues and the conditions under which they were identified. 

.2 Complicated Reactor Scram due to Loss of Offsite Power on February 8, 2013 

On February 8, 2013, during a significant winter storm, Pilgrim lost offsite power and 

experienced an automatic reactor scram from 83 percent power. This was a selfrevealing event caused by external faults on the 345 kilovolt (kV) system which resulted 

in the loss of both 345 kV transmission lines connected to the Pilgrim switchyard ring 

bus. The loss of transmission lines resulted in a LOOP and a main generator load reject 

followed by an automatic reactor scram. During this event, Pilgrim experienced two 

subsequent LOOP events following the initial reactor scram. On February 8, 2013, and 

February 10, 2013, when the start-up transformer (SUT) was reenergized, two 

flashovers (phase to ground fault) occurred on the insulator supporting the ‘B’ phase of 

the 345 kV line supply to the SUT. The flashovers were determined to be caused by icebridging on the insulator. The subsequent LOOP events were caused by faults internal 

to the Pilgrim switchyard, which is operated and maintained by Entergy. 

The inspectors determined that Entergy’s RCE appropriately documented the 

identification of the issues and conditions under which they were identified. 

.3 Complicated Reactor Scram due to Trip of All Three RFPs on August 22, 2013 

On August 22, 2013, operators inserted a manual scram when all three RFPs tripped 

due to a low cooling water flow signal. This was a self-revealing event, triggered by an 

electrical ground in the circuit for level control valve LV-3067 which tripped open breaker 

Y1-24 and caused a loss of power to the cooling water flow instrumentation. The loss of 

power resulted in a low cooling water flow signal to the pumps because of a modification 

installed in 2011. This modification created a SPV in that an electrical transient on the 

Y-1 bus could cause a low cooling water flow trip of all three RFPs, requiring a manual 

scram in accordance with abnormal operating procedures. The ground occurred on an 

improperly fabricated splice installed in 1999. 

The inspectors determined that Entergy’s RCE appropriately documented the 

identification of the issues and the conditions under which they were identified. 

.4 Complicated Reactor Scram due to Loss of Offsite Power on October 14, 2013 

On October 14, 2013, during steady state reactor operations with one of two 345 kV 

transmission lines, Line 342, out of service for planned maintenance, the remaining 345 

kV transmission, Line 355, de-energized unexpectedly, causing a LOOP and a main 

generator load reject followed by an automatic reactor scram. This was a self-revealing 

event, which was caused by the failure of equipment outside the control of Entergy. Line 

355 de-energized when a wooden pole supporting the ‘B’ phase structure failed at an 

offsite substation. 

The inspectors determined that Entergy’s RCE appropriately documented the 

identification of the issues and conditions under which they were identified. 

 
11 

Enclosure 

b. IP 95002 requires that the inspection staff determine that the licensee’s evaluation of the 

issue documents how long the issue existed and prior opportunities for identification. 

.1 Reactor Scram due to Inadvertent Trip of Both RRPs on January 10, 2013 

Difficulties with relay cover installation were a long-standing problem at Pilgrim. Entergy 

personnel developed a tool to assist in cover reinstallation, but did not incorporate steps 

in their procedures to verify the relay had not changed state during installation. The 

RCE documented that the department was accustomed to overcoming difficulties and 

working around them. 

Entergy had prior opportunities to identify the issue with relay cover installation during 

their review of operating experience (OE) from plants outside the Entergy fleet. 

Specifically, Entergy staff reviewed reports on inadvertent logic actuations due to relay 

cover replacement on June 14, 2011, and August 16, 2012. Their RCE states that at the 

time of review, Entergy believed the OE was not relevant to Pilgrim. 

The inspectors determined that Entergy’s RCE was adequate with respect to identifying 

how long the issue existed and prior opportunities for identification. 

.2 Complicated Reactor Scram due to Loss of Offsite Power on February 8, 2013 

The RCE for this event documented that a similar event occurred in 2008, when weather 

related build-up of snow and ice on a bushing associated with the ‘A’ phase of an aircircuit breaker in the switchyard caused a current path to ground, known as a flashover, 

resulting in a main generator load reject and reactor scram. During that event, a LOOP 

occurred due to a flashover of the arcing horn on the transmission line which was 

isolated by breaker operations at the Pilgrim switchyard. Procedures were revised to 

provide guidance for increased monitoring of switchyard during winter storms. However, 

corrective actions taken in 2008 were not adequate to prevent the event of February 8, 

2013. Those previous corrective actions to prevent recurrence (CAPRs) failing to 

prevent recurrence of the event was identified as one of the contributing causes in the 

RCE. 

The inspectors determined that Entergy’s RCE was adequate with respect to identifying 

how long the issue existed and prior opportunities for identification. 

.3 Complicated Reactor Scram due to Trip of All Three RFPs on August 22, 2013 

Plant design change 98-38 installed the splice on the non-safety-related cables to a level 

control valve, LV-3067, in 1999. The splice was inside the flexible conduit leading to the 

valve, and its location was not marked on any drawings. Because of this, Entergy 

determined that there were no prior opportunities for identification of the deficient splice. 

Entergy had two prior opportunities to identify the SPV introduced by the low cooling coil 

flow instrument modification in 2011, and documented both of them in the RCE. An 

individual in the training department wrote CR-PNP-2011-3253 on July 7, 2011, 

observing that all three feed pumps would now trip on a sustained loss of power to their 

cooling coil flow instruments, and that the procedures had not been updated to reflect 

this. Entergy determined that the trips were acceptable because a loss of all feedwater 

is an analyzed transient. The corrective actions to address the CR included changing 
12 

Enclosure 

the procedures, training operators on the new trip, and issuing a human performance 

clock reset memo discussing the importance of updating all procedures following design 

changes. Because of these corrective actions, Entergy staff at all levels had an 

opportunity to question the introduction of a new SPV. 

Additionally, an individual in the operations department wrote CR-PNP-2011-5012 on 

November 5, 2011. This CR questioned why the feed pumps tripped automatically on 

low flow, and yet the operating procedure for the turbine building closed cooling water 

system had an attachment that allowed bypassing the feed water pump low cooling coil 

flow trip. The CR was closed with no action taken, and a work tracking assignment was 

given to system engineering to determine whether it was better to trip the pumps 

automatically on low flow or to manually trip them on high bearing temperature. This 

was an opportunity to remove the pump trip on low flow and prevent the event on 

August 22, 2013. Instead, system engineering recommended maintaining the automatic 

trip and removing the procedure instruction to bypass it. 

The inspectors determined that Entergy’s RCE was adequate with respect to identifying 

how long the issue existed and prior opportunities for identification. 

.4 Complicated Reactor Scram due to Loss of Offsite Power on October 14, 2013 

The RCE for this event documented that similar LOOP events that occurred were 

weather related and that corrective actions that were implemented for the causes could 

not have prevented this event. Entergy’s RCE stated that Pilgrim places the offsite 

transmission lines in a single point vulnerable condition for maintenance in accordance 

with procedures and that, following entering this condition, the single offsite line failed 

due to a degraded electrical pole. Entergy determined that there were no missed 

opportunities for identification of the defective pole because it was outside of the Pilgrim 

switchyard and therefore outside of Entergy’s control. 

The inspectors determined that Entergy’s RCE was adequate with respect to identifying 

how long the issue existed and prior opportunities for identification. 

c. IP 95002 requires that the inspection staff determine that the licensee’s evaluation 

documents the plant specific risk consequences, as applicable, and compliance 

concerns associated with the issues both individually and collectively. 

.1 Reactor Scram due to Inadvertent Trip of Both RRPs on January 10, 2013 

Entergy’s RCE reviewed and documented the consequences of the scram. A trip of both 

RRPs is an analyzed transient documented in Pilgrim’s updated final safety analysis 

report (UFSAR). Pilgrim did not challenge safety limits, design limits, or fission product 

barriers. Entergy’s risk significance determination for the scram resulted in a value of 

2.5 E-7 for Conditional Core Damage Probability (CCDP). 

The inspectors determined that Entergy appropriately documented the plant-specific risk 

consequences and compliance concerns for this event. 

 
13 

Enclosure 

.2 Complicated Reactor Scram due to Loss of Offsite Power on February 8, 2013 

Entergy’s RCE reviewed and documented the consequences of this event. The safety 

significance of this event was primarily associated with the initial main generator load 

reject and reactor scram, which is an analyzed transient in Pilgrim’s UFSAR. Despite 

the loss of power to the SUT during and following the storm, operators established and 

maintained safe shutdown conditions in accordance with station procedures. The 

emergency diesel generators started and loaded as expected following the loss of the 

SUT. Based on the challenges to safety systems during and following the event, CCDP 

for the event was estimated to be 3.2E-05. 

The inspector determined that Entergy appropriately documented the plant-specific risk 

consequences and compliance concerns associated with this event. 

.3 Complicated Reactor Scram due to Trip of All Three RFPs on August 22, 2013 

Entergy’s RCE reviewed and documented the consequences of the scram. A loss of all 

feedwater is an analyzed transient documented in Pilgrim’s UFSAR. Pilgrim did not 

challenge safety limits, design limits, or fission product barriers. Entergy’s risk 

significance determination for the scram resulted in a value of 4.3 E-7 for CCDP. 

The inspectors determined that Entergy appropriately documented the plant-specific risk 

consequences and compliance concerns for this event. 

.4 Complicated Reactor Scram due to Loss of Offsite Power on October 14, 2013 

Entergy’s RCE reviewed and documented the consequences of this event. The safety 

significance of this event was primarily associated with the main generator load reject 

and reactor scram that occurred when transmission Line 355 de-energized, which is an 

analyzed transient in Pilgrim’s UFSAR. Despite the LOOP to the SUT, operators 

established and maintained safe shutdown conditions in accordance with station 

procedures. The emergency diesel generators started and loaded as expected following 

the loss of SUT. During the event, the availability of the shutdown transformer and 

station blackout diesel generator was not challenged. Based on challenges to safety 

systems, CCDP for the event was estimated to be 2.7E-05. 

The inspectors determined that Entergy appropriately documented the plant-specific risk 

consequences and compliance concerns associated with this event. 

.5 Root Cause Evaluation of Degraded Initiating Events Cornerstone 

Entergy’s RCE of the Degraded Initiating Events Cornerstone evaluated risk significance 

collectively and determined that the four events did not overlap in time. The station 

modified the average maintenance full power model to evaluate the collective impact of 

the events and determined that the increase in core damage frequency was 8.30E-7 per 

year which is less than the 1E-6 per year screening criterion for risk significance. 

The inspectors determined that Entergy appropriately documented the risk 

consequences and compliance concerns associated with the collective events. 

 
14 

Enclosure 

d. Findings 

No findings were identified.

02.02 Root Cause, Extent of Condition, and Extent of Cause Evaluation. 

a. IP 95002 requires that the inspection staff determine that the licensee evaluated the 

issue using a systematic methodology to identify the root and contributing causes. 

.1 Reactor Scram due to Inadvertent Trip of Both RRPs on January 10, 2013 

Entergy performed a RCE in accordance with Entergy procedure EN-LI-118, “Causal 

Evaluation Process,” and its associated attachments. Entergy used the following 

systematic methods to complete the RCE: 

 Behavioral Analysis; 

 Barrier Analysis; 

 Event and Causal Factor Charting; 

 Failure Mode Analysis; and 

 “Why” Staircase tool. 

The inspectors determined that Entergy evaluated the issues using a systematic method 

to identify root and common causes. 

.2 Complicated Reactor Scram due to Loss of Offsite Power on February 8, 2013 

Entergy performed a RCE in accordance with Entergy procedure EN-LI-118, “Cause 

Evaluation Process,” and its associated attachments. Entergy used the following 

systematic methods to complete RCE: 

 Organization and Programmatic Causal Evaluation; 

 Fault Tree Analysis; 

 Failure Mode Analysis; 

 Barrier Analysis; and 

 Comparative Timeline. 

The inspectors determined that Entergy evaluated the issue using a systematic method 

to identify root and common causes. 

.3 Complicated Reactor Scram due to Trip of All Three RFPs on August 22, 2013 

Entergy performed a RCE in accordance with Entergy procedure EN-LI-118, “Causal 

Evaluation Process,” and its associated attachments. Entergy used the following 

systematic methods to complete the RCE: 

 

 Barrier Analysis; 

 Event and Causal Factor Charting; 

 Failure Mode Analysis; and 

 “Why” Staircase tool. 
15 

Enclosure 

The inspectors determined that Entergy evaluated the issues using a systematic method 

to identify root and common causes. 

.4 Complicated Reactor Scram due to Loss of Offsite Power on October 14, 2013 

Entergy performed a RCE in accordance with Entergy procedure EN-LI-118, “Cause 

Evaluation Process,” and its associated attachments. Entergy used the following 

systematic methods to complete RCE: 

 Event and Causal Factor Charting; and 

 “Why” Staircase Tool. 

The inspectors determined that Entergy evaluated the issue using a systematic method 

to identify root and common causes. 

.5 Root Cause Evaluation of Degraded Initiating Events Cornerstone 

Entergy performed a RCE in accordance with Entergy procedure EN-LI-118, “Cause 

Evaluation Process,” and associated attachments. Entergy used the following 

systematic methods to complete the evaluation: 

 Pareto analysis (data binning); 

 Stream analysis; 

 Trend code binning, using trend codes assigned to each of the four individual 

root causes; and 

 Kepner-Tregoe analysis. 

The inspectors determined that Entergy evaluated the issues using a systematic method 

to identify root and common causes. 

b. IP 95002 requires that the inspection staff determine that the licensee’s RCE was 

conducted to a level of detail commensurate with the significance of the issue. 

.1 Reactor Scram due to Inadvertent Trip of Both RRPs on January 10, 2013 

Entergy assembled a multi-discipline team to perform the RCE for this issue. In addition 

to the direct cause of the inadvertent seal-in of a relay during cover replacement, the 

evaluation identified one root cause and two contributing causes: 

 I&C department personnel failed to ensure that the surveillance procedure included 

adequate barriers during surveillance testing to mitigate potential adverse 

consequences. Specifically, personnel did not ensure the procedure included steps 

of sufficient detail to remove and reinstall relay covers and the validation of relay 

state was not completed immediately prior to the resetting of logic (Root Cause); 

 Inadequate application of human performance tools by I&C department personnel 

(Contributing Cause); and 

 Overconfidence and complacency was demonstrated by I&C department personnel 

who were tolerant to the difficulty in relay cover installation. Personnel were aware 

that replacing the relay covers was difficult, but it became a normal practice to make 
16 

Enclosure 

multiple attempts because no consequences had previously occurred at Pilgrim. 

(Contributing Cause). 

Based on the in-depth analysis performed for this RCE, the inspectors concluded that 

the evaluation was conducted to a level of detail commensurate with the significance of 

the problem. 

.2 Complicated Reactor Scram due to Loss of Offsite Power on February 8, 2013 

Entergy assembled a multi-discipline team to perform the RCE for this issue. The RCE 

identified two root causes and three contributing causes: 

 The coincident loss of transmission lines from faults external to Pilgrim resulted 

in a LOOP, main generator load reject, and reactor scram. This cause was 

determined to be outside the control of Entergy (Root Cause); 

 Entergy failed to ensure that procedures established adequate pre-defined, riskbased criteria to guide operators confronted with deteriorating switchyard 

conditions during and following a blizzard (Root Cause); 

 Entergy failed to ensure that procedure 2.1.42, “Operation During Severe 

Weather,” provided guidance for operators to determine which severe snow 

storms were most likely to challenge Pilgrim switchyard reliability (Contributing 

Cause); 

 Entergy did not ensure that CAPRs from previous severe weather events 

prevented recurrence (Contributing Cause); and 

 Previously identified internal OE was not successfully utilized by Entergy to 

direct removal of snow and ice from transformer insulators prior to reenergizing 

(Contributing Cause). 

Based on the extensive work performed for this RCE, the inspectors concluded that the 

RCE was conducted to a level of detail commensurate with the significance of the 

problem. 

.3 Complicated Reactor Scram due to Trip of All Three RFPs on August 22, 2013 

Entergy assembled a multi-discipline team to perform the RCE for this issue. The 

evaluation identified a direct cause, a root cause and a contributing cause: 

 An undocumented splice associated with LV-3067 failed and damaged the cable 

section resulting in a short to ground and the tripping of breaker Y1-24, which 

removed power from the RFP seal cooling coil flow instruments and generated 

trip signals for all three RFPs (Direct Cause); 

 The SPV design criteria associated with the RFP low seal cooling water flow 

modification was not clearly defined by Entergy. The intent of the modification 

was to reduce the likelihood of a spurious feed pump trip due to a failed switch. 

However, the modification ultimately resulted in the introduction of a SPV such 

that a loss of circuit 24 on bus Y1 would trip all three RFPs. When the design 

was initially approved, Entergy personnel did not recognize that the instruments 

were all powered from the same source because the design criteria did not 

specifically call out that design aspect (Root Cause); and 
17 

Enclosure 

 Corrective actions to address a CR which identified the above SPV failed to 

adequately address the concern (Contributing Cause). 

Inspectors concluded that the RCE was conducted to a level of detail necessary to 

evaluate Entergy’s introduction of a SPV as well as their failure to effectively use the 

CAP when it was subsequently identified. However, Entergy did not identify a root or 

contributing cause for the failure of the undocumented splice, even though without the 

short to ground the event would not have occurred. Entergy considered the causes of 

the failed splice in their event and causal factor chart and in their “Why” staircase. 

Entergy terminated their event and causal factor chart at “maintenance work practices,” 

which does not meet the criteria listed in governing procedure for a root or contributing 

cause. The procedure for the “Why” staircase method cautions that it may only get to 

the general area of the cause and most likely will require further analysis to establish the 

exact cause. Based on this, the inspectors determined that the RCE was not conducted 

to a sufficient level of detail. The related finding is documented in Section 4OA4.02.02.e 

of this report. 

.4 Complicated Reactor Scram due to Loss of Offsite Power on October 14, 2013 

Entergy assembled a multi-discipline team to perform the RCE for this issue. In addition 

to the direct cause of the failure of a defective pole at an offsite substation, which was 

determined to be outside the control of Entergy, the RCE documented one root and one 

contributing cause: 

 Entergy failed to ensure that station procedures contained adequate pre-defined, 

risk-based criteria for planned maintenance on offsite transmission equipment 

which places Pilgrim in an SPV to an automatic scram (Root Cause); and 

 The design for generation at Pilgrim is less than robust, with only two paths for 

generation output and offsite power supply (Contributing Cause). 

The inspectors concluded that the RCE was conducted to a level of detail 

commensurate with the significance of the problem. 

.5 Root Cause Evaluation of Degraded Initiating Events Cornerstone 

Entergy performed a RCE in response to Pilgrim’s entry into the Degraded Cornerstone 

column of the ROP Action Matrix. This RCE was performed by a multi-disciplined team 

consisting of personnel from Maintenance, Engineering, Regulatory Affairs, and 

Corporate Regulatory Assurance, as well as a specialist consultant. The root cause 

team used multiple analysis methods and identified one root cause and three 

contributing causes: 

 Site leadership did not effectively ensure specific corrective or mitigating actions 

were developed and implemented to address operational risk (Root Cause); 

 Entergy did not ensure that the CAP was effective at ensuring adequate 

corrective actions were taken to prevent subsequent reactor scrams. The station 

previously entered issues either similar or directly related to the January 10, 

2013, February 8, 2013, and August 22, 2013, scrams into the CAP, but did not 

develop corrective actions to effectively fix the issues (Contributing Cause); 
18 

Enclosure 

 Entergy did not ensure the OE program was effectively used to ensure proactive 

measures were taken to prevent similar events from occurring at Pilgrim 

(Contributing Cause); and 

 Entergy did not ensure that procedures included all elements of operational risk. 

Specifically, procedures did not adequately define frequency/probability, address 

passive risk, or provide formal tracking of compensatory measures (Contributing 

Cause). 

 

Based on review of this RCE, the inspectors concluded that Entergy conducted the 

collective evaluation to a level of detail commensurate with the significance of the 

problem. 

c. IP 95002 requires that the inspection staff determine that the licensee’s RCE included a 

consideration of prior occurrences of the issue and knowledge of OE. 

.1 Reactor Scram due to Inadvertent Trip of Both RRPs on January 10, 2013 

Entergy’s RCE contained a review of both internal and external OE. Entergy did not 

identify any other plant trips caused by human performance errors during relay 

maintenance at Pilgrim. 

Entergy did identify two OE communications relevant to the issue from the last five 

years. In both cases, the I&C point of contact for OE had reviewed the communications 

and determined they did not need to share them further with the rest of the department. 

During the pre-job brief, personnel discussed OE on a different subject that was also 

relevant to the task. The evaluation considered the OE communications to be missed 

opportunities, but did not consider them as missed barriers because personnel used OE 

as expected prior to the event. 

Entergy determined that latent organization issues associated with the previously 

identified causes existed. The evaluation determined that there was evidence of an 

omission of relevant information in the procedure that would have prevented the 

recirculation pump trip from occurring. Specifically, if the procedure had contained steps 

directing when to reinstall the relay cover, Entergy could have assured that the relay 

state would be verified after the cover was replaced. Additionally, Entergy determined 

that there was evidence that personnel had insufficient awareness of the impact of their 

actions on safety, and that management follow-up of activities was ineffective in 

identifying shortcomings. In particular, the technicians were not sufficiently aware that 

relay cover replacement could change the relay’s state, and management did not 

recognize the significance of difficult to replace relay covers. Finally, Entergy 

determined that there was evidence that the response to the repetitive issue of difficult to 

replace relay covers was untimely. 

Based on Entergy’s detailed evaluation and conclusions, the inspectors determined that 

the RCE included a consideration of prior occurrences of the issues and knowledge of 

prior OE. 

.2 Complicated Reactor Scram due to Loss of Offsite Power on February 8, 2013 

Entergy’s RCE contained a review of both internal and external OE. Entergy’s review 

included a search on internal OE for the Entergy Fleet and a search of OE external to 
19 

Enclosure 

Entergy. Review was also performed to determine if any Entergy responses to industry 

OE were applicable or could have mitigated this event. 

Entergy’s internal OE review identified one event applicable to this RCE. The root cause 

of that event (CR-PNP-2008-3963) was similar to the scram which occurred on 

February 8, 2013. Entergy determined that those previous CAPRs associated with the 

previous LOOP event failed to prevent recurrence of this event. The RCE identified this 

as one of the contributing causes. 

Based on Entergy’s detailed evaluation and conclusions, the inspectors determined that 

the RCE included a consideration of prior occurrences of the issues and knowledge of 

prior OE. 

.3 Complicated Reactor Scram due to Trip of All Three RFPs on August 22, 2013 

Entergy’s RCE contained a review of both internal and external OE. Entergy identified 

several trips caused by incorrect modifications or SPVs at other sites, but determined 

that none were similar enough to prompt corrective actions that could have prevented 

the scram on August 22, 2013. An internal OE search identified a similar SPV at 

another Entergy site several years prior. Entergy did not identify any additional 

corrective actions as a result of their OE search. 

Entergy determined that latent organization issues associated with the previously 

identified causes existed. The evaluation determined that there was evidence that 

personnel had insufficient awareness of the impact of their actions on safety and that job 

standards were not adequately defined or communicated because engineering 

management did not appropriately challenge the design change after reviewing the CRs 

questioning it. It also determined that there is a lack of program evaluation process 

because the engineering quality review team did not adequately challenge the 

engineering change during their review. Additionally, the approval of the engineering 

change is evidence that there was a lack of evaluation of risk and consequences prior to 

making a change that would have an adverse impact. Finally, the evaluation concluded 

that the corrective actions for previously identified problems failed to take meaningful 

corrective actions. Specifically, the corrective actions to two CRs questioning the design 

change did not have corrective actions that addressed the issue. 

Based on Entergy’s detailed evaluation and conclusions, the inspectors determined that 

the RCE included a consideration of prior occurrences of the issues and knowledge of 

prior OE. 

.4 Complicated Reactor Scram due to Loss of Offsite Power on October 14, 2013 

Entergy’s RCE contained a review of both internal and external OE. Entergy’s review 

included a search on internal OE for the Entergy Fleet and search for OE external to 

Entergy. Review was also performed to determine if any Entergy responses to external 

OE were applicable or could have mitigated this event. 

The RCE indicated that the events described in the OE section were not directly related 

to this root cause. Those events were associated with a weather related event (e.g. 

lighting strike, high winds, hurricane, etc.). The RCE identified that those events were 

not missed opportunities because they were not directly applicable to this event. 
20 

Enclosure 

Based on Entergy’s detailed evaluation and conclusions, the inspectors determined that 

the RCE included a consideration of prior occurrences of the issues and knowledge of 

prior OE. 

.5 Root Cause Evaluation of Degraded Initiating Events Cornerstone 

Entergy’s RCE included a review of internal, fleet, and industry OE. Additionally, the 

RCE determined that one of the contributing causes was ineffective utilization of the site 

OE program in that the station did not take measures based on industry events to 

prevent similar events from occurring at Pilgrim. OE issues were available, but did not 

result in actions to prevent issues. The station identified the following corrective actions: 

 Benchmark other stations in the fleet to identify any gaps in the program; 

 Complete an OE familiarization briefing for site managers in various 

departments; 

 Complete an OE familiarization briefing for the department OE points of contact; 

and 

 Review OE PIs during the CRG meetings. 

Based on Entergy’s evaluation and conclusions, the inspectors determined that the RCE 

included a consideration of prior occurrences of the issues and knowledge of prior OE. 

However, the inspectors did note some weaknesses in implementation of the corrective 

actions related to this contributing cause. These weaknesses are discussed in Section 

4OA4.02.03.a.5 of this report. 

d. IP 95002 requires that the inspection staff determine that the licensee’s RCE addresses 

the extent of condition and extent of cause of the issues. 

.1 Reactor Scram due to Inadvertent Trip of Both RRPs on January 10, 2013 

Entergy performed an extent of condition review on the direct cause of the event, a relay 

left in an energized state following surveillance restoration. Entergy reviewed site 

procedures in all departments and identified those which required personnel to remove 

and replace relay covers in order to perform work. 

Entergy performed an extent of cause review for the lack of annotation of critical steps to 

prevent a major plant event in the “return to normal” section of procedure 8.M.2-2.10.2-9, 

the maintenance procedure that resulted in the reactor scram. They considered other 

actions involving relays that otherwise have immediate adverse consequences in 

procedure 8.M.2-2.10.2-9 and in other maintenance procedures. 

Entergy also performed an extent of cause review for the failure to use the human 

performance tool Stop-Think-Act-Review (STAR) during relay cover removal and 

reinstallation. They considered the failure to use STAR during other procedurallycontrolled maintenance department work and the failure to use other human 

performance tools during relay cover work as well as other types of work. 

The inspectors noted that Entergy’s RCE did not include an extent of cause assessment 

for the contributing cause of overconfidence and complacency by personnel in the I&C 
21 

Enclosure 

department, nor did it include a discussion of why one was not necessary. Entergy 

documented this issue in CR-PNP-2014-5772 and updated their RCE. Revision 5 of the 

RCE, dated November 16, 2014, included an extent of cause discussion on technician 

complacency and overconfidence during relay cover removal and installation. They 

considered the impact of those same technicians, as well as other technicians, exhibiting 

complacency and overconfidence during relay cover removal and installation and other 

critical procedure work. The corrective actions identified to address the extent of cause 

were either previously identified and implemented to address this issue, or were the 

same as the corrective actions for the other causes. 

Because an extent of cause discussion for the contributing cause was needed, the 

inspectors concluded that omitting it was a weakness. The inspectors determined this 

weakness was a minor issue because Entergy’s review showed that no new corrective 

actions were necessary as a result of the assessment. 

The inspectors concluded that Entergy’s RCE addressed the extent of condition and 

extent of cause of the issues. 

.2 Complicated Reactor Scram due to Loss of Offsite Power on February 8, 2013 

Entergy’s RCE reviewed the extent of condition for this event using the “same-similar” 

methodology in accordance with procedure EN-LI-118, “Cause Evaluation Process.” 

Entergy defined the condition as the loss of the SUT due to accumulation of salt and 

snow causing a flashover. Entergy’s extent of condition review focused on ensuring that 

other possible conditions that could cause a flashover were addressed in the other 

severe weather procedures. 

Entergy reviewed the extent of cause for each root cause and each contributing cause 

using the “same-similar” methodology. The RCE stated that the first root cause was the 

coincidental loss of transmission lines 342 and 355 from faults external to the Pilgrim 

switchyard. Entergy determined that the extent of cause for the first root cause would 

include loss of either transmission line from faults external to the switchyard. However, 

because faults occurring external to the Pilgrim switchyard are outside the control of 

Entergy, corrective actions included determining what actions the transmission operator 

took in response to the LOOP events to improve reliability of service to the SUT and 

providing them a demonstration of a LOOP event in the plant simulator with the intent of 

improving the working relationship between the transmission operator and Entergy. 

For the second root cause, inadequate pre-defined, risk based criteria established to 

guide operators confronted with deteriorating switchyard conditions during and following 

a blizzard, Entergy determined that the extent of cause would include procedural 

guidance for deteriorating switchyard conditions during and following other severe 

weather. Entergy addressed the extent of cause by documenting the review of 

procedure EN-FAP-EP-010, “Severe Weather Response,” and other severe weather 

procedures that could result in a LOOP. 

The inspectors concluded that Entergy’s RCE addressed the extent of condition and 

extent of cause of the issues. 

 
22 

Enclosure 

.3 Complicated Reactor Scram due to Trip of All Three RFPs on August 22, 2013 

Entergy performed an extent of condition review on the direct cause of the event, an 

undocumented splice installed in a flexible conduit under PDC 98-38. Entergy 

considered the potential impact of other legacy cable splice failures that could have been 

installed during the same design change. 

Entergy performed an extent of cause review for the engineering change review process 

to identify the inadequate design introduced by the SPV modification. Entergy 

considered the possibility of other modifications introducing new SPVs and other SPV 

modifications having unintended consequences. Corrective actions included reviewing 

all engineering changes intended to resolve SPVs as well as all modifications completed 

in the past five years to ensure new SPVs were not created. 

Entergy also performed an extent of cause review for the inadequate response to CRPNP-2011-3253, which was screened as a category ‘C’ CR. Entergy considered the 

failure to resolve design vulnerabilities raised in other CRs. Entergy reviewed other 

category ‘C’ CRs in the past five years which identified design vulnerabilities to 

determine whether the response to each was adequate. The cause report itself 

discussed two category ‘C’ level CRs that provided opportunities for prior identification of 

the new SPV. The CAP tracking system search performed as part of the extent of cause 

corrective action used keywords that only captured one of the two CRs. Inspectors 

determined that this called into question the quality of the search and associated results. 

Entergy wrote CR-PNP-2014-5722 and performed a new extent of cause search which 

did not identify any additional CRs that were not previously identified. Because 

additional review was needed, the inspectors concluded that Entergy’s search was a 

weakness in their extent of cause review. However, the inspectors determined this 

weakness was a minor issue because Entergy’s review showed that no new corrective 

actions were necessary as a result of the assessment. 

In general, the inspectors concluded that Entergy’s RCE addressed the extent of 

condition and extent of cause of the issues. However, follow-up inspection of the extent 

of cause will be performed for additional causes determined as a result of corrective 

actions to address the finding documented in section 4OA4.02.02.e of this report. 

.4 Complicated Reactor Scram due to Loss of Offsite Power on October 14, 2013 

Entergy reviewed the extent of condition for this event using the “same-similar” 

methodology in accordance with procedure EN-LI-118, “Cause Evaluation Process.” 

Entergy defined the condition as the failure of the in-service offsite power line when 

operating with a single source and therefore focused their extent of condition review on 

other conditions where a single failure could result in a LOOP. Because the failure that 

was experienced was outside of the control of Entergy, corrective actions were taken to 

ensure that the risk of operating with a single source was managed appropriately. 

Entergy reviewed the extent of cause for each root cause and each contributing cause. 

The review was performed using the “same-similar” methodology. Entergy identified the 

root cause as the station procedure contained inadequate pre-defined risk-based criteria 

for planned maintenance on offsite transmission equipment that places station in a SPV 

susceptible to an automatic reactor scram. Entergy determined that the extent of cause 

would include review of other procedure deficiencies for planned maintenance on offsite 
23 

Enclosure 

transmission equipment in procedure 1.5.22, “Station Risk Assessment Process,” and 

other station risk procedures. Entergy’s corrective actions to address the extent of 

cause included a revision to procedure 1.5.22 requiring a critical evolution meeting for 

any activity that would require single 345 kV line operation as well as the development of 

mitigating actions to be implemented prior to removing either 345 kV line from service. 

The inspectors concluded that Entergy’s RCE addressed the extent of condition and 

extent of cause of the issue. 

.5 Root Cause Evaluation of Degraded Initiating Events Cornerstone 

The purpose of Entergy’s RCE of the Degraded Initiating Events Cornerstone was to 

identify any causes common to the four unplanned scrams that occurred between 

January 10, 2013 and October 14, 2013. The station performed extent of cause reviews 

on the root and contributing causes that were common to the events. 

Entergy’s corrective actions developed from the extent of cause review included: 

 Training focused on risk awareness and risk management for site management; 

 Review of all CAPRs issued since 2008 to ensure that these actions adequately 

address the applicable root causes; 

 Apparent cause and RCE training for individuals in various departments across 

the station; 

 Benchmarking other stations in the fleet to identify any gaps in the OE program 

at Pilgrim; 

 OE familiarization briefings for the department OE points of contact; 

 Reviewing OE PIs during the CRG meetings; 

 Reviewing other areas where low regulatory margin may exist, such as other 

NRC PIs that may be close to threshold, and areas where the station may be 

close to developing cross-cutting themes; and 

 Implementing a procedure upgrade project in the Maintenance department to 

bring procedures up to fleet standards. 

The RCE noted that one of the contributing causes was that the site OE program was 

not effectively used to ensure proactive measures were taken based on industry events 

to prevent similar events from occurring at Pilgrim. Inspectors reviewed the extent of 

cause actions for this issue and noted that the station did not include the security 

organization in the OE familiarization briefings. Though OE in the security department is 

covered under a different procedure, the inspectors concluded that the security 

department would also potentially be vulnerable to inadequate implementation of its OE 

program. The station generated CR-PNP-2014-05795 and generated an action to 

provide the training to the Security department. 

The inspectors concluded that the extent of condition and extent of cause identified in 

Entergy’s RCE, including additional action in response to inspector’s concerns, was 

adequate. 

 
24 

Enclosure 

e. Findings 

Introduction: The inspectors identified a green finding because Entergy did not fully 

derive the causes of the manual scram on August 22, 2013, following a loss of all 

feedwater. Specifically, Entergy did not investigate the causes of the failed cable splice 

which directly caused an electrical transient that resulted in the automatic tripping of all 

three RFPs in accordance with CAP requirements. 

Description: On August 22, 2013, Pilgrim station experienced a failed splice on a nonsafety-related power supply to a level control valve, which caused an electrical transient 

that directly led to the automatic trip of all three RFPs when combined with a latent issue 

related to a modification. Entergy performed a RCE of the event and identified the failed 

splice as a direct cause. Inspectors determined that Entergy failed to investigate the 

cause of the electrical transient in accordance with station CAP procedures sufficiently to 

ensure all of the root and contributing causes of the event were understood. Their 

investigation determined that the splice failed because it was improperly fabricated when 

it was installed in 1999 as a part of a modification package on balance of plant valves. 

The splice was inside a flexible conduit, had two splices on parallel wires places right 

next to each other instead of being staggered, and the splice had not been properly 

crimped. Entergy performed an extent of condition review to verify there were no other 

splices installed in flexible conduit by the same modification package. 

Entergy used multiple causal evaluation methods as part of their RCE. Three of these 

(event and causal factor charting, failure modes analysis, and the “why” staircase 

analysis) discussed the failed splice. Entergy’s CAP procedures state that neither the 

failure modes analysis nor the “why” staircase are acceptable stand-alone methods of 

evaluation. The failure modes analysis method is described in EN-LI-118-08, “Failure 

Modes Analysis,” Revision 2. This procedure states that the output of the failure modes 

analysis will only be the direct cause, so it must be used with another method. The 

“why” staircase method is described in EN-LI-118-11, “Why Staircase,” Revision 0. This 

procedure states that for human performance problems, the method may only get to the 

general area of the cause and most likely will require further analysis to establish the 

exact cause. In the “why” staircase for this RCE, Entergy stopped at “failure to follow 

requirements of design change and [procedure] 3.M.3-51,” which is a human 

performance issue. 

The event and causal factor charting method is described in EN-LI-118-01, “Event and 

Causal Factor Charting,” Revision 2, and is the only method of the three intended for 

stand-alone use. This procedure directs them to “continue to investigate and develop 

the chart until one of the following limits is reached: (1) the cause is outside the control 

of Entergy, (2) the correction of the cause is determined to be cost prohibitive, (3) the 

primary effect is fully explained, or (4) there are no other causes that explain the effect 

being evaluated.” Entergy terminated their chart at “maintenance work practices,” which 

does not meet any of the criteria listed in EN-LI-118-01. 

Ultimately, Entergy did not identify corrective actions to correct the cause of the failed 

splice and inspectors could not verify that actions taken to ensure other splices were not 

improperly installed were sufficient. The inspectors questioned why Entergy had not 

continued to investigate what caused the splice to be improperly fabricated in 

accordance with station procedures such that either appropriate corrective actions could 

be planned or justification as to why no corrective actions were required could be 
25 

Enclosure 

provided. In response to inspectors’ questions, Entergy entered the issue into the CAP 

as CR-PNP-2014-5796 and initiated additional causal analysis to determine why the 

splice was improperly fabricated. 

Analysis: Contrary to the standards in Entergy procedures EN-LI-118, “Cause Evaluation 

Process,” and EN-LI-118-01, “Event and Causal Factor Charting,” Entergy did not fully 

derive the causes of the manual scram following a loss of all feedwater. Specifically, 

Entergy did not investigate the causes of the failed splice until the cause was outside 

their control, correction was cost prohibitive, the effect was fully explained, or there were 

no other causes. This performance deficiency affects the equipment performance 

attribute of the Initiating Events cornerstone, because the failure to fully derive the 

causes of the failed splice prevented them from taking appropriate actions to evaluate 

and correct those causes. This impacts the cornerstone objective to limit the likelihood 

of events that upset plant stability and challenge critical safety functions during shutdown 

as well as power operations because unidentified deficiencies could lead to similar 

electrical transients which could cause similar transients. 

The inspectors determined the significance of the finding using IMC 0609, Appendix A, 

“The Significance Determination Process for Findings At-Power.” The finding was 

determined to be of very low safety significance (Green) because the finding was a 

transient initiator and, although the event being evaluated for causal factors caused a 

reactor scram and loss of mitigation equipment, the failure to identify all the causes of 

the event and plan appropriate corrective actions has not resulted in a subsequent 

reactor scram or loss of mitigating equipment. 

This finding had a cross-cutting aspect in the area of Problem Identification and 

Resolution, Evaluation, because Entergy did not thoroughly evaluate the issue of the 

manual scram to ensure that resolutions address causes and extent of conditions 

commensurate with their safety significance. Specifically, Entergy focused on the 

causes related to the modification of the feed pump trips and did not evaluate the causes 

related to the failed splice. [P.2] 

Enforcement: This finding does not involve enforcement action because no regulatory 

requirement violation was identified. Because this finding does not involve a violation 

and is of very low safety significance, it is identified as a finding (FIN 

05000293/2014008-01, Failure to Fully Derive the Causes of a Manual Scram). 

02.03 Corrective Actions. 

a. IP 95002 requires that the inspection staff determine that (1) the licensee specified 

appropriate corrective actions for each root and/or contributing cause, or (2) an 

evaluation that states no actions are necessary is adequate. 

.1 Reactor Scram due to Inadvertent Trip of Both RRPs on January 10, 2013 

Entergy’s RCE identified corrective actions addressing each of the root and contributing 

causes as well as any additional identified weaknesses. CAPRs were identified for the 

root cause. The inspectors reviewed all of the corrective actions to ensure that they 

addressed the identified causes. The CAPRs included revising I&C and electrical 

maintenance procedures to include steps, marked as critical steps, to remove and 

replace relay covers, and to verify relay state after the covers are replaced. Entergy 
26 

Enclosure 

recognized that performing the procedure revisions would take some time and 

developed a maintenance standing order that required supervisors to review the 

applicable maintenance procedures prior to the pre-job brief as well as enhanced 

supervisor oversight of relay cover removal and installation until the CAPRs had been 

completed. 

Inspectors determined that the procedure changes specified by the CAPRs will not 

prevent inadvertent relay actuation, but should prevent adverse consequences if 

technicians properly apply human performance tools. No consideration was discussed 

in the RCE for corrective actions that did not rely on human performance, such as test 

method changes or hardware modifications. Entergy documented this observation in 

CR-PNP-2014-5714 and determined that no changes to the corrective action plan were 

required. 

Additional corrective actions to address the extent of cause of the root cause included 

adding critical steps to remove and replace relay covers in other procedures, including 

operations and mechanical maintenance procedures. They also included implementing 

a procedure upgrade project for all of the procedures in the Maintenance department. In 

the interim, actions were established for maintenance supervisors to review procedures 

prior to or at the pre-job brief to ensure that critical steps are annotated and that the 

supervisor understands what potential adverse consequences could occur during 

performance of the maintenance. 

Corrective actions for the contributing causes included training on procedure use and 

adherence for the technicians involved during the event and for all maintenance 

supervisors. Corrective actions also included developing a checklist of good procedure 

use behaviors and performing increased supervisor observations of surveillances using 

the checklist. This checklist included verification that technicians are identifying critical 

steps in procedures and implementing appropriate human performance tools during 

maintenance. Maintenance supervisors, as well as supervisors from other departments 

at Pilgrim, performed these observations. 

In general, the inspectors determined that the proposed corrective actions were 

appropriate and addressed each root and contributing cause. However, inspectors 

reviewed those corrective actions that were completed at the time of the inspection and 

noted deficiencies in the execution of some of the corrective actions. 

Entergy conducted assessments of the RCE prior to the inspection and self-identified in 

CR-PNP-2014-3931 that many of the completed actions to had either not been 

completed as intended or lacked sufficient evidence to support closure. Despite 

additional actions being specified to correct the licensee-identified deficiencies, 

inspectors’ review of the completed corrective actions and interview of maintenance 

supervisors identified that some of the corrective actions were either cancelled or closed. 

A maintenance standing order was created and signed by maintenance supervisors in 

September 2014 which directed interim actions for enhanced supervisor oversight and 

procedure review in preparation for maintenance be implemented. Despite this, 

inspectors identified that the maintenance standing order was not being implemented at 

the time of the on-site inspection. In response, Entergy stated that continued 

improvement in the area of human performance in maintenance was intended to be 

corrected by other routine processes that had been implemented outside the RCE. 
27 

Enclosure 

To determine whether the closure of the corrective actions was appropriate, inspectors 

reviewed a sampling of other surveillances performed during October and November. 

Despite the corrective actions being completed, inspectors noted several similar 

deficiencies: 

 Several procedures did not have critical steps annotated as such; 

 A technician identified a critical step during a pre-job brief, but did not generate a 

CR or a procedure feedback form to document and permanently correct the 

deficiency; and 

 One procedure contained steps that directed calibration of an instrument after 

fuses and alarms had been verified restored, an action that if performed without 

re-performing steps in the body of the procedure would result in an adverse 

consequence. 

Entergy generated CR-PNP-2014-5909, CR-PNP-2014-5976, and CR-PNP-2014-5977 

to document these observations. 

Additionally, inspectors observed similar behaviors to those exhibited in the two 

contributing causes of the RCE during in-progress maintenance. On November 4, 2014, 

the inspectors observed primary containment isolation logic testing that included 

installing a switched jumper to set up the correct logic for the testing. The technicians 

were sensitive to the risk of a jumper coming loose, but they proceeded on with the test 

even after struggling to install the jumper. Later during the surveillance, the jumper 

detached from the plant equipment. After discussing with their supervisor, who was 

present during the test, the technicians restored the disconnected jumper and continued 

with the surveillance. Entergy determined that proceeding when initially challenged by 

jumper installation and failing to inform the shift manager when the jumper became 

detached were contrary to expectations. Entergy wrote CR-PNP-2014-5682 to 

document the issue. 

Finally, during reactor protection system testing on November 3, 2014, a half scram 

occurred earlier than expected when a technician’s finger slipped off the “INOP/INHIBIT” 

pushbutton. A precaution in the procedure warned that not engaging the pushbutton 

would bring in a half scram and Entergy staff stated that the challenge of continuously 

holding the button down had been recognized historically. Despite this known challenge, 

Entergy proceeded with the planned work. Entergy wrote CR-PNP-2014-5625 to 

document the half scram. 

Section 5.6[4](c) of EN-LI-102 states that corrective action response must address the 

intent of the action. Inspectors determined that failing to perform the action as 

documented did not meet the intent of the action specified in the RCE. Ultimately, 

inspectors determined that observations of maintenance execution did not support 

closure or cancellation of corrective actions identified in the RCE. In response to 

inspectors concerns, Entergy revised the RCE to include additional corrective actions for 

procedural reviews prior to performance of work and enhanced oversight. Ultimately, 

inspectors determined that the numerous procedure deficiencies and human 

performance issues identified by inspectors represented conditions adverse to quality 

that were reasonably within Entergy’s ability to identify and correct by execution of 

corrective actions identified in the RCE. This performance deficiency and associated 

finding are documented in section 4OA4.02.03.f of this report. 

 
28 

Enclosure 

.2 Complicated Reactor Scram due to Loss of Offsite Power on February 8, 2013 

Entergy’s RCE identified several corrective actions addressing each of the root and 

contributing causes as well as any additional identified weaknesses. Higher tiered 

CAPRs were identified for the second root cause. The first root cause did not have a 

CAPR assigned because the faults occurred outside of Entergy’s control. The 

inspectors determined that this basis was acceptable in accordance with procedure ENLI-118, “Cause Evaluation Process.” The inspectors reviewed all of the corrective 

actions to ensure that they addressed the identified causes. The CAPRs included: 

 Revising procedure 2.1.42, “Operations During Severe Weather,” to develop and 

implement procedural guidance containing a systematic process for removal and 

restoration of bus sections during and following blizzard conditions; and 

 Developing procedural guidance for de-icing insulating material susceptible to a 

flashover event in the switchyard following blizzard conditions. 

In addition to the CAPRs listed above, Entergy identified additional corrective actions to 

fully address the causes, including the extent of those causes. Those corrective actions 

included: 

 Reviewing the actions taken by the grid operator to improve reliability of service 

to the SUT; 

 Conducting an engineering study to determine feasible switchyard upgrades to 

improve resistance to flashovers; 

 Replacing the insulator on the T-931 disconnect that faulted during the event and 

sending to a vendor for analysis; 

 Revision to severe weather procedures to provide operators guidance for 

reducing reactor power during blizzard conditions based on grid reliability; 

 Revision to procedure 3.M.3-71 for cleaning and inspection of insulators; 

 Performing a review of all open and closed RCEs since 2008 to validate that 

completed CAPRs adequately addressed the applicable root causes; 

 Revision to procedure 2.2.1, “345 kV System,” to add a statement to inspect the 

switchyard for conditions that could cause flashover if restoring 345 kV line 

during storm recovery; and 

 Revision to procedure 8.C.40, “Seasonal Weather Surveillance,” to ensure 

equipment necessary for de-icing insulators is available for the winter season. 

In general, inspectors determined that the proposed corrective actions were appropriate 

and addressed each of the root and contributing causes. However, inspectors reviewed 

those corrective actions that were completed at the time of the inspection and noted 

deficiencies in the execution of some of the corrective actions. 

With regard to the changes to severe weather procedures, inspectors identified that 

there were no substantive procedure changes for pre-storm actions and one change that 

directed a down power of the plant under the specific conditions could have precluded 

operators from taking action to down power the plant under the same conditions 

observed during the February 8, 2013, winter storm. Specifically, changes made to the 

procedure for severe storm preparations directed operators to reduce power to within the 

capacity of the turbine bypass valve if an “imminent” load reject is expected. The 

conditions provided for “imminent” load reject in the procedure revision did not match the 
29 

Enclosure 

conditions encountered during the 2013 winter storm. The inspectors noted that these 

inadequacies were not identified when performing the effectiveness review for the 

procedure change, which included a table top demonstration of the procedure. Entergy 

entered the issue into the CAP as CR-PNP-2014-05826 and made numerous additional 

changes to the procedure. The inspectors reviewed the changes and determined that 

they reasonably corrected the cause identified in the RCE. Section 5.6[4](c) of EN-LI102 states that corrective action response must address the intent of the action. 

Inspector determined the implemented corrective actions had not met the intent of the 

action specified by the RCE because it did not adequately address the causes. 

Additionally, Entergy identified as a contributing cause that corrective actions for 

previous similar LOOPs did not preclude recurrence, in part, because failure analysis 

had not been conducted on faulted insulators in a previous LOOP event. To address 

this, the RCE assigned a corrective action to replace the insulator that faulted twice 

during the winter storm and send it to a vendor for failure analysis. The intent of this 

testing was to assist in determining a replacement strategy for insulators and is used to 

determine the condition of the insulator exterior glazing which is effective against 

contamination from coastal salt, fog, and/or mist conditions. Inspectors identified that, 

despite the insulator having been removed from service and stored in a warehouse since 

June 2014, it had not been sent off for analysis at the time of the inspection. In review of 

the corrective actions specified in the RCE, inspectors notified that an action was 

created as a priority 1 correct condition action to replace the insulator and send to a 

vendor for failure analysis. The work order that removed and replaced the faulted 

insulator was completed in June 2014. Maintenance personnel closed the corrective 

action on September 2, 2014 by opening a new action, assigned to engineering 

personnel, to send the component for failure analysis. This new corrective action was 

categorized as a “priority 4 general action” (i.e. enhancement). Section 5.6[4](c)of ENLI-102 states that corrective action response “must not indicate correction or 

implementation based on future action.” 

On August 28, 2014, Entergy generated CR-2014-4265 due to unsatisfactory closure of 

the corrective actions. Specifically, the CR stated that the “response did not complete 

action specified in [the] RCE.” It continued that “not completing the task as described 

should need CARB approval. This alters the RCE Interim Actions as specified.” In 

response to the CR, Entergy generated two new actions which resulted in coaching on 

the inadequate corrective action closure and approval of the deviation. In review of the 

actions performed, inspectors identified that response to the new actions failed to 

identify that the CAP was not implemented correctly and failed to ensure the action was 

prioritized appropriately. Ultimately, inspectors determined that the actions taken by 

Entergy were not in accordance with their CAP because the corrective action was closed 

improperly. In response to inspectors concerns, Entergy generated CR-PNP-2014-

05735 and sent the insulator for failure analysis and was awaiting results and the 

completion of this inspection. This performance deficiency and associated finding are 

documented in section 4OA4.02.03.f of this report. 

.3 Complicated Reactor Scram due to Trip of All Three RFPs on August 22, 2013 

Entergy’s RCE identified corrective actions addressing each of the root and contributing 

causes. CAPRs were identified for the root cause. The inspectors reviewed all of the 

corrective actions to ensure they addressed the identified causes. The CAPRs included 

implementing a modification to remove the RFP low cooling coil flow trip entirely, and 
30 

Enclosure 

reviewing all modifications done to address SPVs to ensure unintended consequences 

had not been introduced. 

Additional corrective actions to address the extent of cause of the root cause included a 

review of all modifications implemented since 2008 to ensure none of them created 

unintended SPVs. Entergy corrected the direct cause by repairing the splice and 

addressed the extent of condition by verifying all other splices done under plant design 

change 98-38 were located in junction boxes or conduit. Corrective action for the 

identified contributing cause was to conduct a search of the CAP for other category ‘C’ 

CRs documenting design vulnerabilities initiated since 2008 to verify the responses fully 

addressed the issues raised. Additionally, Entergy credited corrective actions performed 

under CR-PNP-2013-1572 and CR-PNP-2013-1577 to address this contributing cause. 

Those corrective actions included training and new expectations for the engineering 

department on using technical rigor. 

In general, the inspectors determined that the proposed corrective actions were 

appropriate and addressed each identified root and contributing cause. 

.4 Complicated Reactor Scram due to Loss of Offsite Power on October 14, 2013 

Entergy’s RCE identified several corrective actions addressing each of the root and 

contributing cause as well as any additional identified weaknesses. CAPRs were 

identified for the root cause. The inspectors reviewed all of the corrective actions to 

ensure that they addressed the identified causes. The CAPRs included: 

 Revising procedure 1.5.22, “Risk Assessment Process,” to recognize and assess 

345 kV single line vulnerability; 

 Developing and formalizing mitigation actions required to be implemented prior to 

removing either 345 kV line from service; and 

 Developing additional requirements to control work during operations with a 

single offsite power source. 

In addition to the CAPRs listed above, Entergy identified the following corrective actions 

to fully address the root and contributing causes: 

 Contact industry organizations to determine if any standard or guidance 

document exists for addressing planned maintenance on a transmission line; 

 Revision to procedure 1.5.22 and procedure EN-FAP-WM-002 to require a 

critical evolution meeting for any activity that would require single 345 kV line 

operations; 

 Perform a feasibility study to install third transmission line and present it to the 

Plant Health Committee; and 

 Verify replacement of the wooden poles at the offsite substation with a metal 

structure. 

The inspectors determined that the proposed corrective actions were appropriate and 

addressed each root and contributing cause. 

 
31 

Enclosure 

.5 Root Cause Evaluation of Degraded Initiating Events Cornerstone 

Entergy’s RCE identified one root cause and three contributing causes related to the four 

scrams that transitioned the station into the Degraded Cornerstone of the NRC’s Action 

Matrix. The inspectors reviewed all of the corrective actions to ensure that they 

addressed the identified causes. 

Entergy identified the root cause of the collective evaluation that site leadership did not 

effectively ensure specific corrective or mitigating actions were developed and 

implemented to address operational risk. This occurred because the likelihood 

(frequency) of potential events was underestimated and existing site conditions and 

practices were viewed as acceptable. In addition to the corrective actions already 

identified in each of the individual root causes for each of the scrams, Entergy developed 

and implemented a new site procedure for risk management. Specifically, as a CAPR, 

the station developed and implemented Pilgrim procedure 1.3.142, “PNPS Risk Review 

and Disposition.” The purpose of this procedure is to provide guidance for disposition of 

certain risk elements that currently may not get site management risk consideration 

including active and “latent” or passive risk decisions. This procedure also provides a 

structure for evaluating passive risk associated with not taking action, such as deferring 

work or not adding scope to an outage, and can also be used on an as-needed basis 

when this risk decision is not clear, or there are competing organizational priorities. This 

procedure was not intended to supersede any specific existing guidance. 

Entergy is tracking implementation of this procedure in LO-PNPLO-2014-00122. At the 

time of this inspection, Entergy had completed four evaluations in accordance with this 

procedure; three were in progress. 

It appears that the procedure has provided Entergy an additional tool for making riskinformed decisions. However, it was not clear to the inspectors how implementation of 

this procedure would have resulted in a different outcome for the events analyzed in this 

RCE. Other established station procedures, such as those for evaluating OE, on-line 

work management, and the CAP, all provide a process for evaluating a condition and 

reaching a decision. For each of the events described in this root cause, it appears 

Entergy was implementing established station procedures without giving due 

consideration to the risk associated with those decisions. 

Entergy acknowledged that a new procedure in and of itself will not solve the issue 

related to inadequate risk-based decision-making because that process is , in part, 

related to the culture at the site. In addition to implementation of this new process, 

Entergy has completed some one-time training related to risk. The inspectors 

questioned the sustainability of this action given the limited training, and the station 

noted that the need for additional training will be monitored via the Department 

Performance Review Meeting process, as described in Entergy procedure EN-LI-121, 

“Trending and Performance Review Process.” Pilgrim staff also indicated that station 

management is reinforcing these expectations, and holding personnel accountable via 

the station’s accountability model. Inspectors determined that the CAPR, in conjunction 

with other actions planned to address the station’s cultural perception of risk, would 

reasonably correct the identified root cause. 
32 

Enclosure 

As part of this RCE, Entergy identified contributing causes associated with 

implementation of the CAP, implementation of the OE program, and procedure quality as 

it pertained to inclusion of operational risk. 

In addition to corrective actions already implemented as part of the individual RCEs, 

Entergy: 

 Assigned mitigating strategy reviews for items on the long standing equipment 

issues list, including SPVs and first-time high critical preventive maintenance; 

 Adjusted the CRG meeting agenda such that the group would complete review of 

the oldest/longest corrective actions as well as the corrective actions with 

upcoming due dates, with a focus on priorities and any interim or compensatory 

actions that may be needed; and 

 Completed OE familiarization briefing for various site managers. 

Finally, inspectors reviewed Entergy’s CCA which assessed if any safety culture aspects 

caused or significantly contributed to the events. As discussed in section 4OA4.02.05, 

the CCA identified challenges in CAP implementation, adherence to standards, and 

leader behaviors as drivers to the performance issues. In addition to the corrective 

actions implemented for the five RCEs discussed above, Entergy’s corrective action plan 

for the CCA included: 

 Mentoring of the department performance improvement coordinators (DPICs) to 

include coverage of their roles and responsibilities and expectations; 

 Reviewing corrective action closure documentation that did not meet 

expectations, as well as requirements for closure documentation with the CRG; 

 Developing and implementing an accountability model; and 

 Implementing CAP recovery indicators that are reflective of CAP performance 

issues. 

In general, inspectors determined that the proposed corrective actions were appropriate 

and addressed each of the root and contributing causes. However, inspectors reviewed 

those corrective actions that were completed at the time of the inspection and noted 

deficiencies in the execution of some of the corrective actions that were relevant to CAP 

implementation improvement: 

 CA13 to the safety culture aspect CCA stated, in part, “Mentor DPICs. This is 

recommended to be done over several months in a comprehensive manner to 

include coverage of roles, responsibilities, and expectations...This activity shall 

commence on or before June 6th (start date considered critical) and be tracked 

and updated weekly for six months.” Based on interviews with station personnel 

and review of documentation associated with the corrective action, the inspectors 

determined that the station started the action, but did not complete it as written. 

 CA15 to the safety culture aspect CCA stated, in part, “Review corrective action 

closures where performance falls short of expectations with the CRG and the 

leader and supervisory team meeting...Create new action and repeat for four 

consecutive months.” Based on review of documentation and interviews with 

station personnel, the inspectors determined that the station completed this 

action for April, but did not complete any additional sessions, as required by the 

approved corrective action. 
33 

Enclosure 

For both of these examples, inspector’s discussion with Entergy personnel revealed that 

the performance improvement department determined that these actions were not 

producing the desired results, and decided to implement training instead. However, 

Entergy staff never brought these corrective actions to the CARB for approval of the 

revision as required by EN-LI-102. These were entered into the CAP as CR-PNP-2014-

06040. 

b. IP 95002 requires that the inspection staff determine that the licensee prioritized 

corrective actions with consideration of risk significance and regulatory compliance. 

.1 Reactor Scram due to Inadvertent Trip of Both RRPs on January 10, 2013 

Entergy prioritized corrective actions with consideration of risk significance and 

regulatory compliance. CAPRs were given adequate due dates and were completed 

commensurate with their risk significance. The procedures that required relay cover 

removal and replacement were revised in the order in which they were required for 

maintenance, ensuring that those needed for scheduled work would be ready prior to 

execution of the activity. 

.2 Complicated Reactor Scram due to Loss of Offsite Power on February 8, 2013 

Entergy prioritized corrective actions with consideration of risk significance and 

regulatory compliance. With the exception of the finding and observations documented 

in sections 4OA4.02.03.f and 02.03.a.2, respectively, CAPRs and corrective actions 

associated with two root causes and three contributing causes were given adequate due 

dates and were completed commensurate with their risk significance. At the time of the 

inspection, all CAPRs and corrective actions that were not already completed had 

reasonably scheduled due dates. 

.3 Complicated Reactor Scram due to Trip of All Three RFPs on August 22, 2013 

Entergy prioritized corrective actions with consideration of risk significance and 

regulatory compliance. CAPRs were given adequate due dates and were completed 

commensurate with their risk significance. Entergy completed the splice repair and 

removal of the low flow trip prior to returning the plant to power. All other corrective 

actions were complete prior to the inspection. 

.4 Complicated Reactor Scram due to Loss of Offsite Power on October 14, 2013 

Entergy prioritized corrective actions with consideration of risk significance and 

regulatory compliance. CAPRs and corrective actions associated with a root cause and 

a contributing cause were given adequate due dates and were completed 

commensurate with their risk significance. At the time of inspection, all CAPRs and 

corrective actions were completed. 

 
34 

Enclosure 

.5 Root Cause Evaluation of Degraded Initiating Events Cornerstone 

The inspectors reviewed the prioritization of the corrective actions associated with the 

RCE, as well as the procedural requirements found in Entergy procedure EN-LI-102, 

“Corrective Action Program.” The inspectors verified that the prioritization was in 

accordance with site procedures and based on consideration of risk significance and 

regulatory compliance. 

c. IP 95002 requires that the inspection staff determine that the licensee established a 

schedule for implementing and completing the corrective actions. 

.1 Reactor Scram due to Inadvertent Trip of Both RRPs on January 10, 2013 

Entergy established a schedule for completing corrective actions associated with this 

event and assigned corrective actions to the appropriate individuals or organizations to 

ensure that the actions were planned or taken in a timely manner. In general, CAPRs 

and corrective actions associated with the identified root cause and the contributing 

causes were scheduled commensurate with their risk significance. However, inspectors 

identified that several corrective actions were entered into the CAP tracking system as 

“acknowledge that...” the corrective action will occur, rather than execution of corrective 

action itself. For example, inspectors identified that corrective actions 21-24, which 

specified that procedures be prioritized and reviewed for deficiencies similar to the ones 

revealed by the scram, were entered into the CAP tracking system as an action to each 

supervisor to acknowledge that they will prioritize and review the procedures. As 

documented in section 4OA4.02.03.a.1 and in the finding in 4OA4.02.03.f of this report, 

inspectors identified multiple examples where corrective actions were not completed as 

specified in the RCE. 

.2 Complicated Reactor Scram due to Loss of Offsite Power on February 8, 2013 

Entergy established a schedule for completing corrective actions associated with this 

event and assigned corrective actions to the appropriate individuals or organizations to 

ensure that the actions were planned or taken in a timely manner. In general, CAPRs 

and corrective actions associated with the two identified root causes and the contributing 

causes were adequately scheduled and completed commensurate with their risk 

significance. At the time of the inspection, all CAPRs and corrective actions that were 

not already completed had reasonably scheduled due dates. However, inspectors 

identified that one corrective action that was intended to address a contributing cause 

had not been taken in a timely manner. Specifically, the inspectors noted that the 

corrective action to conduct an engineering study to determine feasible switchyard 

upgrades to improve the resistance to flashovers due to ice-bridging on insulators was 

extended a total of 11 times. At the time of inspection (21 months since the event), 

Entergy had not made a decision as to whether the modification would be funded and 

implemented. The inspectors determined that Entergy did not prioritize this corrective 

action to address the issue in a timely manner commensurate with its safety 

significance. Entergy entered this into the CAP as CR-PNP-2014-05824 and CR-PNP2014-05827 and subsequently approved the funding for the modification of the 

switchyard. Because the action was not completed in a timely manner, inspectors 

determined that it was a weakness. However, inspectors determined that actions taken 

by Entergy during the inspection were adequate and no additional follow-up inspection 

was required. 
35 

Enclosure 

.3 Complicated Reactor Scram due to Trip of All Three RFPs on August 22, 2013 

Entergy established a schedule for completing corrective actions associated with this 

event and assigned corrective actions to the appropriate individuals or organizations to 

ensure that the actions were taken in a timely manner. CAPRs and other corrective 

actions associated with the identified causes were adequately scheduled and completed 

commensurate with their risk significance. At the time of the inspection, all corrective 

actions were completed. 

.4 Complicated Reactor Scram due to Loss of Offsite Power on October 14, 2013 

Entergy established a schedule for completing corrective actions associated with this 

event and assigned corrective actions to the appropriate individuals or organizations to 

ensure that the actions were planned or taken in a timely manner. CAPRs and 

corrective actions associated with root cause and the contributing cause were 

adequately scheduled and completed commensurate with their risk significance. At the 

time of the inspection, all CAPRs and corrective actions were completed. 

.5 Root Cause Evaluation of Degraded Initiating Events Cornerstone 

Entergy’s corrective action plan provided dates for completion of the actions as 

described in the RCE of the Degraded Initiating Events Cornerstone. At the time of the 

inspection, all but three of the corrective actions related to CR-PNP-2013-07830 have 

been completed. The remaining corrective actions are completion of SPV training, 

completion of training on Pilgrim Procedure No. 1.3.142, “PNPS Risk Review and 

Disposition,” and implementation of the Maintenance procedure upgrade project. 

The inspectors reviewed the open corrective actions related to training and determined 

that the schedule for implementation and completion was reasonable. With respect to 

the procedure upgrade project in the Maintenance department, corrective action 59 

documents that the current due date for this corrective action is April 30, 2015. Based 

on documentation review and interviews with station personnel, the inspectors noted that 

the procedure upgrade project is off schedule and will not be complete by this date. 

Discussion with Maintenance department management identified that they had 

developed a revised procedure scope and were implementing the procedure upgrades 

with dedicated resources to a revised schedule. Inspectors determined that this longterm action was reasonable when considered in conjunction with other corrective actions 

intended to identify procedure deficiencies prior to and during maintenance execution. 

With regard to the action to assign mitigating strategy reviews for all items on the long 

standing equipment issues list, the station completed assignment of these reviews and 

opened corrective actions 35-53 to develop the mitigating strategies for each of the 

issues. Entergy staff completed documentation of each of these mitigating strategies 

and closed the associated corrective actions. 

Per EN-DC-336, “Plant Health Committee,” Revision 8, mitigating strategy reviews are to 

be reviewed and challenged by the Plant Health Committee when initially developed, 

when revised, and at least annually. The inspectors inquired as to the status of this 

review. The station scheduled Plant Health Committee review of the SPV mitigating 

strategies, and this review is scheduled to be completed by the end of the year. 
36 

Enclosure 

However, the station has not yet scheduled the Plant Health Committee review of the 

mitigating strategies for the first-time high critical preventive maintenance tasks. 

The root cause identified for this RCE was that site leadership did not effectively ensure 

specific corrective or mitigating actions were developed and implemented to address 

operational risk. Though the CR associated with this RCE had actions to track 

assignment and development of the mitigating strategy reviews, there were no actions 

tracking the Plant Health Committee’s review of the mitigating strategies (i.e., station 

management accepting the risk associated with these strategies). Entergy identified an 

action to have the Plant Health Committee review these items prior to the next refueling 

outage. Inspectors determined that failing to track management review of the mitigating 

strategies was a weakness. However, inspectors determined that actions taken by 

Entergy during the inspection were adequate and no additional follow-up inspection was 

required.

d. IP 95002 requires that the inspection staff determine that the licensee developed 

quantitative and/or qualitative measures of success for determining the effectiveness of 

the corrective actions to preclude repetition. 

.1 Reactor Scram due to Inadvertent Trip of Both RRPs on January 10, 2013 

Entergy plans to complete the effectiveness review by January 30, 2015. It includes 

observation of the use of five procedures revised as part of the CAPRs. Success criteria 

include the presence of steps to remove and replace relay covers and to verify relay 

state after replacing the cover, and technician implementation of the procedure in 

accordance with procedure EN-HU-106, “Procedure and Work Instruction Use and 

Adherence.” 

The inspectors determined that Entergy had established adequate measures for 

determining the effectiveness of the CAPRs. 

.2 Complicated Reactor Scram due to Loss of Offsite Power on February 8, 2013 

Entergy identified two effectiveness reviews, one for each CAPR, to ensure that these 

actions prevent recurrence and are complete and appropriate. Each CAPR has 

quantitative and qualitative criteria assigned in the effectiveness review plan in 

accordance with procedure EN-LI-118, “Cause Evaluation Process.” 

The inspectors determined that Entergy had established adequate measures for 

determining the effectiveness of the CAPRs. Inspectors noted that one of the 

effectiveness reviews was completed at the time of the inspection and determined that it 

appropriately evaluated the effectiveness of the corrective action assigned to address 

the root cause. As documented in section 4OA4.02.03.f of this report, inspectors 

identified that the second effectiveness review had not been completed in accordance 

with the CAP requirements. Entergy entered the issue into the CAP as CR-PNP-2014-

06067.

.3 Complicated Reactor Scram due to Trip of All Three RFPs on August 22, 2013 

On August 26, 2013, just after implementation of the modification to remove the low flow 

trip from the RFPs, a new ground caused breaker Y1-24 to trip open again. The feed 
37 

Enclosure 

pumps did not receive trip signals, verifying the effectiveness of that CAPR. Entergy 

plans to complete the effectiveness review for the CAPR to review other modifications by 

November 25, 2014. It includes a snapshot assessment of modifications to address 

SPVs and includes a criterion for success to identify no new issues with the 

modifications. 

The inspectors determined that Entergy had established adequate measures for 

determining the effectiveness of the CAPRs. 

.4 Complicated Reactor Scram due to Loss of Offsite Power on October 14, 2013 

Entergy identified one effectiveness review addressing three CAPRs to ensure that 

these actions prevent recurrence and are complete and appropriate. The effectiveness 

review plan assigned quantitative and qualitative criteria. The method described in the 

plan was to perform a snapshot self-assessment to review implementation of revised 

procedural guidance for risk management of 345 kV planned maintenance. Success 

criteria were established that required adequate documentation of the systematic 

process for risk review. The inspectors reviewed the completed effectiveness review 

and determined that it appropriately evaluated the effectiveness of the CAPR. 

The inspectors determined that Entergy had established adequate measure for 

determining the effectiveness of the CAPRs. 

.5 Root Cause Evaluation of Degraded Initiating Events Cornerstone 

Entergy has planned two effectiveness reviews for the CAPR to ensure that this action is 

complete, appropriate, and prevents recurrence. These two effectiveness reviews 

include one initial implementation review, and one snapshot self-assessment. Each 

effectiveness review contains success criteria, and has been drafted in accordance with 

Entergy procedure EN-LI-118, “Cause Evaluation Process.” Entergy originally 

scheduled the initial implementation review to be completed August 15, 2014. However, 

due to the limited number of times the station has implemented Pilgrim procedure 

1.3.142 since its issuance on July 31, 2014, the station has rescheduled this 

effectiveness review twice. The current due date is February 18, 2015. 

The inspectors determined that Entergy had established an effectiveness review plan for 

the CAPR associated with the root cause identified in this evaluation. 

e. IP 95002 requires that the inspection staff determine that the licensee’s planned or taken 

corrective actions adequately address a Notice of Violation (NOV) that was the basis for 

the supplemental inspection, if applicable. 

The NRC staff did not issue an NOV to Entergy; therefore, this inspection requirement 

was not applicable. 

 
38 

Enclosure 

f. Findings and Observations 

.1 Finding for Failure to Complete Several Corrective Actions as Required by Program 

Requirements 

Introduction: The inspectors identified a Green finding for Entergy's failure to identify 

and correct conditions adverse to quality by implementing adequate and timely actions 

to address similar conditions. Specifically, inspectors identified multiple examples of 

failure to implement the corrective actions in accordance with CAP requirements which 

resulted in failing to identify and correct several conditions adverse to quality. Two of the 

examples also involved a violation of 10 CFR Part 50, Appendix B, Criterion XVI, 

"Corrective Action," which is being treated as a NCV, as described below. 

Description: In 2013, four reactor scrams occurred at Pilgrim which resulted in two PIs 

in the Initiating Events cornerstone crossing the Green to White threshold. To address 

these risk significant performance issues, both individually and collectively, Entergy 

performed four RCEs for the individual scram events which occurred on January 10, 

February 8, August 22, and October 14. Additionally, Entergy performed a RCE to 

assess the commonalities between the four scram events and CCA to assess if any 

safety culture aspects caused or significantly contributed to the events. 

EN-LI-102, “Corrective Action Program,” Revision 23, “provides instructions for the 

administration of Entergy corrective action process, including the identification, reporting, 

evaluation, and correction of a broad range of problems, areas for improvements, and 

standards performance deficiencies. Issues addressed in the corrective action process 

must include Adverse Conditions and Conditions Adverse to Quality, and can include 

minor problems that may be precursors to more significant events, areas for 

improvement and standards performance deficiencies identified during assessments and 

other activities.” To that end, EN-LI-102 contains instructions for review and approval of 

corrective action development, response and documentation, and due date extensions. 

Section 5.6[4] of EN-LI-102 states that corrective action response must address the 

intent of the action and must not indicate correction or implementation based on future 

action. In review of the corrective action plans and status of completed or scheduled 

corrective actions to address the risk-significant performance issues, inspectors 

identified multiple deficiencies in implementing the CAP procedure. 

As documented in section 4OA4.02.03.a.1, a.2, a.4, and d.2 of this report, inspectors 

identified that some of the corrective actions specified in the RCEs were not completed 

in accordance with CAP requirements. Specifically, inspectors identified: 

 Several of the human performance related corrective actions from the RCE of a 

scram on January 10, 2013, during surveillance testing had been cancelled or 

closed. To determine whether the closure of the corrective actions was 

appropriate, inspectors reviewed a sampling of recently performed surveillances 

and observed performance of maintenance in the field. During this review, 

inspectors noted that several procedures did not have critical steps annotated as 

such, one procedure directed work to be performed following system restoration, 

and identified examples of technicians proceeding with testing when challenged 

with test equipment challenges or unexpected system response. Ultimately, 

inspectors determined that observations of maintenance execution did not 

support closure or cancellation of corrective actions identified in the RCE and 
39 

Enclosure 

determined that the numerous procedure deficiencies and human performance 

issues identified by inspectors represented conditions adverse to quality that 

were reasonably within Entergy’s ability to identify and correct by execution of 

corrective actions identified in the RCE; 

 Despite corrective actions to upgrade severe weather procedures to address 

deficiencies revealed during a winter storm on February 8, 2013, inspectors 

identified that the procedure changes did not fully meet the intent of the 

corrective actions because there were no substantive changes to the procedures 

for pre-storm actions. Additionally, inspectors determined that the inadequate 

guidance for pre-storm actions represented a condition adverse to quality that 

was reasonably within Entergy’s ability to identify and correct by execution of 

corrective actions identified in the RCE; 

 An action to send a transformer insulator that faulted offsite for vendor analysis 

was not completed as required by CAP requirements. Despite being selfidentified by Entergy in preparation for the inspection, this deficiency still existed 

at the time of the inspection; and 

 One of two effectiveness reviews for a RCE was not completed as required by 

CAP requirements. 

Entergy entered the issues into the CAP as CR-PNP-2014-5909, CR-PNP-2014-5976, 

CR-PNP-2014-5977, CR-PNP-2014-5682, CR-PNP-2014-5625, CR-PNP-2014-5826, 

CR-PNP-2014-5735, and CR-PNP-2014-06067 and took action to address the identified 

deficiencies. In particular, for the first example, Entergy revised the RCE to include 

additional corrective actions for procedural reviews prior to performance of work and 

enhanced oversight of maintenance activities. For the second example, Entergy made 

numerous additional changes to severe weather procedures. 

 

As discussed in section 4OA4.02.05.b.1, Entergy’s site safety culture review adequately 

identified the components of nuclear safety culture that caused or significantly 

contributed to the four scram events. In particular, inspectors noted Entergy identified 

that implementation of the station’s CAP has not been effective in ensuring adequate 

corrective actions are taken to address issues in a timely manner, and Entergy identified 

corrective actions to improve performance in this area. As discussed in section 

4OA4.02.05.a.5, inspectors identified examples of approved corrective actions intended 

to address challenges in CAP implementation not being completed as prescribed. For 

these corrective actions, inspector’s discussion with Entergy personnel revealed that the 

performance improvement department determined that the actions were not producing 

the desired results, and decided to implement CAP training instead. However, Entergy 

did not present these change to the CARB for approval of the revision as required by 

EN-LI-102. This was entered into the CAP as CR-PNP-2014-06040. 

Ultimately, inspectors determined that the specific deficiencies in execution of corrective 

actions identified by inspectors were symptomatic of the identified challenges in CAP 

implementation, and correspondingly determined that corrective actions specified in the 

common cause and safety culture evaluations were not effective at ensuring that 

performance issues identified by the numerous RCEs were corrected. 

Analysis: The failure to implement CAP procedural requirements with respect to 

corrective action response and documentation was a performance deficiency. This 

finding was determined to be more than minor because it was similar to IMC 0612, 

"Power Reactor Inspection Reports," Appendix E, "Examples of Minor Issues," Example 
40 

Enclosure 

3.j in that it represents a significant programmatic deficiency that could lead to worse 

errors if uncorrected. Specifically, not following an established process for completing 

corrective actions could result in a failure to identify and correct conditions adverse to 

quality or other adverse conditions. Additionally, this performance deficiency affects the 

procedure quality, equipment performance, and human performance attributes of the 

Initiating Events cornerstone, and impacts the objective to limit the likelihood of events 

that upset plant stability and challenge critical safety functions during shutdown as well 

as power operations. Specifically, a severe weather procedure did not prescribe 

sufficient actions that would limit the likelihood of ice bridging or place the plant in a 

condition that it could respond to a LOOP without potentially upsetting plant stability and 

the failure to conduct insulator testing prevented the station from assessing its 

replacement strategy. Additionally, several surveillance procedures did not provide 

sufficient barriers (e.g. critical step annotation, test equipment verification, etc.) in 

accordance with the station programs to limit the likelihood of scrams and other 

transients during testing. 

The inspectors determined the significance of the finding using IMC 0609, Appendix A, 

“The Significance Determination Process for Findings At-Power.” The finding was 

determined to be of very low safety significance (Green) because the failure to 

implement corrective actions has not resulted in a subsequent reactor scram or loss of 

mitigating equipment. This finding had a cross-cutting aspect in the area of Problem 

Identification and Resolution, Resolution, because Entergy did not take effective 

corrective actions to address issues in a timely manner commensurate with their safety 

significance. Specifically, corrective actions were not completed in accordance with 

Entergy’s CAP and, in some cases, after identification of unsatisfactory closure by 

Entergy, follow-up actions were inadequate to resolve the deficiencies. [P.3] 

Enforcement: 10 CFR Part 50, Appendix B, Criterion XVI, "Corrective Action," requires, 

in part, that measures shall be established to assure that conditions adverse to quality, 

such as failures, malfunctions, deficiencies, deviations, defective material and 

equipment, and non-conformances are promptly identified and corrected. Contrary to 

the above, inspectors identified multiple examples prior to November 7, 2014, where 

Entergy did not establish measures to assure that conditions adverse to quality were 

promptly identified and corrected. Specifically, inspectors determined that a severe 

weather procedure did not provide adequate guidance for operators to prepare the plant 

for an incoming storm. The inspectors determined that this condition adverse to quality 

was not adequately corrected when it was revealed by a storm on February 8, 2013. 

Additionally, inspectors identified several conditions adverse to quality in the execution 

or documentation of quality related surveillance procedures. The inspectors determined 

that these deficiencies were not identified and corrected by adequate implementation of 

human performance related corrective actions. Other examples provided are not 

associated with safety-related equipment and therefore failure to implement the CAP did 

not result in the failure to identify or correct conditions adverse to quality. Entergy’s 

immediate corrective actions included entering the issues into their CAP as CR-PNP2014-5909, CR-PNP-2014-5976, CR-PNP-2014-5977, CR-PNP-2014-5682, CR-PNP2014-5625, CR-PNP-2014-5826, CR-PNP-2014-5735, and CR-PNP-2014-06067. 

Additionally, Entergy revised the severe weather procedure to adequately address the 

deficiencies, sent the faulted insulator for failure analysis, and implemented additional 

corrective actions to address similar surveillance procedure deficiencies, including 

additional procedure reviews and enhanced supervisor oversight. Because the violation 

is of very low safety significance and has been entered into Entergy's CAP, this violation 
41 

Enclosure 

is being treated as a NCV, consistent with section 2.3.2.a of the Enforcement Policy. 

(NCV 05000293/2014008-02, Failure to Complete Several Corrective Actions as 

Required by Program Requirements) 

.2 Parallel White PI Findings 

Introduction: The NRC assigned two parallel PI inspection findings of low to moderate 

safety significance (White) for the failure to adequately evaluate the causes and 

implement corrective actions sufficient to address the root and contributing causes that 

resulted in the White Unplanned Scrams per 7000 Critical Hours and White Unplanned 

Scrams with Complications PIs. 

Description: The inspectors identified deficiencies regarding Entergy’s execution of 

corrective actions documented in the RCEs, as well as understanding of some of the 

causes of the issues. Specifically, inspectors identified several examples in the RCEs 

where corrective actions were not completed as intended or were closed prematurely. 

Additionally, for one of the RCEs, inspectors determined that Entergy failed to 

investigate a deficient condition sufficiently to ensure they fully understood all of the 

causes of the event. 

Inspectors determined that the specific deficiencies in execution of CAP procedures 

discussed in the findings in sections 02.02.e.1 and 02.03.f.1 of this report were indicative 

of the CAP implementation weakness that Entergy identified as part of their common 

cause and safety culture evaluations. Correspondingly, inspectors determined that 

corrective actions specified in the common cause and safety culture evaluations were 

not effective at ensuring that all the causes of the performance issues were understood 

and that corrective actions taken were adequate to address the identified root and 

contributing causes. Taken collectively, the issues associated with the two White PIs 

represent a significant weakness, as discussed in IP 95002. 

Analysis: In accordance with IMC 0305, "Operating Reactor Assessment Program," the 

inspectors identified two parallel PI inspection findings because Entergy failed to 

adequately evaluate all the causes and implement corrective actions sufficient to 

address the identified root and contributing causes that resulted in the White Unplanned 

Scrams per 7000 Critical Hours and White Unplanned Scrams with Complications PIs. 

The parallel PI findings are assigned the same safety significance as the initiating PIs. 

Since the initiating PIs were both White, these inspection findings have been assigned a 

low to moderate safety significance (White). These parallel PI inspection findings 

provide for additional NRC review of Entergy's actions to address the weaknesses 

identified in this report. 

Because these are parallel PI inspection findings, they were not assessed for crosscutting aspects. 

Enforcement: No violation of regulatory requirements is associated with these findings. 

The parallel inspection finding associated with the White Unplanned Scrams per 7000 

Critical Hours PI will take effect in the 1st quarter of 2014, which is the quarter the White 

PI was no longer considered an Action Matrix input in accordance with Section 11.02.b 

of IMC 0305, “Operating Reactor Assessment Program.” Similarly, the parallel finding 

associated with the White Unplanned Scrams with Complications PI will take effect in the 

3rd quarter of 2014. The findings will be removed from consideration of future agency 
42 

Enclosure 

action (per the Action Matrix) in the quarter following the successful completion of the 

follow-up supplemental inspection. The parallel PI inspection findings will not be doublecounted with the PIs with which they are associated. (FIN 05000293/2014008-03, 

Parallel White Unplanned Scrams per 7000 Critical Hours PI Finding; FIN 

05000293/2014008-04, Parallel White Unplanned Scrams with Complications PI 

Finding) 

02.04 Independent Assessment of Extent of Condition and Extent of Cause. 

a. Inspection Scope 

IP 95002 requires that the inspection staff perform a focused inspection to independently 

assess the validity of the licensee’s conclusions regarding the extent of condition and 

extent of cause of the issue(s). The objective of this requirement is to independently 

sample performance, as necessary, within the key attributes of the cornerstone(s) that 

are related to the subject issue(s) to ensure that the licensee’s evaluation regarding the 

extent of condition and extent of cause is sufficiently comprehensive. 

In conducting this independent review, the inspectors interviewed station management 

and personnel, reviewed procedures and program documentation, and reviewed existing 

station program monitoring and improvement efforts, including review of corrective 

action documents. The inspectors observed performance of maintenance and reviewed 

completed maintenance documents. 

b. Assessment 

.1 Reactor Scram due to Inadvertent Trip of Both RRPs on January 10, 2013 

In conducting this independent review, the inspectors observed the pre-job brief for and 

the performance of primary containment isolation system logic testing by I&C technicians 

while onsite. In the office, the inspectors reviewed the documentation associated with 

12 completed surveillance activities from October 2014 and discussed observations with 

Entergy staff. The inspectors also reviewed a sampling of maintenance department 

supervisor observations and procedure feedback forms. 

The inspectors concluded that Entergy’s determination of extent of condition and extent 

of cause for this scram event were valid and sufficiently comprehensive. Findings and 

observations related to the corrective actions to address the extent of condition and 

extent of cause discovered during the independent assessment are discussed in 

sections 4OA4.02.03.a.1 and 4OA4.02.03.f of this report. 

.2 Complicated Reactor Scram due to Loss of Offsite Power on February 8, 2013 

Entergy identified as causal to the event that procedures contained inadequate predefined risk-based criteria for operators to manipulate switchyard components during 

and following a blizzard, previous CAPRs taken did not prevent recurrence, and 

previously identified internal OE was not successfully utilized to direct removal of snow 

and ice from insulators on the SUT bus prior to reenergizing. 

The inspectors assessed whether Entergy’s extent of condition and extent of cause 

evaluations sufficiently identified operational challenges in the other severe weather 
43 

Enclosure 

related procedures. The inspectors identified that minor deficiencies existed in Entergy 

procedure 5.2.2, “High Winds (Hurricane).” In this procedure, various steps described a 

self-sustaining condition that was not consistent with the design of the system. The 

procedure stated that reducing power to 130 megawatts will provide the capability to 

maintain the reactor in service in the event both 345 kV lines are de-energized. The 

inspectors reviewed the design documentation for the 345 kV system and interviewed 

operations personnel to assess the validity of this statement and whether it would impact 

the station’s response to a severe weather event. During interviews, Entergy staff stated 

that the loss of both 345 kV lines to the Pilgrim switchyard would result in a reactor 

scram regardless of initial reactor power. The inspectors also noted that the procedure 

provided unclear guidance for operators to address flooding during a hurricane. Section 

4.1, Step [2](h) of the procedure stated “consider taking precautionary measures to 

prevent/limit water ingress into the essential equipment area.” Inspectors determined 

that this step did not provide clear pre-defined guidance for what actions should be 

performed. Entergy entered the issues into the CAP as CR-PNP-2014-06051 so that 

action could be taken to revise the procedure. 

The inspectors determined that Entergy conducted a comprehensive extent of condition 

and extent of cause review. In general, the inspectors concluded that Entergy’s 

determination of extent of condition and extent of cause for this event were valid and 

sufficiently comprehensive, and that corrective actions, including actions taken to 

address concerns identified by inspectors, were sufficient to address them. 

.3 Complicated Reactor Scram due to Trip of All Three RFPs on August 22, 2013 

To independently assess Entergy’s extent of cause assessment for the contributing 

cause which documented inadequate response to a category ‘C’ CR, the inspectors 

conducted searches of the CAP tracking system to verify Entergy was not continuing to 

close out category ‘C’ CRs which identified design vulnerabilities without fully addressing 

the concerns raised by the writer. During this review, the inspectors identified two CRs 

that did not have corrective actions that fully addressed the concerns raised in the 

initiation statement: 

 CR-PNP-2014-2515, assigned to security, documented a concern related to 

cyber security. While the primary concern raised turned out to be a drawing error 

and not the true configuration, the CR raised a secondary concern which was not 

addressed by Entergy. Entergy documented and addressed the second concern 

in CR-PNP-2014-6012. 

 CR-PNP-2014-4247, assigned to project management, documented a growing 

shoal that could impact the flow of cooler temperature water to the plant, 

potentially resulting in the high temperatures that required downpowers in 2013. 

The only corrective actions taken to date have included putting the issue on the 

margin management list and writing a funding request. In discussions with 

inspectors, Entergy stated that they did not need to take further actions because 

the shoal is only a minor impact on the intake temperatures. Though inspectors 

determined this was reasonable, they determined that there was insufficient 

documentation in the CR response to reach this conclusion. 

The corrective action that was intended to address the extent of this contributing cause 

only addressed the engineering department. Since both of these CRs were assigned 

outside of the Engineering department, they were not reviewed as part of the extent of 
44 

Enclosure 

cause action. Inspectors determined that not considering CRs from other departments 

that could identify design vulnerabilities was a weakness. However, inspectors 

determined that the weakness was minor because it did not affect the ability to meet the 

inspection objectives. 

In general, the inspectors concluded that Entergy’s determination of extent and condition 

and extent of cause for this scram event, as well as the corrective actions assigned to 

each, were valid and sufficiently comprehensive. As discussed in the finding in section 

4OA4.02.02.e of this report, Entergy had not completed evaluating the causes of the 

failed splice at the conclusion of this inspection. Validation of the extent of those causes 

through independent assessment will be reexamined during the follow-up inspection. 

.4 Complicated Reactor Scram due to Loss of Offsite Power on October 14, 2013 

Entergy determined that the scope of the extent of condition for this event was to assess 

the 345 kV system for other potential single failure vulnerabilities in the switchyard and 

transmission lines. Entergy initiated corrective actions to perform a feasibility study of 

installing a 3rd transmission line and required conduct of critical evolution meetings for 

any activity that would require operation with a single 345 kV offsite power line. The 

RCE addressed the extent of condition and extent of cause, and assigned corrective 

actions based on the identified extent of condition and extent of cause. 

The inspectors determined that Entergy conducted a comprehensive extent of condition 

and extent of cause review. The inspectors did not identify any substantive extent of 

condition and extent of cause issues that Entergy was not aware of and had not already 

identified with corrective action plans in place. The inspectors concluded that Entergy’s 

determination of extent of condition and extent of cause for this event, as well as the 

corrective actions assigned to each, were valid and sufficiently comprehensive. 

.5 Root Cause Evaluation of Degraded Initiating Events Cornerstone 

The inspectors concluded that Entergy’s determination of extent of condition and extent 

of cause for the collective evaluations of the two White PIs, and the corrective actions 

identified, were of reasonable breadth and depth. The two White PIs ultimately revealed 

organizational issues associated with the consideration of operational risk, both in 

decision making and procedures, and implementation of the corrective action and OE 

programs. To independently assess the extent of those causes, the inspectors’ review 

focused on corrective actions to address operational risk decision-making and 

implementation of the CAP. The inspectors observed various station meetings, including 

a CRG meeting as well as an Operations Focus Meeting. In preparation for the 

inspection, Entergy self-identified that extent of condition and extent of cause 

evaluations were narrowly focused and took additional action to address each of the five 

RCEs that were subject to this inspection. Based on the additional weaknesses in CAP 

implementation identified by the inspectors, the scope of the team’s independent review 

was expanded to provide further assurance that the station had adequately identified the 

extent of the issue and ensure that corrective actions were adequate. Using portions of 

IP 71152, inspectors reviewed a sampling of recent RCEs to ensure that the extent of 
45 

Enclosure 

conditions and causes were reasonable and that corrective actions were adequate. 

Inspectors identified: 

 The RCE for a loss of control room annunciators (CR-PNP-2013-5208) did not 

include sufficient justification for not identifying corrective actions to address the 

extent of condition. The direct cause was the failure of the primary controller 

card due to age. The report stated that the backup card was identical but did not 

require replacement because it was operating properly when the primary failed. 

When questioned, Entergy proved that they had replaced the backup card 

several months before the event and therefore it did not need immediate 

replacement. The root cause report should have included this information and 

did not. Entergy documented this observation in CR-PNP-2014-6096. 

 The RCE for a manual scram during a reactor shutdown due to an unexpected 

vessel depressurization (CR-PNP-2013-2275) identified as a root cause of the 

scram that an incorrect step was inserted into the shutdown procedure in 2003. 

Two specific weaknesses were identified during this review: 

o The extent of cause reviewed all procedure changes to the shutdown and 

startup procedures made between 2003 and 2013. The extent of cause 

discussion in the report did not discuss why the scope was limited to the 

startup and shutdown procedures, nor did it perform a risk assessment of 

potential extent of cause actions. Entergy wrote CR-PNP-2014-6070 to 

document this. 

o Cause and/or corrective actions for CR-PNP-2013-2275 were potentially 

incorrect. The contributing cause was the processing of a new step in the 

shutdown procedure as a non-intent change instead of an intent change. 

The corrective action added a step to supplement this determination. 

Inspectors reviewed other procedure changes and determined the cause 

was potentially more attributed to implementation of the existing process 

vice a process inadequacy. Entergy wrote CR-PNP-2014-6076 to 

document this. 

 The RCE for a failed post-work test on the 2C main steam isolation valve (MSIV) 

(CR-PNP-2013-4041) identified the condition as packing leakage due to a galled 

valve stem which occurred during reassembly. The cause was identified as 

inadequate supplemental worker oversight. The inspectors determined that 

corrective actions for extent of condition and extent of cause were potentially 

inadequate. Specifically, the extent of condition was limited to the other seven 

MSIVs and did not include other motor operated valves or a justification for why 

they could not be affected. The extent of cause was limited to outage oversight 

issues and did not consider whether oversight of on-line activities completed by 

supplemental workers was affected. Entergy wrote CR-PNP-2014-6087 to 

document this observation. 

Based on these observations, inspectors determined that CAP implementation issues 

existed across several departments at the station and inspectors confirmed that Entergy 

had existing corrective actions planned or implemented to address the issues. However, 

based on observations documented throughout this report, inspectors concluded that 

these corrective actions were not effective at ensuring that the inspection objectives of 

this IP could be met. 
46 

Enclosure 

c. Findings 

 No findings were identified. 

02.05 Safety Culture Consideration 

a. Inspection Scope 

IP 95002 requires that the inspection staff perform a focused inspection to independently 

determine that the licensee’s RCE appropriately considered whether any safety culture 

component caused or significantly contributed to any risk significant issue. 

Inspectors reviewed Entergy’s apparent cause evaluation which documented the Safety 

Culture Aspect CCA (CR-PNP-2014-1669). As part of this cause evaluation, Entergy 

reviewed 135 causal evaluations associated with recent events and conducted 35 small 

group feedback sessions with the workforce that gathered opinions and impressions 

about the safety culture at the station. The station then binned this data against various 

safety culture aspects and conducted a stream analysis as a method of causal 

evaluation. The evaluation identified three apparent causes: 

 Resolution – In some cases, the site has not taken effective corrective actions to 

address identified issues and causes in a timely manner. The cause evaluation 

documented that this is the leading driver behind issues with nuclear safety 

culture behaviors at Pilgrim. 

 Standards – In some cases, individuals do not understand the importance of 

adherence to nuclear standards. 

 Leader Behaviors – In some cases, leaders have not exhibited behaviors that set 

the standard for safety. 

The inspectors independently assessed the relationship between the safety culture 

aspects and the performance issues through use of focus groups and interviews, 

observation of a Nuclear Safety Culture Monitoring Panel (NSCMP) meeting, and review 

of cause evaluations, self-assessments, and corrective action documents. The 

inspectors interviewed 85 staff members, including 12 supervisors and senior 

management personnel. Based on review of the applicable cause evaluations, the 

inspectors selected participants for the focus groups and interviews from the following 

organizations: Operations, Engineering, Maintenance, Radiation Protection, Chemistry, 

and Security. Focus groups did not combine supervisors with staff-level personnel. The 

inspectors designed the focus groups and interviews to gather information on the safety 

culture at the station with questions directed towards specific safety culture aspects. 

The questions covered the following areas1

: 

 Leadership safety values and actions, including station resources and leader 

behaviors; 

 Problem identification and resolution; 

 Personal accountability, including the Pilgrim accountability and culpability 

models; 

 

1

 For more information on the specific topics included in these areas, refer to NRC Inspection Manual Chapter 0310, 

“Aspects Within the Cross-Cutting Areas,” issued 12/19/2013 (ADAMS Accession Number ML13351A028). 
47 

Enclosure 

 Work processes, including work management, procedure adequacy, and 

procedural adherence; 

 Continuous learning, including initial and continuing training and use of OE; 

 Safety conscious work environment and alternative processes for raising 

concerns; 

 Effective safety communication, including communicating the basis for decisions; 

 Questioning attitude; and 

 Decision-making, including station processes used for decision making. 

b. Assessment 

The inspectors reviewed the apparent cause evaluation and confirmed though 

independent assessment that the three safety culture aspects identified were 

appropriate. In addition, based on input from the focus groups, interviews, and review of 

documentation, the inspectors had the following safety culture observations: 

 Most employees interviewed expressed confidence in the current leadership 

team, and believed there had been improvements in the nuclear safety culture at 

the station over the past year. Most employees believe the station is headed in a 

positive direction. 

 There was no evidence of an issue with the safety conscious work environment 

at the station. All employees interviewed felt encouraged to raise nuclear safety 

concerns through multiple avenues. There were no indications that harassment 

or retaliation for raising safety concerns was tolerated at Pilgrim. 

 Employees expressed a willingness to use the station’s CAP to identify plant 

issues and deficiencies. Employees stated that they were willing to raise safety 

issues through the CAP, and were aware of the availability of alternate reporting 

channels, including the Employee Concerns Program. Additionally, workers 

noted that they would not hesitate to stop work in the event they receive an 

unexpected response, or if there was a problem with a step in a procedure. 

 Employees noted an increased emphasis on communication at the station, 

specifically related to communicating the bases for decisions. This increased 

emphasis was apparent to most of the workforce interviewed, and employees 

stated that they appreciated management’s willingness to communicate. 

 There were several examples of confusion regarding the Pilgrim “Accountability 

Model.” In particular, the implementation of the “200% Accountability” concept 

was not well understood in all departments. However, employees indicated that 

there is good differentiation between discipline and accountability. Employees 

recognized that they were accountable for station performance and believed that 

discipline was administered fairly. 

 The focus groups revealed examples of challenges with communication in the 

Security department on both day and night shifts. Officers indicated they were 

not receiving adequate pre-shift briefs, primarily because there was not time set 

aside to perform briefings with the entire crew of officers when they began their 

shift. Instead, supervisors were delivering communications to officers one-onone or via radio. Station management was aware of the communication issues 

and was working on corrective actions to make improvements in this area. 

 Some employees interviewed expressed concern that maintenance employees 

were not receiving adequate training, which was leaving them feeling unprepared 

to perform work for some tasks. Employees believed that some of the training 
48 

Enclosure 

concerns were due to a lack of knowledge transfer when employees turn over. 

Many employees interviewed held the perception that Entergy had a policy that 

prohibited the site from filling positions before the positions were vacated. The 

team verified with the Human Resources Manager that there is no such Entergy 

policy; however, the manager acknowledged the perception of a policy and 

planned to continue to communicate staffing strategies to station personnel. 

During the inspection, the team observed a NSCMP meeting. The station identified the 

NSCMP process as the primary means of monitoring safety culture effectiveness and 

sustainability in CR-2014-01669. However, the station also self-identified weaknesses 

with the effectiveness of the monitoring panel in early 2014. During interviews, 

management indicated they had taken actions to improve the effectiveness of the 

monitoring panel. The team observed many of these improvements at the panel 

meeting, including constructive dialog, respectful challenging, and development of 

corrective actions for improvement. A monitoring panel member from another Entergy 

site was also at the meeting to offer feedback for benchmarking and continued 

improvement. 

The team identified a potential gap in the safety culture assessment in that the design of 

the assessment did not allow for reviewing data from individual departments, which 

could have prevented the station from identifying challenges in safety culture within 

specific departments. However, the team did not identify any departments with safety 

culture concerns beyond those that had previously been identified by Pilgrim through 

their safety culture monitoring process. The departments with specific challenges in 

safety culture components had corrective actions underway and were given special 

attention during the NSCMP meeting. 

The team discussed these safety culture observations with senior management at the 

station. In most cases, the senior management team was aware of the perceptions of 

plant staff and had corrective actions in place to address identified weaknesses. 

Overall, the inspectors determined that the cause evaluations associated with this 

inspection appropriately considered safety culture aspects as they related to the various 

root and significant contributing causes. 

Additionally, the inspectors reviewed Entergy’s corrective action plan related to this 

CCA. In general, the inspectors determined that the corrective actions appeared to be 

adequate to address the causes. However, based on identified deficiencies in execution 

of the CAP documented throughout this report, inspectors determined that corrective 

actions intended to address this area were not yet sufficiently effective to ensure that the 

inspection objectives were met. 

02.06 Evaluation of IMC 0305 Criteria for Treatment of Old Design Issues 

Entergy did not request credit for self-identification of an old design issue; therefore, the 

risk-significant issues were not evaluated against the IMC 0305 criteria for treatment of 

an old design issue. 

 
49 

Enclosure 

4OA6 Meetings 

Exit Meeting Summary 

On November 20, 2014, the inspectors met with Mr. J. Dent, Site Vice President, and 

other members of his staff to discuss preliminary observations and issues identified 

during the onsite inspection. The inspectors informed Entergy that the material provided 

and gathered during the onsite inspection would be reviewed in office and discussed 

with regional management prior to the completion of the inspection. 

On December 12, 2014, the inspectors presented the inspection results to Mr. J. Dent, 

Site Vice President, and other members of his staff. The inspectors asked Entergy 

whether any material examined during the inspection should be considered proprietary. 

No proprietary information was retained by the inspection team. 

ATTACHMENT: SUPPLEMENTAL INFORMATION 
A-1 

Attachment 

SUPPLEMENTAL INFORMATION 

KEY POINTS OF CONTACT 

Licensee Personnel 

N. Berg Contractor 

T. Bordelon Performance Improvement Manager 

S. Burke Senior Staff Engineer 

K. Connerton Operations 

B. Chenard Engineering Director 

S. Das Senior Lead Engineer 

B. Deacon Senior Maintenance Specialist 

M. Farrell Nuclear Control Technician 

J. Freeman Lead Nuclear Control Technician 

J. Gerety System Engineering Manager 

P. Gerry Operating Experience Coordinator 

B. Hannigan Equipment Reliability Coordinator 

E. Herbert I&C Superintendent 

S. Hudson System Engineer 

K. Kee Engineering Design Programs Supervisor 

J. Macdonald Operations Department Manager 

A. Madeiras Design Engineering, Mechanical and Civil 

E. McCaffrey System Engineer 

M. McDonald Shift Supervisor 

F. McGinnis Licensing Engineer 

D. Miller Maintenance Coordinator 

J. O’Donnell NSSS Supervisor 

P. O’Neil Contractor 

J. Ohrenberger Senior Maintenance Manager 

B. Rancourt Senior Lead Engineer 

F. Russell Preventive Maintenance Engineer 

J. Shumate Senior Manager, Production 

R. Swanson Balance of Plant Systems Manager 

T. Wheble I&C Supervisor 

T. White Design and Program Engineering Manager 

M. Williams Nuclear Safety Licensing Specialist 

K. Woods Engineer 

LIST OF ITEMS OPENED, CLOSED, AND DISCUSSED 

Opened 

05000293/2014008-03 FIN Parallel White Unplanned Scrams per 7000 

Critical Hours PI Finding (4OA4.02.03.f) 

05000293/2014008-04 FIN Parallel White Unplanned Scrams with 

Complications PI Finding (4OA4.02.03.f) 
A-2 

Attachment 

Opened/Closed 

05000293/2014008-01 FIN Failure to Fully Derive the Causes of a 

Manual Scram (4OA4.02.02.e) 

05000293/2014008-02 NCV Failure to Complete Several Corrective 

Actions as Required by Program 

Requirements (4OA4.02.03.f) 

LIST OF DOCUMENTS REVIEWED 

Procedures 

1.3.142, PNPS Risk Review and Disposition, Revision 0 

1.3.142, PNPS Risk Review and Disposition, Revision 1 

1.3.143, PNPS Accountability Model, Revision 1 

1.4.4, New England Power Grid Operations/Interfaces, Revision 26 

1.5.22, Risk Assessment Process, Revision 24 

2.1.14, Station Power Changes, Revision 112 

2.1.37, Coastal Storm – Preparation and Actions, Revision 35 

2.1.42, Operations During Severe Weather, Revision 20 

2.2.1, 345 kV System, Revision 41 

2.2.7, 480V AC System, Revision 32 

2.4.150, Loss of Feedwater Heating, Revision 22 

3.M.3-71, Inspection and Maintenance of 345 kV Disconnects, Insulators, and Miscellaneous 

Switchyard Components, Revision 7 

5.2.2, High Winds (Hurricane), Revision 35 

5.2.3, Tornado, Revision 21 

8.M.2-1.5.3.1, Primary Containment Isolation Logic Channel Test – Channel A1 – Critical 

Maintenance, Revision 23 

8.M.2-2.10.2-9, RHR System Reactor Pressure Permissive Loop Selection Logic Functional 

Test, Revision 24, 25, 28 

8.M.2-2.10.2-9, RHR System Reactor Pressure Permissive Loop Selection Logic Functional 

Test, completed 1/12/13 

8.M.2-3.6.1, Control Rod Block from (A) RPS APRM System Logic, Revision 32 

2.2.31.1, Att. 8, Temporary Modification to Disable RFP Flow Switches while Performing 

Maintenance on TBCCW Heat Exchangers, Revision 15 

3.M.3-17.1, Raychem or Taping of 1000 Volt and Under Cables and/or Wires, Revision 17 

3.M.3-51, Electrical Termination Procedure, Revision 20EN-DC-336, Plant Health Committee, 

Revision 8 

EN-FAP-EP-010, Severe Weather Response, Revision 1 

EN-FAP-EP-012, Severe Weather Recovery, Revision 0 

EN-FAP-OM-020, Comprehensive Recovery Plans, Revision 0 

EN-FAP-OU-104, Refueling Outage Scope Identification and Control, Revision 3 

EN-FAP-OU-105, Refueling Outage Execution, Revision 3 

EN-FAP-WM-002, Critical Evolutions, Revision 1 

EN-HU-104, Engineering Task Risk and Rigor, Revision 5 

EN-HU-106, Procedure and Work Instruction Use and Adherence, Revision 3 
A-3 

Attachment 

EN-LI-102, Corrective Action Program, Revision 24 

EN-LI-118, Cause Evaluation Process, Revision 20 and 21 

EN-LI-118-01, Event and Causal Factor Charting, Revision 2 

EN-LI-118-06, Common Cause Analysis (CCA), Revision 4 

EN-LI-118-08, Failure Modes Analysis, Revision 2 

EN-LI-118-11, Why Staircase, Revision 0 

EN-LI-121, Trending and Performance Review Process, Revision 17 

EN-NS-221, Security Organization, Standards, and Expectations, Revision 6 

EN-OE-100, Operating Experience Program, Revision 21 

EN-OE-100-02, Operating Experience Evaluations, Revision 1 

EN-OP-111, Operational Decision-Making Issue (ODMI) Process, Revision 11 

EN-OP-116, Infrequently Performed Tests or Evolutions, Revision 12 

EN-OP-122, Operational Decision-Making Issue Precursor Process, Revision 0 

EN-OU-103, Long Range Outage Planning, Revision 3 

EN-PL-187, Safety Conscious Work Environment (SCWE) Policy, Revision 1 

EN-PL-190, Maintaining a Strong Safety Culture, Revision 2 

EN-TQ-104, Engineering Support Personnel Training Program, Revision 18 

EN-TQ-127, Supervisor Training Program, Revision 14 

EN-WM-101, On-Line Work Management Process, Revision 11 

EN-WM-104, On-Line Risk Assessment, Revision 9 

EN-WM-105, Planning, Revision 13 

EN-WM-109, Scheduling, Revision 7 

NOP98A1, Procedure Process, Revision 36 

W10112, Pilgrim Line Outage Risk Mitigation Procedure, Revision 0 

Drawings 

M1H20-4, Elementary Diagram Residual Heat Removal System, Revision 9, Sheet 16 

M1H10-10, Elementary Diagram Residual Heat Removal System, Revision 16, Sheet 6 

M1H8-10, Elementary Diagram Residual Heat Removal System, Revision 20, Sheet 4 

E415, Schematic Diagram Recirculation System, Revision 16 

M1H9-12, Elementary Diagram Residual Heat Removal System, Revision 21, Sheet 5 

M1H7-12, Elementary Diagram Residual Heat Removal System, Revision 21, Sheet 3 

M1H5-1-15, Elementary Diagram Residual Heat Removal System, Revision 18, Sheet 1 

M1H6-9, Elementary Diagram Residual Heat Removal System, Revision 19, Sheet 2 

E112, Schematic Diagram Reactor Feed Pump System, Revision 14 

E115, Schematic Diagram Reactor Feed Pump System, Revision 12, Sheet 1 

E115, Schematic Diagram Reactor Feed Pump System, Revision 4, Sheet 2

E1, Single Line Diagram Station, Revision 24, Sheet 1 

SE155, Station Electrical Single Line Composite Diagram 4.16 kV & 480V AC, Revision 73, 

Sheet 2 

SE155, Station Electrical Single Line Composite Diagram 4.16 kV & 480V AC, Revision 33, 

Sheet 3 

SE155, Station Electrical Single Line Composite Diagram 4.16 kV & 480V AC, Revision 26, 

Sheet 4 

Condition Reports (*denotes NRC identified during this inspection) 

CR-PNP-2011-5642 CR-PNP-2013-1325 CR-PNP-2013-4577 

CR-PNP-2014-0380 CR-PNP-2014-1669 CR-PNP-2014-2746 

CR-PNP-2014-4527 CR-PNP-2014-5795* CR-PNP-2014-5801* 

CR-PNP-2014-6040* CR-PNP-2014-7830 CR-PNP-2010-4510 

CR-PNP-2011-3253 CR-PNP-2011-5012 CR-PNP-2011-5190 
A-4 

Attachment 

CR-PNP-2011-5532 CR-PNP-2011-5591 CR-PNP-2011-5879 

CR-PNP-2012-0139 CR-PNP-2012-0183 CR-PNP-2012-0385 

CR-PNP-2012-0658 CR-PNP-2012-0766 CR-PNP-2012-1120 

CR-PNP-2012-1454 CR-PNP-2012-1558 CR-PNP-2012-1584 

CR-PNP-2012-1594 CR-PNP-2012-1731 CR-PNP-2012-2081 

CR-PNP-2012-2357 CR-PNP-2012-3801 CR-PNP-2012-4146 

CR-PNP-2013-0193 CR-PNP-2013-0271 CR-PNP-2013-0384 

CR-PNP-2013-0550 CR-PNP-2013-1184 CR-PNP-2013-1417 

CR-PNP-2013-1486 CR-PNP-2013-1845 CR-PNP-2013-1903 

CR-PNP-2013-2275 CR-PNP-2013-2594 CR-PNP-2013-3520 

CR-PNP-2013-3968 CR-PNP-2013-4162 CR-PNP-2013-4205 

CR-PNP-2013-4378 CR-PNP-2013-5208 CR-PNP-2013-5369 

CR-PNP-2013-5962 CR-PNP-2013-6264 CR-PNP-2013-6298 

CR-PNP-2013-7066 CR-PNP-2013-7927 CR-PNP-2014-2093 

CR-PNP-2014-2515 CR-PNP-2014-2852 CR-PNP-2014-2988 

CR-PNP-2014-3087 CR-PNP-2014-3108 CR-PNP-2014-3134 

CR-PNP-2014-3910 CR-PNP-2014-3931 CR-PNP-2014-4185 

CR-PNP-2014-4230 CR-PNP-2014-4247 CR-PNP-2014-4509 

CR-PNP-2014-4951 CR-PNP-2014-5625* CR-PNP-2014-5675* 

CR-PNP-2014-5682 CR-PNP-2014-5714* CR-PNP-2014-5722* 

CR-PNP-2014-5729* CR-PNP-2014-5751* CR-PNP-2014-5752* 

CR-PNP-2014-5772* CR-PNP-2014-5794* CR-PNP-2014-5796* 

CR-PNP-2014-5802* CR-PNP-2014-5867* CR-PNP-2014-5909* 

CR-PNP-2014-5976* CR-PNP-2014-5977* CR-PNP-2014-6012* 

CR-PNP-2014-6044* CR-PNP-2014-6070* CR-PNP-2014-6076* 

CR-PNP-2014-6083* CR-PNP-2014-6087* CR-PNP-2014-6096* 

CR-PNP-2014-5696* CR-PNP-2014-5735* CR-PNP-2014-5824* 

CR-PNP-2014-5826* CR-PNP-2014-5827* CR-PNP-2014-6051* 

CR-PNP-2014-6067* CR-PNP-2012-4884 CR-PNP-2014-3573 

CR-PNP-2014-5216 CR-PNP-2012-4884 

Learning Organization Documents 

LO-PNPLO-2011-00105 LO-PNPLO-2014-00105 LO-PNPLO-2014-00111 

LO-PNPLO-2014-00122 LO-PNPLO-2013-00026-7 LO-PNPLO-2013-00026-77 

LO-PNPLO-2013-00026-78 LO-PNPLO-2013-00026-79 LO-PNPLO-2013-00026-8 

Work Orders 

MR 19501568 MR 19700986 MR 19701193 MR 19701780 

MR 19800175 MR E9800086 00275489 00311632 

00350369 00391533 52420952 52452448 

52525177 52569241 52572398 52572594 

52574175 52575101 52580464 52582236 

00341530 00342515 52190999 52314012 

52586743 

Miscellaneous 

Condition Review Group Meeting Agenda, dated 11/04/2014 

Corrective Action Program Recovery Performance Indicators 

Entergy Operating Experience A2 Report – Pilgrim, dated 11/18/2014 

Entergy Operating Experience Point of Contact List – Pilgrim, dated 11/05/2014 

EN-WM-101, Attachment 9.1, dated 11/1/2014 through 11/14/2014 
A-5 

Attachment 

List of condition report due date extensions for 11/12/2014 – 11/14/2014 

List of Condition Reports related to Unsatisfactory Condition Report Closure, dated 11/18/2014 

List of Open First-Time High Critical Preventive Maintenance Items as of 11/17/2014 

On-Line Emergent Work Addition/Deletion Approval Form (EN-WM-101 Attachment 9.1), 

11/01/2014 – 11/07/2014 

Operational Focus Meeting Agenda, dated 11/04/2014 

Performance Overview, Pilgrim Nuclear Power Station 

Pilgrim Corrective Action Program Recovery Plan 

Plant Health Committee Meeting Minutes, dated 06/09/2014 

Schedule for Plant Health Committee Review of Single Point Vulnerability Mitigating Strategies, 

as of 11/18/2014 

Schedule for presentation of mitigating strategies related to single point vulnerabilities to Plant 

Health Committee 

Maintenance Excellence Plan Procedure Review Checklist 

Maintenance Procedure Review Requirements 

Pilgrim Maintenance Department Procedures Project Scope, 07/2014 

Engineering Quality Review Comment Sheet for EC 30944 

WT-WTPNP-2011-0036, Determine if loss of TBCCW to RFPs should be revised to a 

temperature based manual trip 

Plant Design Change 98-38, Replacement of Feed Water Heater Dump Valves, Moisture 

Separator Drain and Dump Valves and the Condensate Pump Min Flow Valve 

DRN 13-674, Source Range Monitoring System Revision 24 

DRN 14-015, Loss of Instrument Bus Y1 Revision 39 

DRN 14-135, Daily Surveillance Log Revision 217 

DRN 14-315, Reactor Building Closed Cooling Water System Revision 76 

DRN 14-317, Loss of RBCCW Revision 34 

DRN 14-401, Loss of Instrument Bus Y1 Revision 40 

DRN 14-456, Main Condenser Vacuum System Revision 71 

DRN 14-458, Loss of Feedwater Heating Revision 22 

DRN 14-674, 120V AC Safeguard Power Supply Revision 47 

DRN 14-759, Recirculation Pump(s) Trip Revision 45 

DRN 14-873, Reactor Cleanup System Revision 120 

DRN 14-955, Operation during Severe Weather Revision 19 

Maintenance October 2014 Procedure Use and Adherence Coaching Observations 

Procedure Use and Adherence WILL Sheets, completed 9/8/14, 9/22/14, 9/30/14 and 10/24/14 

I&C Procedure Feedback Forms completed in October 

8.M.2-2.10.2-9, RHR System Reactor Pressure Permissive Loop Selection Logic Functional 

Test, completed 1/12/2013 

Maintenance Department Standing Order 2014-001 

EC 44835, Update Documents to Reflect All Scram Solenoids Wired Backwards 

CARB Meeting Agenda, dated 9/26/14 

Master/LCC Procedure No. 1 – Nuclear Plant Transmission Operations, Revision 12 

PMQR 50076985-01 / 00029164-01 

PNPS-FSAR, Section 8, Electrical Power System 

PNPS Technical Specification 3.9, Auxiliary System 

Strategic Talent Solutions Leadership Assessments 

Letter No. QA-14-001, dated July 30, 2014 

Letter No. QA-14-002, dated July 30, 2014 

Nuclear Safety Culture Monitoring Panel Meeting Minutes dated January 2014 
A-6 

Attachment 

LIST OF ACRONYMS 

10 CFR Title 10 of the Code of Federal Regulations

ADAMS Agencywide Documents Access and Management System 

CAP Corrective Action Program 

CAPR Corrective Action to Prevent Recurrence 

CARB Corrective Action Review Board 

CCA Common Cause Analysis 

CCDP Conditional Core Damage Probability 

CR Condition Report 

CRG Condition Review Group 

DPIC Departmental Performance Improvement Coordinator 

Entergy Entergy Nuclear Operations, Inc. 

I&C Instrumentation & Control 

IMC Inspection Manual Chapter 

IP Inspection Procedure 

IR Inspection Report 

kV Kilovolt 

LOOP Loss of Offsite Power 

NCV Non-Cited Violation 

NOV Notice of Violation 

NRC U.S. Nuclear Regulatory Commission 

NSCMP Nuclear Safety Culture Monitoring Panel 

OE Operating Experience 

PI [NRC] Performance Indicator 

Pilgrim Pilgrim Nuclear Power Station 

RCE Root Cause Evaluation 

RFP Reactor Feed Pump 

ROP Reactor Oversight Program 

RRP Reactor Recirculation Pump 

SPV Single Point Vulnerability 

STAR Stop-Think-Act-Review 

SUT Startup Transformer 

UFSAR Updated Final Safety Analysis Report