J. Dent 

UNITED STATES

NUCLEAR REGULATORY COMMISSION 

REGION I 

2100 RENAISSANCE BLVD., SUITE 100 

KING OF PRUSSIA, PA 19406-2713 

May 20, 2016 

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 – SUPPLEMENTAL INSPECTION 

REPORT (PHASE ‘B’) 05000293/2016009 

Dear Mr. Dent: 

On April 8, 2016, the U.S. Nuclear Regulatory Commission (NRC) completed Phase ‘B’ of 

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

Cornerstones, Multiple Degraded Cornerstones, Multiple Yellow Inputs or One Red Input,” at 

your Pilgrim Nuclear Power Station (Pilgrim). The enclosed inspection report documents the 

inspection results, which were discussed with you and members of your staff. 

Consistent with the NRC Reactor Oversight Process Action Matrix in Inspection Manual 

Chapter 0305, “Operating Reactor Assessment Program,” the NRC is performing this 

supplemental inspection because Pilgrim transitioned into the Repetitive Degraded Cornerstone 

Column (Column 4), as discussed in the annual assessment letter, dated March 2, 2016, 

(ML16061A4191). The NRC completed the Phase ‘A’ portion of this supplemental inspection on 

January 15, 2016. The purpose of this inspection was to review aspects of Pilgrim’s corrective 

action program and to determine whether continued operation of Pilgrim was acceptable and 

whether additional regulatory actions were necessary to arrest declining plant performance. 

The Phase ‘A’ inspection evaluated Entergy Nuclear Operations, Inc. (Entergy’s) progress in 

addressing corrective action program weaknesses identified during previous inspections by 

reviewing long-standing open corrective actions, corrective actions associated with a sample of 

NRC violations, and classification of adverse versus non-adverse condition reports. The Phase 

‘B’ inspection reviewed Entergy’s overall corrective action program performance since the last 

biennial problem identification and resolution inspection in August 2015. 

To accomplish these objectives, the team examined selected procedures and representative 

records, observed activities, and interviewed personnel. In particular, the team concentrated on 

the quality of cause evaluations for identified issues, and whether the corrective actions 

adequately addressed the causes identified in the cause analyses. The results of the Phase ‘A’ 

 

 

1 Designation in parentheses refers to an Agencywide Documents Access and Management System 

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

accession number in ADAMS. 
J. Dent -2- 

and Phase ‘B’ inspections will inform the final scope of the Phase ‘C’ inspection, which will 

complete the review of the IP 95003 inspection objectives. The results of the IP 95003 

inspection will be used to inform future regulatory actions and oversight. 

Based on the samples selected for review, the team determined that Entergy generally identified 

problems, entered them into the corrective action program, properly prioritized and evaluated 

the issues commensurate with the safety significance of the problem, and generally 

implemented corrective actions appropriately. However, the team identified four condition 

reports that were not closed out in accordance with process requirements. One of these cases 

resulted in inadequate corrective action implementation, as noted below. Based on the overall 

results of this inspection, as well as a review of performance indicators and inspection results 

from the first quarter of 2016, the NRC concluded that Pilgrim continues to operate safely, and 

additional regulatory actions beyond those prescribed for plants in Column 4 are not required at 

this time. 

This report documents one finding of very low safety significance (Green), which was also 

determined to be a violation of NRC requirements. The finding involved inadequate 

implementation of a corrective action to revise a maintenance procedure, as described in the 

enclosed report. However, because of the very low safety significance and because it has been 

entered into your corrective action program, the NRC is treating this finding as a non-cited 

violation (NCV), consistent with Section 2.3.2.a of the NRC Enforcement Policy. If you contest 

the NCV 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 U.S. Nuclear Regulatory Commission, 

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

Administrator, Region I; the Director, Office of Enforcement, U.S. Nuclear Regulatory 

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

addition, if you disagree with the cross-cutting aspect assignment discussed in the enclosure, 

you should provide a response within 30 days of the date of this inspection report, with the basis 

for your disagreement, to the Regional Administrator, Region I, and the NRC Resident 

Inspectors at Pilgrim. 

 
J. Dent -3- 

In accordance with Title 10 of the Code of Federal Regulations 2.390 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 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 Scott C. Flanders for/ 

David C. Lew 

Acting Regional Administrator 

Docket No. 50-293 

License No. DPR-35 

Enclosure: 

Inspection Report 05000293/2016009 

 w/Attachment: Supplementary Information 

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

In accordance with Title 10 of the Code of Federal Regulations 2.390 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 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 Scott C. Flanders for/ 

David C. Lew 

Acting Regional Administrator 

Docket No. 50-293 

License No. DPR-35 

Enclosure: 

Inspection Report 05000293/2016009 

 w/Attachment: Supplementary Information 

cc w/encl: Distribution via ListServ 

DISTRIBUTION: (via email) 

DLew, RA SFlanders, DRA MScott, DRP 

DPelton, DRP RLorson, DRS ABurritt, DRP 

MFerdas, DRP CBickett, DRP LCline, DRP 

ECarfang, DRP, SRI BPinson, DRP, RI JPfingsten, DRP, RI 

ACass, DRP, AA JBowen, RI OEDO RidsNrrPMPilgrim Resource 

RidsNrrDorlLPL1-1 Resource ROPReports Resource 

 

 DOCUMENT NAME: G:\DRP\BRANCH5\Inspection Reports\Final\2016\Pilgrim 2016009 95003 Phase B final.docx 

 ADAMS Accession No. ML16144A027 

 SUNSI Review  Non-Sensitive 

 Sensitive 

 Publicly Available 

 Non-Publicly Available 

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

NAME NPerry/NSP via 

email CBickett/CAB ABurritt/ALB RLorson/RKL MScott/MLS DLew/SCF for 

DATE 5/18/16 5/19/16 5/19/16 5/18/16 5/18/16 5/20/16 

OFFICIAL RECORD COPY
1 

Enclosure 

U.S. NUCLEAR REGULATORY COMMISSION 

REGION I 

Docket No. 50-293 

License No. DPR-35 

Report No. 05000293/2016009 

Licensee: Entergy Nuclear Operations, Inc. (Entergy) 

Facility: Pilgrim Nuclear Power Station (Pilgrim) 

Location: 600 Rocky Hill Road 

Plymouth, MA 02360 

Dates: April 4 to April 8, 2016 

Inspectors: N. Perry, Senior Resident Inspector, Team Leader 

A. DeFrancisco, Technical Assistant 

M. Draxton, Project Engineer 

J. Vazquez, Resident Inspector (Acting) 

Approved by: Arthur L. Burritt, Chief 

Reactor Projects Branch 5 

Division of Reactor Projects 
2 

SUMMARY 

Inspection Report 05000293/2016009; 04/04/2016 – 04/08/2016; Pilgrim; Supplemental 

Inspection – Inspection Procedure (IP) 95003.

The inspection was conducted by a senior resident inspector, two region-based inspectors, and 

a resident inspector. The inspectors identified one non-cited violation (NCV), which was of very 

low safety significance (Green). 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,” dated April 29, 2015. Cross-cutting 

aspects are determined using IMC 0310, “Aspects Within the Cross-Cutting Areas,” dated 

December 4, 2014. All violations of U.S. Nuclear Regulatory Commission (NRC) requirements 

are dispositioned in accordance with the NRC’s Enforcement Policy, dated February 4, 2015. 

The NRC’s program for overseeing the safe operation of commercial nuclear power reactors is 

described in NUREG-1649, “Reactor Oversight Process,” Revision 5. 

The NRC performed this supplemental inspection in accordance with IP 95003, “Supplemental 

Inspection for Repetitive Degraded Cornerstones, Multiple Degraded Cornerstones, Multiple 

Yellow Inputs or One Red Input,” to review Energy’s progress in addressing corrective action 

program (CAP) weaknesses identified in previous inspections. This inspection served as partial 

completion of IP 95003, Section 02.02.a. 

Cornerstone: Mitigating Systems 

 Green. The inspectors identified a Green NCV of Title 10 of the Code of Federal 

Regulations (10 CFR) 50, Appendix B, Criterion XVI, “Corrective Action,” because Entergy 

did not ensure that an identified condition adverse to quality related to maintenance work on 

the salt service water (SSW) pumps was corrected. Specifically, Entergy did not implement 

a procedure change to require installation of additional anti-rotation pins. This procedure 

change was specified as a corrective action in an equipment apparent cause evaluation 

(E-ACE) [condition report (CR)-2015-09189], and addressed the assembly of a pump 

component relied upon to maintain operability of the SSW system. As immediate corrective 

action, Entergy captured this issue in their CAP as CR-2016-02401, CR-2016-02446, and 

CR-2016-02454. Additionally, Entergy implemented the necessary procedure change and 

ensured additional anti-rotation pins were installed during the most recent rebuilds of the ‘A’ 

and ‘B’ SSW pumps. 

The finding was more than minor because it was associated with the procedure quality 

attribute of the Mitigating Systems cornerstone, and adversely affected the cornerstone 

objective of ensuring the availability, reliability, and capability of systems that respond to 

initiating events to prevent undesirable consequences. Specifically, the absence of 

additional anti-rotation pins contributed to the failure of the spider bearings, which led 

Entergy to declare the ‘A’ SSW pump inoperable on November 7, 2015. Absent a 

procedure change identified as a corrective action for this condition that required installation 

of additional anti-rotational pins, this vulnerability continued to exist, which could contribute 

to subsequent spider bearing failure, thereby rendering a SSW pump inoperable. In 

accordance with IMC 0609.04, “Initial Characterization of Findings,” and IMC 0609, 

Appendix A, “The Significance Determination Process for Findings At-Power,” the inspectors 

determined that this finding was of very low safety significance (Green) because the 

performance deficiency was not a design or qualification deficiency, and did not involve an 

actual loss of a safety function of a single train for greater than its technical specification 
3 

allowed outage time. The inspectors determined that this finding had a cross-cutting aspect 

in the area of Problem Identification and Resolution, Resolution, because Entergy failed to 

ensure that established corrective actions adequately resolved and corrected the identified 

issues in a manner commensurate with their safety significance. Specifically, Entergy did 

not ensure that the corrective action taken adequately captured the intent of the corrective 

action as prescribed in the E-ACE. Furthermore, four CR closeout barriers within Entergy’s 

CAP failed to recognize and correct the issue. [P.3] (Section 4OA4.c) 

 
4 

REPORT DETAILS 

4. OTHER ACTIVITIES 

 

4OA4 Supplemental Inspection (95003) 

.1 Problem Identification and Resolution Assessment 

 a. Inspection Scope 

The NRC performed this supplemental inspection in accordance with IP 95003, 

“Supplemental Inspection for Repetitive Degraded Cornerstones, Multiple Degraded 

Cornerstones, Multiple Yellow Inputs or One Red Input,” to review Entergy’s progress in 

addressing CAP weaknesses identified in previous inspections. This inspection served 

as partial completion of IP 95003, Section 02.02.a. The objectives of this inspection 

were to assess Entergy’s ability to identify and correct problems by reviewing problem 

identification, prioritization and evaluation of issues, and corrective actions. Specific 

guidance for this objective is provided in IP 95003, which directs the inspectors to 

evaluate whether Entergy’s evaluations into significant deficiencies are of a depth 

commensurate with the significance of the issue; that root and contributing causes of 

risk-significant deficiencies are identified; and corrective actions are taken to correct 

immediate problems and to prevent recurrence. Specifically, the team reviewed a 

sampling of: (1) CRs initiated since August 2015 to determine if cause evaluations were 

thorough and if corrective actions were taken and addressed the causes; (2) NRC 

violations that have not been reviewed by other inspections to determine if Entergy had 

taken appropriate actions to address the issues; and (3) corrective action documentation 

closed since August 2015 for CRs initiated prior to then to determine if they appropriately 

addressed the identified causes. The inspection team compared performance in these 

areas to the requirements and standards contained in 10 CFR 50, Appendix B, Criterion 

XVI, “Corrective Action,” and Entergy’s procedures. Additionally, the inspection team 

attended multiple meetings involving the review, prioritization, disposition, and closeout 

of CRs. 

 Effectiveness of Identification 

In addition to the items described above, the inspectors toured areas in the plant with 

plant staff, interviewed plant personnel at all levels, reviewed completed surveillance 

tests, and observed a post-maintenance testing activity in the control room. The 

inspectors also reviewed a sample of CRs written to document issues identified 

regarding CAP areas for improvement. The inspectors completed this review to verify 

that Entergy entered conditions adverse to quality into their CAP as appropriate. 

 Effectiveness of Prioritization and Evaluation 

The inspectors reviewed the evaluation and prioritization of CRs including the 

appropriateness of the assigned significance, the scope and depth of the causal 

analysis, and the timeliness of resolution. The inspectors assessed whether the 

evaluations identified likely causes for the issues and developed appropriate corrective 

actions to address the identified causes. Further, the inspectors reviewed equipment 

operability determinations, reportability assessments, and extent-of-condition reviews for 

selected problems to verify these processes adequately addressed the issues. 
5 

 Effectiveness of Corrective Actions 

The inspectors reviewed Entergy’s completed corrective actions through documentation 

review and, in some cases, field walkdowns to determine whether the actions addressed 

the identified causes of the problems. The inspectors also reviewed CRs for adverse 

trends and repetitive problems to determine whether corrective actions were effective in 

addressing the broader issues. The inspectors reviewed Entergy’s timeliness in 

implementing corrective actions and effectiveness in precluding recurrence for significant 

conditions adverse to quality. 

 b. Observations 

 Effectiveness of Identification 

Based on the selected samples, plant walkdowns, and interviews of site personnel in 

multiple functional areas, the inspectors determined that Entergy generally identified 

problems and entered them into the CAP at a low threshold. The inspectors observed 

staff and supervisors at screening and condition review group meetings appropriately 

questioning and challenging CRs to ensure clarification and proper classification of the 

issues. Based on the samples reviewed, the inspectors determined that Entergy trended 

equipment and programmatic issues and appropriately identified problems in CRs. The 

inspectors verified that conditions adverse to quality identified through this review were 

entered into the CAP as appropriate. In response to questions by the inspectors, 

Entergy personnel promptly initiated CRs and/or took immediate action to address the 

issues. The inspectors identified one observation regarding Entergy’s problem 

identification: 

 Failure to Identify Adverse Condition Related to Safety-Related Flow Converter 

10 CFR Part 50, Appendix B, Criterion XVI, “Corrective Action,” states, in part, that 

conditions adverse to quality are promptly identified and corrected. Contrary to the 

above, as of April 5, 2016, a condition adverse to quality, related to the as-found 

condition of the safety-related neutron monitoring systems flow converter FC-Z7-A, 

was not promptly identified. On April 5, 2016, upon removing and replacing the flow 

converter under work order 52370722-01, Entergy technicians observed that the 

removed original flow converter was missing the two screws that secure the cover to 

the chassis. The replaced flow converter was installed with the two screws in place; 

however, it was slightly modified under an engineering change to have its washers 

removed, such that it would fit flush in the rack. Although Entergy identified via the 

CAP that the replacement converter needed to have its washers removed during the 

replacement, it did not note or assess the discrepant condition of the original 

converter. CR-2016-2392 was initiated on the issue. This issue screened to minor 

in accordance with IMC 0612, Appendix B, because the discrepant condition did not 

impact the safety function of the flow converter or surrounding equipment; for 

example, Entergy did not credit the screws for seismic restraint. 

 Effectiveness of Prioritization and Evaluation 

The inspectors determined that, in general, Entergy appropriately prioritized and 

evaluated issues commensurate with the safety significance of the identified problem. 

Entergy screened CRs for operability and reportability, categorized the CRs by 
6 

significance, and assigned actions to the appropriate department for evaluation and 

resolution. The CR screening process considered human performance issues, 

radiological safety concerns, repetitiveness, adverse trends, and potential impact on the 

safety conscious work environment. 

Based on the sample of CRs reviewed, the inspectors noted that the guidance provided 

by Entergy CAP implementing procedures appeared sufficient to ensure consistency in 

categorization of issues. Operability and reportability determinations were generally 

performed when conditions warranted, and the evaluations supported the conclusions. 

Causal analyses appropriately considered the extent of condition or problem, generic 

issues, and previous occurrences of the issue. 

 Effectiveness of Corrective Actions 

The inspectors concluded that corrective actions for identified deficiencies were 

generally timely and adequately implemented. For significant conditions adverse to 

quality, Entergy identified actions to prevent recurrence. The inspectors concluded that 

corrective actions to address the sample of NRC NCVs and findings since the last 

problem identification and resolution inspection were timely and effective. However, the 

inspectors did observe some weaknesses in Entergy’s resolution of identified issues. 

Entergy procedure EN-LI-102, “Corrective Action Program,” Section 5.6[5](e) states, 

“individuals closing corrective actions verify that the required action has been taken and 

any additional actions are issued.” It goes on to state that “ensuring that the response is 

adequate, answers all aspects of the assigned action, and the intent of the action is 

met.” Contrary to the above, the inspectors identified four examples where Entergy did 

not close out CRs with moderate significance in accordance with process requirements. 

Additionally, multiple closure reviews conducted as part of the CAP process did not 

identify these deficiencies. One of these cases resulted in inadequate corrective action 

implementation, as described in the finding documented in Section 4OA4.c. 

 Failure to Complete Corrective Action Prior to Closure in Corrective Action Tracking 

System 

The corrective action for an apparent cause evaluation (ACE) was closed out in the 

corrective action tracking system on March 27, 2016, and was not complete. The 

ACE addressed the lessons learned from a partial loss of offsite power event, 

resulting from a winter storm in January 2015, which had not been adequately 

implemented. The key corrective action addressing the apparent cause was to 

provide a briefing. A training performance needs analysis was attached but was 

incomplete, although the ACE stated that training had been completed on March 25, 

2016. No further actions for performing the briefing were being tracked in the 

corrective action tracking system. In addition, the ACE did not address why an 

effectiveness review was not required (CR-2016-01113). This issue screened to 

minor in accordance with IMC 0612, Appendix B, because the ACE was scheduled 

for review by the Corrective Action Review Board and at least one board member 

had identified the discrepancies. 
7 

 Failure to Properly Document Procedure Revisions 

EN-LI-102, Section 5.6[4](e) states, “when a procedure change is required per a 

CR’s corrective action plan, document the procedure and revision number in the 

corrective action.” Contrary to the above, on January 8, and March 23, 2016, actions 

taking credit for closing out operations department standing orders to station 

procedure revisions in two corrective action evaluation documents did not document 

the procedure number and revision number (CR-2015-09233 and CR-2016-01114). 

This issue screened to minor in accordance with IMC 0612, Appendix B, because the 

procedures were changed and this was only a documentation issue that did not 

significantly affect plant stability or challenge critical safety functions. 

 Failure to Adhere to Required Actions 

On March 7, 2016, a corrective action was closed without adhering to the required 

actions of the corrective action. Specifically, the corrective action required a briefing 

to all operations work liaisons on the lessons learned from a delay in relocating a 

room temperature sensor for the ‘A’ emergency diesel generator. The corrective 

action closure required that a brief summary of the event presented to the operations 

work liaisons be attached to the closure documentation. Instead, only the ACE, 

referenced station procedures, and the attendance sheet were attached (CR-2016-

00523). This issue screened to minor in accordance with IMC 0612, Appendix B, 

because the required briefing did occur. This was only a documentation issue and 

did not significantly affect plant stability or challenge critical safety functions. 

 c. Findings 

Failure to Correct a Condition Adverse to the Quality Associated with the SSW System 

Introduction. The inspectors identified a Green NCV of 10 CFR 50, Appendix B, 

Criterion XVI, “Corrective Action,” because Entergy did not ensure that an identified 

condition adverse to quality related to maintenance work on the SSW pumps was 

corrected. Specifically, Entergy did not implement a procedure change specified as a 

corrective action in an E-ACE (CR-2015-09189), which addressed the assembly of a 

pump component relied upon to maintain operability of the SSW system. 

Description. The SSW system at Pilgrim consists of two loops, each containing two 

SSW pumps, along with a fifth pump that can be connected to either loop. The safety 

function of the SSW system is to provide cooling to the reactor building closed cooling 

water system, which cools emergency and safety-related systems, during all modes of 

operation. 

On November 7, 2015, the ‘A’ SSW pump was declared inoperable after divers 

discovered debris at the bottom of the SSW bay, identified to be pieces of the pump’s 

spider bearings. These circular bearings provide radial support to the pump shaft in 

order to maintain its position within the pump column. Each of these bearings contains 

two anti-rotation pins, which prevent the bearings from spinning within the pump column. 

Prior to this event, a maintenance procedure associated with periodic SSW pump 

rebuilds, 3.M.4-14.2, “Salt Service Water Pumps: Routine Maintenance,” Attachment 6, 

recommended the installation of up to three additional anti-rotation pins. 
8 

Subsequent to the pump being declared inoperable, CR-2015-09189 was generated, 

and an E-ACE was completed. Through this E-ACE, it was determined that the 

apparent cause of the pump failure was an angular misalignment of the pump, which 

resulted in excessive loading of the spider bearings and led to their premature failure. 

Additionally, a contributing cause was that the anti-rotation bearings were not robust 

enough to handle the long-term dynamic loading associated with the misalignment. In 

light of this contributing cause, the E-ACE called for the 3.M.4-14.2 procedure to be 

revised to make the installation of three additional anti-rotation pins a requirement for 

subsequent pump rebuilds. This had previously been a recommendation within the 

procedure, but the E-ACE determined that the installation of additional pins needed to be 

mandatory. The corrective action, as listed in the E-ACE, explicitly stated, “This is 

currently optional.” However, when the corrective action from the E-ACE was translated 

to Entergy’s condition reporting system, this statement was omitted, and the corrective 

action thus failed to adequately capture the intent of the corrective action as prescribed 

in the E-ACE. As a result, the required procedure change was not incorporated into the 

procedure. 

The inspectors identified four CR closeout barriers within Entergy’s CAP that failed to 

recognize and correct the issue. These barriers involved the failure to revise the 

procedure, and the required reviews by the maintenance department performance 

improvement coordinator (DPIC), an engineering reviewer responsible for performing the 

CR closure review, and an engineering manager ultimately responsible for ensuring 

proper closure of the CR and associated corrective actions. Additionally, although not 

required by Entergy procedures, another review, involving a DPIC Closure Review 

Committee, also missed the inadequate corrective action. This committee review was 

implemented as an additional measure to improve the quality of CR closeout packages 

and to ensure all corrective actions were appropriately implemented. Furthermore, the 

individual tasked with implementing the corrective action was also involved in two of the 

other failed barriers. The practice of an individual being involved in the process of 

reviewing his/her own work was not explicitly prohibited by Entergy procedures; 

however, having the DPIC who performed the action also be responsible for reviewing 

the adequacy of the closure reduced the effectiveness of the additional checks on the 

work performed. 

As immediate corrective action, Entergy captured these issues in their CAP as 

CR-2016-02401, CR-2016-02446, and CR-2016-02454. Additionally, Entergy 

incorporated the necessary changes into an updated version of procedure 3.M.4-14.2. 

Entergy also confirmed that during rebuilds of the ‘A’ and ‘B’ SSW pumps, which took 

place after the November 7, 2015, failure of the ‘A’ SSW pump, the additional 

anti-rotation pins were installed. 

Analysis. The inspectors determined that inadequately implementing a procedure 

change specified to address a condition adverse to quality was a performance deficiency 

within Entergy’s ability to foresee and correct, and should have been prevented. The 

inspectors determined this performance deficiency was more than minor because it was 

associated with the procedure quality attribute of the Mitigating Systems cornerstone, 

and adversely affected the cornerstone objective of ensuring the availability, reliability, 

and capability of systems that respond to initiating events to prevent undesirable 

consequences. Specifically, the absence of additional anti-rotation pins contributed to 

the failure of the spider bearings, which led Entergy to declare the ‘A’ SSW pump 

inoperable on November 7, 2015. Absent a procedure change identified as a corrective 
9 

action for this condition that required installation of additional anti-rotational pins, this 

vulnerability continued to exist, which could contribute to subsequent spider bearing 

failure, thereby rendering a SSW pump inoperable. In accordance with IMC 0609.04, 

“Initial Characterization of Findings,” and IMC 0609, Appendix A, “The Significance 

Determination Process for Findings At-Power,” the inspectors determined that this 

finding was of very low safety significance (Green) because the performance deficiency 

was not a design or qualification deficiency, and did not involve an actual loss of a safety 

function of a single train for greater than its technical specification allowed outage time. 

The inspectors determined that this finding had a cross-cutting aspect in the area of 

Problem Identification and Resolution, Resolution, because Entergy failed to ensure that 

established corrective actions adequately resolved and corrected the identified issues in 

a manner commensurate with their safety significance. Specifically, Entergy did not 

ensure that the corrective action taken fulfilled the intent of the corrective action 

prescribed by the associated E-ACE. Furthermore, four CR closeout barriers within 

Entergy’s CAP failed to recognize and correct this deficiency. [P.3] 

Enforcement. 10 CFR 50, Appendix B, Criterion XVI, requires, in part, that measures 

shall be established to assure that conditions adverse to quality are promptly identified 

and corrected. Contrary to the above, following the November 7, 2015, failure of the ‘A’ 

SSW pump, Entergy corrective measures did not ensure that an identified condition 

adverse to quality associated with a procedure for the performance of SSW pump 

maintenance was corrected. Specifically, Entergy failed to revise a maintenance 

procedure to require the installation of additional anti-rotation pins in accordance with a 

corrective action established by an E-ACE. Entergy entered this issue into their CAP as 

CR-2016-02401, CR-2016-02446, and CR-2016-02454 and subsequently made the 

required procedural changes in Revision 67 of procedure 3.M.4-14.2. This violation is 

being treated as an NCV, consistent with Section 2.3.2 of the NRC Enforcement Policy. 

(NCV 05000293/2016009-01, Failure to Correct a Condition Adverse to Quality 

Associated with the Salt Service Water System)

 d. Assessment Result 

 Based on the samples selected for review, the team determined that Entergy generally 

identified problems, entered them into the CAP, properly prioritized and evaluated the 

issues commensurate with the safety significance of the problem, and generally 

implemented corrective actions appropriately. However, the team identified four CRs 

that were not closed out in accordance with process requirements. The actions affected 

in these cases included the implementation of: lessons learned from previous events, 

procedure changes, and staff briefings and training. One of these cases resulted in a 

violation related to inadequate corrective action implementation. Based on the overall 

results of this inspection, as well as a review of performance indicators and inspection 

findings from the first quarter of 2016, the NRC concluded that Pilgrim continues to 

operate safely, and additional regulatory actions beyond those prescribed for plants in 

Column 4 are not required at this time. 

 
10 

4OA6 Meetings, Including Exit 

On April 8, 2016, the inspectors presented the inspection results to Mr. John Dent, Site 

Vice President, and other members of his staff. The inspectors confirmed that all 

proprietary information examined during the inspection had been returned to the Entergy 

staff. 

ATTACHMENT: SUPPLEMENTARY INFORMATION 
A-1 

Attachment 

SUPPLEMENTARY INFORMATION 

KEY POINTS OF CONTACT

Licensee Personnel: 

J. Dent, Site Vice President 

E. Cota, Maintenance 

B. Deacon, Maintenance 

K. Drown, Performance Improvement Manager 

J. Falconieri, Engineering 

A. Ferris, Operations Reactor Manager 

P. Gavin, Instrumentation and Control 

K. Gracia, Operations Shift Manager 

M. Lynch, Engineering Fix It Now 

P. Miner, Regulatory Assurance 

D. Mortimer, Senior Operations Specialist 

J. Ohrenburger, Maintenance Manager 

J. Parameter, Senior Emergency Planner 

E. Perkins, Manager, Regulatory Assurance 

B. Vandermeer, Instrumentation and Control 

T. White, Design Engineering 

LIST OF ITEMS OPENED, CLOSED, DISCUSSED, AND UPDATED

Opened and Closed 

05000293/2016009-01 NCV Failure to Correct a Condition Adverse to 

 Quality Associated with the Salt Service 

 Water System (Section 4OA4.c) 

LIST OF DOCUMENTS REVIEWED 

Procedures 

3.M.3-1, A5/A6 Buses 4kV Protective Relay Calibration/Functional Test and Annunciator 

 Verification – Critical Maintenance, Revisions 143 and 144 

3.M.4-14.2, Salt Water Service Pumps: Routine Maintenance, Revisions 65, 66, and 67* 

8.M.2-2.64, RCIC Steam Line Low Pressure – Critical Maintenance, Revisions 34 through 44 

EN-DC-178, System Walkdowns, Revision 7 

EN-FAP-LI-001, Condition Review Group (CRG), Revision 5 

EN-FAP-OU-110, Critical Maintenance Identification and Oversight, Revision 3 

EN-FAP-WM-011, Work Planning Standard, Revision 4 

EN-LI-102, Corrective Action Program, Revisions 25 and 26 

EN-LI-108, Event Notification and Reporting, Revision 12 

EN-LI-118, Cause Evaluation Process, Revision 22 

EN-MA-101-03, Maintenance Work Preparation Process, Revision 6 

EN-OE-100, Operating Experience Program, Revision 24 

EN-OP-112, Night and Standing Orders, Revision 2 
 A-2 

EN-OP-117, Operations Assessment Resources, Revision 9 

EN-TQ-129, Planner Training Program, Revision 0 

EN-WM-105, Planning, Revisions 11, 12, and 16 

EP-AD-270, Equipment Important To Emergency Response (EITER), Revision 1 

NOP98A1, Nuclear Organization Procedure, Revision 37 

Drawing 

M8-4, Assembly Drawing Service Water Pump P208 A, B, C, D, and E, Revision 31 

Quality Assurance Audits, Peer Reviews, and Self-Assessments 

Pilgrim Nuclear Oversight Functional Area Performance Report - September to October 2015, 

November 19, 2015 

Pilgrim Nuclear Oversight Functional Area Performance Report - February 2016, March 8, 2016 

Pilgrim Nuclear Oversight Functional Area Performance Report - July to August 2016, 

September 30, 2015 

Cause Evaluations 

ACE 2016-0036, Breaker Rackup for Residual Heat Removal PP ‘C’ 

E-ACE 2015-8300, Relay 127A-A6/2 Failed to Operate on Loss of Voltage (2015-8300) 

Root Cause Evaluation 2013-04302, Shut Down Due to Degraded Condenser 

Root Cause Evaluation 2014-4052, Feedwater Heater E-103B Shell Leak 

Completed Surveillances 

8.M.2-2-6.4, RCIC Steam Line Low Pressure – Critical Maintenance, Revision 44, completed 

 September 30, 2014 

8.M.2-3.6.5, FC-Z7-A, APRM Flow Converter Post Maintenance Test, Revision 44, completed 

 April 5, 2016 

8.M.2-3.6.5, Neutron Monitoring System Flow Converter and Calibration Test, Revision 15, 

 completed October 2002 

EN-MA-101-03, Maintenance Work Preparation Process for FC-Z7-A, Flow Converter 

 Replacement, Revision 6, completed under WO 52370722 

Work Orders 

334804 436069 52370722 52587750 

Miscellaneous 

ACE, Multiple Opportunities Missed to Understand and Identify Risk Significance and Perform 

Appropriate Cause Analyses (CR-2015-09853) dated December 18, 2015 

Corrective Action Review Board Meeting Agenda, January 29, 2016 

CRG CR Summary, April 6, 2016 

Daily Plant Status Report, April 4, 2016 

Engineering Change 64069 

E-ACE, ‘A’ SSW Pump Spider Bearing Failure (CR-2015-09189) dated November 11, 2015 

eSOMS Notice of Change Module ID#33, Improper Approval of Surveillance Acceptance 

Criteria dated April 1, 2016 

Licensee Event Report 2015-004-01, 480V Bus B6 Auto Transfer Function Degraded 

MR#02118236, Work Instructions for 35-FC-27-A A Recirc Flow Converter, Revision 0, 

completed October 2002 

Notes from DPIC Closure Review Committee Meeting dated February 24, 2016 

NTWI-15, Nuclear Training Attendance, Course EN-WM-105/EN-FAP-WM-011 Review, 

Revision 5, dated January 14, 2015 
 A-3 

Online T-Week Report, Work Week 1614, T-01 System Review dated March 25, 2016 

Performance Review Meeting Report, Pilgrim Operations, January, and February 2016 

Pilgrim Aggregate Performance Review Meeting Report, October, November, December and 

January (February 2016 Meeting) 

Pilgrim Site Performance Indicators, March 30, 2016 

Pilgrim Station Coordinated Meeting Schedule, March 10, 2016 

PLP-ESPC-R20-3, Presentation Material from Refueling Outage 20 Session 3 ESP General 

Continuing Training, Revision 1 

PNP CRG Summary Agenda Report Prescreen dated April 6, 2016 

PMID-RQ 50076625-01 

Purchase Order 10461348 issued October 19, 2015, for Flow Converter Circuit Card Assembly 

SSW Monthly Walkdown Checklist 

SDBD-29, System Design Basis for the Salt Service Water System, Revision E1 

V-1096, 4160 Metal-Clad Switchgear, Magne-Blast Circuit Breakers and Vacuum Circuit 

Breakers 

Weekly Online Readiness Indicator dated April 8, 2016 

Condition Reports 

2012-00669 2013-04190 2013-05949 2014-04052 

2015-00375 2015-00558 2015-01759 2015-02109 

2015-03454 2015-05197 2015-06780 2015-07049 

2015-07285 2015-07295 2015-07355 2015-07993 

2015-08286 2015-08403 2015-09139 2015-09189 

2015-09233 2015-09376 2015-09382 2015-09413 

2015-09474 2015-09570 2015-09853 2016-00025 

2016-00070 2016-00120 2016-00523 2016-00707 

2016-01072 2016-01113 2016-01114 2016-01912 

2016-02198 2016-02243 2016-02378* 2016-02392* 

2016-02401* 2016-02439* 2016-02446* 2016-02453* 

HQN-2016-00464* 

*Developed as a result of NRC inspection 

LIST OF ACRONYMS USED

10 CFR Title 10 of the Code of Federal Regulations 

ACE apparent cause evaluation 

CAP corrective action program 

CR condition report 

DPIC department performance improvement coordinator 

E-ACE equipment apparent cause evaluation 

IMC Inspection Manual Chapter 

IP Inspection Procedure 

NCV non-cited violation 

NRC Nuclear Regulatory Commission, U.S. 

SSW salt service water