Heaven knows, we have all made mistakes with our email.
From the accidental "reply all" to picking the wrong "George" in the address book to receive an email, these things happen to all of us.
And, boy, did it happen to Pilgrim Nuclear last week!
Inspectors were visiting the plant and, corresponding among themselves and other NRC officials, one of them accidentially sent an internal email to Diane Turco of Cape Downwinders - one of the Pilgrim plant's most outspoken critics. Ms. Turco kindly provided this email to the media. The most telling words in the long email were "The plant seems overwhelmed by just trying to run the station."
All righty, then!
In every controversy there is a seminal moment that changes the conversation - the proverbial straw that broke the camel's back. If ever there was such a straw in the Pilgrim nuke controversy, those words "overwhelmed by just trying to run the station" should be it.
What more impetus do our public officials need to order this Pilgrim nuclear plant closed immediately and forever?
Hand of God?
The question remains: Was this accidental email the fickle finger of fate at work or perhaps the hand of God?
Full NRC Email of December 6th, accidentally sent to Diane Turco of Cape Downwinders:
From: "Cline, Leonard" <[email protected]>
Date: December 6, 2016 8:57:16 AM EST
To: "Weil, Jenny" <[email protected]>, "Tifft, Doug"
<[email protected]>, "Draxton, Mark"
<[email protected]>, "Sheehan, Neil"
<[email protected]>, Diane Turco
<[email protected]>, "Venkataraman, Booma"
<[email protected]>, "Guzman, Richard"
Subject: FW: Pilgrim 95003 Phase C Update 12/5/16
From: Jackson, Donald
Sent: Monday, December 05, 2016 9:58 PM
To: Dorman, Dan <[email protected]>; Lew, David
<[email protected]>; Lorson, Raymond
<[email protected]>; Yerokun, Jimi
<[email protected]>; Scott, Michael <[email protected]>;
Pelton, David <[email protected]>; Burritt, Arthur
Cc: Duncan, Eric <[email protected]>; Clagg, Rodney
<[email protected]>; Josey, Jeffrey
<[email protected]>; Arner, Frank <[email protected]>;
Carfang, Erin <[email protected]>; Cline, Leonard
<[email protected]>; Keefe-Forsyth, Molly
<[email protected]>; Horvitz, Stacey
<[email protected]>; Bickett, Carey
Subject: Re: Pilgrim 95003 Phase C Update 12/5/16
I will clean this up tomorrow....I left Chaff in there from last week. In
general, if you read the updates later in the paragraphs it provides better
info...the issues are all in play.
USNRC Region I
On: 05 December 2016 19:10, "Jackson, Donald"
<[email protected]> wrote:
The following is a brief (or maybe not so brief) update of inspection
activities associated with the ongoing Pilgrim 95003 Phase C
· The Safety Culture Group conducted additional focus groups
today, bringing the total number of people interviewed so far to over
130. This group plans to conduct 1 on 1 chance interviews in plant
next week to validate observations from the group discussions
· The Operations NRC inspector observed pre-job briefings and
maintenance and operations evolutions in plant
· Many Engineering discussions over the status of the EDGs
· Many team field activity observations
· (Update) The station performed an apparent cause evaluation for
an ‘A’ EDG issue that occurred in September of this year, which
involved oil leakage from the ‘A’ EDG blower gear box relief valve
fitting. We are still inspecting this issue, but items that we are
currently following include:
o Pilgrim only performed a visual inspection of the gear box following
the event, even though there are indications that the gear box was
potentially run with little or no oil. There are two bearings and a pump
in this gear box. We provided this issue as an operability concern to
the control room this afternoon. The initial operability determination
was “operable” based on the fact that they ran the ’A’ EDG
successfully this morning. The NRC Engineering, Maintenance, and
Programs group lead does not now have an immediate operability
concern, but numerous questions are still being addressed by Pilgrim
o The 50.59 that was performed to install this type of gear box
appears to be inadequate, in that it did not account for a new failure
mode (i.e., introduction of a relief valve to the gear box)
o Inadequate causal evaluation of the issue (Pilgrim classified the
cause as “indeterminate” and missed similar operating experience
from North Anna)
o Questions on the pre-startup checks for the EDG were resolved
by Carey and Erin, as they walked down pre-start up checks with
Non Licensed Operators
o Missed reportability call is likely
o The team further questioned the extent of condition of this issue
related to the same gear box on the ‘B’ EDG. We believe that there is
a current operability question on the ‘B’ EDG related to the same
relief valve failure mechanism and leakage. The Pilgrim Systems
Engineering Manager stated to the team that the site did not want to
remove the EDG from service to investigate this concern as it would
result in unavailability time that could place the EDG in Maintenance
Rule A.1. Later in the day the Engineering Director and Site VP tried
to backtrack on this statement, but the team believes that it was a
genuine thought by this senior station manager and is an insight on
Safety Culture. Pilgrim is conducting an inspection of this ‘B’ EDG
Gear Box this evening.
o The licensee analyzed oil from both the ‘A’ and ‘B’ EDG Blower
gear boxes and determined that no component degradation occurred.
o The licensee removed the ‘B’ EDG Gear Box RV, and determined
that adequate thread engagement existed, and a common mode
failure was unlikely. The reset and reinstalled the RV
o The licensee also ‘staked’ the threads on the ‘B’ EDG Gear Box
RV to prevent recurrence of the failure…..However, it appears that
the licensee did not perform a 50.59 screening for this modification to
SR equipment which is an additional example of 50.59 process
· (Update) We are observing evidence of some weaknesses in the
use of Subject Matter Experts (SMEs) as a CAPR in the corrective
action program area. Specifically, the roles and responsibilities of the
SMEs do not appear to be clearly defined (i.e., we are hearing
different things from station personnel, the lead CAP SME, and the
support CAP SMEs about what their role is). At this point, we do not
know if this extends to the other areas or not. The PIR Group is
developing examples to support the teams belief that the CAPRs for
the Root Cause for the Corrective Action Program may not be fully
effective. The plant has completed 123 of 134 corrective actions in
this area, yet we have identified CAP problems through this week.
Preliminarily, CAPRs 1 and 2 involving the use of SMEs and Use of
Performance Indicators appear to be ineffective.
· (No Change) The Engineering, Maintenance, and Programs group
is looking at several examples where well established programs have
not been followed. There was a circuit breaker replacement (swap)
involving 52 circuit breakers covering a wide variety of plant
equipment that was not screened under 50.59 as the licensee
believed that they were exact, "like for like" replacements. The NRC
has determined that lugs used inside of the breakers were a different
size, and should have been evaluated accordingly. Other items that
may also support this issue (though the mods are very dated):
o The EDG gearbox issue described above
o During a walkdown, an inspector noted that the EDG exhaust didn’t
appear to be missile-protected. The exhaust was moved as part of a
o Plant Computer modification that impacted the heat balance
· (No Change) The Engineering, Maintenance, and Programs group
is looking into several examples of corrective actions that may not
have been properly addressed. One involves a 2011 Internal
Flooding issue that was raised, and has not yet been fully addressed.
· (No Change) The Engineering, Maintenance, and Programs
group is inspecting an issue associated with lack of clearance
between grating/ pipe supports and the primary containment liner.
The design requires 1/16 “ clearance and in some cases there is no
clearance. The licensee wrote and closed 4 CRS without properly
evaluating the issue or reviewing extent of condition. We did brief a
10CFR50 AppB Criterion XVI performance deficiency that we are
· (Update) We receive a revised Root Cause Evaluation for the
95001 SRV sample on Monday. The teams preliminary review of the
document appears to provide an inadequate Root Cause Evaluation
and corrective actions that will not prevent recurrence. Essentially,
this revised root cause blames Operations Management and an
inadequate post trip review. The inspector believes that these may
be contributing causes, but the root cause is more aligned to a failure
to properly implement the corrective action process. Frank Arner
reviewed Doug Dodson’s work and has aligned with Doug’s view that
the Root Cause is not adequate. However, there is a possibility,
when you evaluate all of the corrective actions taken to date on the
issue, that they have taken adequate corrective actions. Doug
believes that the Root Cause is an inadequate Operability
Determination for the 2013 SRV Failure, and poor corrective actions
for what they did put in the CAP. Since ODs and CAP are issues
that have had recent actions, we think that they may have taken
adequate corrective action. That being said, it is likely that the
licensee did not adequately complete the 95001 in that they got the
Root Cause wrong.
· (New) Pilgrim has a longstanding (30+Years) issue where the ‘B’
RHR Heat Exchanger bottom flange has been leaking. The have
conducted three non-code furminite repairs over the years. The last
injection was 2007, and the leakage has reinitiated at 30 drops per
minute. Entergy cannot find the paperwork for the first injection, and
does not know the type or the amount of material injected. This
appears to be a non-code repair of a code system that either needed
to be resolved at the next outage, or code relief provided by the
NRC. Neither has been done. Additionally, there is current leakage
(120 drops/min at 50 psig) outside of the drywell that has not been
appropriately evaluated. More to follow on this issue.
· (New) The ECP Manager has not completed the Entergy
qualification program. This seems strange for a Column 4 plant
where Safety Culture is a fundamental problem area.
Common Causal Insights:
· (No Change) The Safety Culture Group is hearing that people are
happy and working to improve the site (Exception- Security). The
observation of actual performance however is somewhat disjointed.
It appears that many staff across the site may not have the standards
to know what “good” actually is. There is a lot of positive energy, but
no one seems to know what to do with it, to improve performance,
leading to procedural non compliances, poor maintenance, poor
engineering practices, and equipment reliability problems. Example-
Jeff Josey questioned operability of ‘A’ EDG Wednesday around 10
AM with a well-developed set of questions, and a direct statement
questioning operability. By 4pm, we were aware that the Shift
Manager was not made aware of this challenge, and no CR was
written. The NRC then approached the Shift Manager with the
Operability challenge. We are still waiting for the answers to our
operability questions (but as mentioned previously, we don’t think
there is now an immediate concern). Additionally, while observing an
IC surveillance, the worker stated that this test would take him much
longer since the NRC was watching. In fact, the channel that we
watched took 2.5 hours to complete, and the other 3 Channels took 2
hours total to complete when we were not observing.
· (Update) We became aware today that corrective actions
associated with the Recovery Plan are being “kicked back” to the
organization by the external contracted review folks after completion
by Pilgrim because the closure actions do not match the required
actions. In several cases that we have reviewed, station
management then changes the recovery action on the CA to match
what was actually done, such that the external contracted review
group agrees with issue closure. We are capturing examples of this
to prove our point. The licensee was in disbelief when we mentioned
this issue. One example that we found today is that the Recovery
Plan calls for all Supervisors and above to have a “Targeted
Performance Improvement Plan” which is tailored to the individual,
have milestones, and due dates for specific actions. Apparently the
plans are not tailored to the individual and are nearly all the same, and
we found that some folks just recently found out that they were on a
TPIP, and were surprised. It does not appear that they met the spirit
of the recovery action.
· (No Change) Overall, we are beginning to see a picture where the
people seem to be willing and happy/excited about change, but
actions seem to be marginalized during implementation. Some of this
marginalization seems to be due to not understanding what the end
state should look like, and frankly some of it seems to be due to a
lack of resources across many groups. We will be probing this
further, as it is a key to making a recommendation whether or not the
plan will be effective/ sustainable.
· (New) A licensee oversight contractor informed me that the
licensee is actively working a further revision to the Recovery Plan to
address the issues that we have found in the last week. They plan to
present this to the NRC later this week. I will likely need to discuss
this with NRR to figure out the rules on reviewing this.
Level of Cooperation:
· In general, the licensee is being responsive, but very disjointed in
their ability to populate meetings and answer questions, staffing
problems seem to impact how fast the licensee can respond. For
example- We attempted to conduct a safety culture focus group with
Security and no one showed up, because the security supervisor
“forgot” he needed to support it. The plant seems overwhelmed by
just trying to run the station. An RP person wrote a CR last evening
that the NRC inspection was significantly impacting getting her work
done, and that we should spread out requests over the whole 3
weeks….seemed very frustrated. We have been very clear that we
are flexible, and that we are sensitive to impact on plant activities.
· The licensee engineering group appears unprepared to address
all of the questions being posed by the team. I am couching this by
questioning their overall Engineering Acumen.
The team is really struggling to figure out what all of this
means. The licensee staff seems to say the right things, and they
are genuinely energized about improving. We believe that there are
some incremental improvements that look bigger than they actually
are to the licensee staff. The corrective actions in the recovery plan
seem to have been hastily developed and implemented, and some
have been circumvented as they were deemed too hard to complete.
We are observing current indications of a safety culture problem that
a bunch of talking probably won’t fix. We did see a paired
supervisory observation that uncovered procedure usage problems
that were not directly identified by the workers supervisor. If the
95001 SRV review is truly UNSAT after almost 2 years, my
confidence will not be very high, and I reiterate we received a revision
dated 4 days ago. The dance associated with EDG operability this
week is also disturbing on many levels- Poor Engineering Expertise,
no communication with the shift manager, Poor original corrective
action, and a Senior Manager stating a reluctance to assure
operability due to a negative impact on maintenance rule status.
Carey, Frank, and met early on Sunday, and discussed several
“themes” that we plan to further develop, namely: Safety Culture,
Ineffective CAP, Conduct of Operations/OPS Standards, Engineering
Acumen, and Work Management. The challenge will be to determine
if Corrective Actions already taken in all of these areas has been
effective or not. On the plus side, we have not identified performance
deficiencies at the same rate as ANO, and the team believes that
procedures are in good shape.
Don Jackson- Team Lead