Monday, October 27, 2014

Response to Special Inspection

So the question remains, in a change to a facilities licence, why can't the NRC catch a wrong call in the screening and 50.59 on a design change. Why does it depend on the licensee declaring they are breaking the rules?


DOMINION NUCLEAR CONNECTICUT, INC. (DNC) MILLSTONE POWER STATION UNITS 2 AND 3 RESPONSE TO AN APPARENT VIOLATION IN NRC SPECIAL INSPECTION REPORT 05000336/2014011AND 05000423/2014011; EA-14-12

Apparent Violation
As stated in the summary section of NRC Special Inspection Report,05000336/2014011 and 05000423/2014011, during an NRC team inspection conducted between June 2 and July 15, 2014, "the NRC identified a Severity Level Ill Apparent Violation (A V) of Title 10 of the Code of Federal Regulations (10 CFR) 50.59, "Changes, Tests, and
So the NRC inspectors should have been in many outage and design change meetings and seen their documents. What didn't the NRC on their own see the Millstone design change on the transmission system and the circuit change, this was big, and entailed an increase of risk. Is the bifurcation of  nuclear safety responsibilities between a on site transmission authority and near site transmission authorities a unreviewed safety issue.  
Experiments," for Dominion's failure to complete a 10 CFR 50.59 evaluation and obtain a license amendment for a change made to the facility as described in the Updated Final Safety Analysis Report (UFSAR). Specifically, ... a
NRC OIG InspectionOn June 7, 2006, SCE notified NRC of its intent and timeline to replace Units 2 and 3 steam generators under 10 CFR 50.59. The SCE briefing document indicated there would be no associated power uprate and that associated technical specification1changes were scheduled to be identified in 2007.
special protection system (SPS), known as severe line outage detection (SLOD), [was removed] which was described in the UFSAR. Dominion concluded in the 10 CFR 50.59 screening that a full 10 CFR 50.59 evaluation was
NRC OIG: An attachment to the inspection report listed, by number, the 15 screens, 8 evaluations, and 12 plant modifications the inspectors reviewed. Included within the list of eight evaluations reviewed was number 800071702, which OIG learned was the number SONGS assigned to its 10 CFR 50.59 screening and evaluation pertaining to its Unit 2 replacement steam generators. 1
not required and, therefore, prior NRC approval was not needed to implement this change. The team concluded that prior NRC approval likely was required because the removal of SLOD may have resulted in more than a minimal increase in the likelihood of occurrence of a malfunction of the offsite power system as described in the UFSAR."

Response to the Apparent Violation

Dominion Nuclear Connecticut, Inc. (DNC) submits the following information in response to NRC Special Inspection Report 05000336/2014011 and 05000423/2014011 which was issued by the NRC on August 28, 2014. DNC chooses to respond in writing to AV 05000336/2014011 and 05000423/2014011 and declined the opportunity for a Pre-decisional Enforcement Conference (PEC) and the opportunity to request Alternative Dispute Resolution (ADR) during a phone call on September 8, 2014, between Lori Armstrong of DNC and Raymond McKinley, Chief, Division of Reactor Projects Branch 5, NRC Region I.

1) The reason for the Apparent Violation (AV) or, if contested, the basis for disputing the violation DNC does not contest the apparent violation.

NRC's review and approval of the change to the Millstone Power Station Unit 2 (MPS2) and 3 (MPS3) licensing basis for the removal of SLOD was not requested by DNC because
Well, there is lots of Millstone's  management levels who had to sign off on this?
of an inadequately prepared 10 CFR 50.59 screen. In the 10 CFR 50.59 screen, Engineering personnel failed to consider that the removal of SLOD was an adverse change
So why didn't Dominion send a notification to the the Plant NRC inspector of major work on our local transmission system potentially affecting safety, we find no increase in risk...please cover our backs with checking out our work???

Why does the licensee and NRC sounds more like enemies to each other, at a complete state of total war with each other relationship, instead of everyone covering each other's back(morally and ethically). Do it the right way and no taking shortcuts?    

Honestly, I can't imagine the NRC not nosing around the site their own and finding the major work was going on in transmission system in the document and the list of potential and on going major work going on. Doesn't that say a lot they couldn't discover this on their own? How much else does the NRC miss with not being "intrusive".

According to the NRC OIG report on SONGs, the NRC is coming out with a major committee report on the agency's lessons learned on the SONGS SG debacle late this fall. I can't wait to see this guy?     
relating to DNC's compliance with General Design Criteria (GDC) 17, and therefore did not conclude that a 10 CFR 50.59 evaluation was needed.

The root cause evaluation for this AV identified the direct cause as a lack in proficiency and skill in performing 10 CFR 50.59 screens. The root cause for this AV was determined to be that continuing training was not adequate to maintain the proficiency and skills for consistent, accurate screens. Corrective actions were needed to address the screening deficiency identified in the apparent violation.

The complexities associated with the technical issue, multiple responsible entities involved, and understanding of the MPS2 and MPS3 licensing basis are also relevant to understanding the contributing factors for the AV. During review of this AV, it was determined that DNC's error of not performing a 10 CFR 50.59 evaluation occurred during the design development for the removal of SLOD by the transmission owner, Northeast Utilities (NU). During the design development, DNC did not recognize that NU's removal of SLOD resulted in a change in the method of compliance with GDC 17 that required DNC to perform a 10 CFR 50.59 evaluation. This matter is further addressed in the Additional Information provided below.

2) The corrective steps that have been taken and the results achieved

With removal of SLOD, and as discussed in the Additional Information provided below, the station no longer met the method for compliance with GDC 17 approved by the NRC at the time of original licensing of MPS3. As documented in NRC Special Inspection Report 05000336/2014011 and 05000423/2014011, DNC implemented a compensatory measure by issuing an Operations standing order for interim guidance on future offsite line outages and plant generation output. In March 2014, prior to the NRC Special Inspection, DNC had separately implemented improvements in the procedural guidance for performing 10 CFR 50.59 screenings.

These improvements were the result of DNC identified gaps in performance of 10 CFR 50.59 screenings. Improvements included a major rewrite and expansion of the guidance for completing 10 CFR 50.59 screens using a more user-
NRC OIG:

"According to the former NRR Director, if there were problems with the 50.59 process, it would have manifested itself in many more issues than just the steam generator issue."


"Although these reviews are never 100 percent because they are done through sampling, his expectations are that the inspectors look hard and that they challenge."

"The Team Leader thought existing 10 CFR 50.59 guidance could be improved."


"She recalled that each region interpreted the inspection procedures differently."


"Additionally, the Team Leader said there was no specific training for 50.59."

"Team Member 1 also thought the 50.59 guidance available to inspectors is too vague."

"From his experience, the licensee and NRC routinely get into disagreements because of interpretation of the guidance."

"He said while there may be an opportunity - if an inspector reviews something while it is being worked on - to identify something that can change the course of the licensee's path, but typically the activities are already done in the field, or on their way to being done, before NRC starts looking."

"The challenge is that there are so many different types of components, structures, and systems and it is hard to write a procedure that captures all those different circumstances."

 "Although these reviews are never 100 percent because they are done through sampling, his expectations are that the inspectors look hard and that they challenge."

"The former Regional Administrator wants them to be as thorough as they can be, but their time is limited."  


"So they can never look at everything."  


"However, he said that inspectors do not look at everything and are trained to sample."

"NRC does not have the resources, including time or manpower, to review everything and so inspectors sample."

"According to the former NRR Director, based on the information provided by OIG pertaining to methodology changes, it appeared that NRC may have done a bad job of reviewing the SONGS 50.59 during the 2009 inspection; however, one should be careful before concluding that this was a broader problem than SONGS."

"Nevertheless, as the NRR Director responsible for the operational safety of 100 nuclear power plants and research and test reactors, he has limited resources."

"Also, he said, "We're only going to be able to sample, and you always want to make sure that you're sampling the items with the highest likely safety significance input."

"The Deputy Executive Director commented that the high frequency with which licensees use the 50.59 process coupled with the relatively low frequency of issues identified by NRC suggests to him that training could be a factor."  

"We had a lot of stuff to look at. ..We didn't look at everything."


"He said the AIT's determination was - based on review of the FSAR, the engineering change package describing the new design, the 50.59 screen and evaluation, and other items - there was no indication that the licensee needed a license amendment."

"He said that reviewing the 50.59 entails reviewing a sampling and based on his years of experience as an inspector, he said, "you don't expect 100 percent of everything, but you review it. . . and you dig deeper into things that don't sound right."

"He said that all inspections are done by sampling."

"However, if the region missed some of the methodology changes it was because inspections have always been no more than a sampling."


"He said to make a definitive decision on whether a license amendment request was required, the agency would have to talk about the resources needed to accomplish that. He said, "It comes down to a prudent use of resources to go back and accomplish that."

 "The Project Manager said that the UFSAR reviews by project managers are a low priority and he was not sure if they could be given a higher priority because project managers have a lot of work already."
friendly format. The procedure now includes more detailed guidance for responses to each section of the screen form
NRC OIG: "In his opinion, the NEI 96-07 guidance is too vague, allows for too many judgment calls, and needs solidifying of definitions. From his experience, the licensee and NRC routinely get into disagreements because of interpretation of the guidance.
including direct references to NEI 96-07, Guidelines for 10 CFR 50.59 Implementation.
NRC OIG: “For example, he said "more than a minimal increase" should be defined by a specific value in 1O CFR 50.59. (OIG notes that "more than a minimal increase" is the terminology used in several of the 1O CFR 50.59(c)(2) screening criteria.” “Team Member 1 told OIG that training for 50.59 inspections could be improved. He said NRC needs to insure inspectors are fully trained and versed in the 50.59 process.”

“The Branch Chief also told OIG that training was an area that needed improvement and that the quality of a 10 CFR 50.59 inspection is dependent on the inspector's knowledge, experience, and background.  He said the guidance is complex and there is a lot of judgment that is applied in using it.” 
In August 2014, training was provided on an expedited basis to a select population (the majority) of 10 CFR 50.59 screeners. The training included discussion on the fundamentals of GDC compliance and the importance of identifying and reviewing the impacts of design changes upon the licensing basis, including the FSAR. Only personnel who have received the training are presently qualified to perform 10 CFR 50.59 screens.

Design changes scheduled for implementation in the remainder of 2014 have been reviewed by Design Engineering to determine whether adequate licensing basis reviews were conducted as part of the 10 CFR 50.59 screenings. No 10 CFR 50.59 screens were identified which should have concluded a 10 CFR 50.59 evaluation was required.

3) The corrective steps that will be taken

To become qualified to perform 10 CFR 50.59 screens, future training will include a discussion of the fundamentals of GDC compliance and the importance of identifying and reviewing the impacts of design changes upon the licensing basis, including the FSAR.
Why don't we need NRC national training on all licencing issues and qualification testing?  
A review of the 10 CFR 50.59 screens for FSAR changes processed in the past three years will be conducted by April 1, 2015 to determine whether adequate licensing basis reviews were conducted.

DNC is evaluating options for addressing compliance with GDC 17. To complete this work, engineering analysis, including consideration of potential design modifications, is necessary. Upon completion, a License Amendment Request (LAR) will be submitted to the NRC requesting review and approval of a licensing basis change to the MPS2 and MPS3 FSAR that addresses the removal of SLOD. DNC will keep the senior resident inspector informed of the status and schedule for resolution.

4) The date when full compliance will be achieved

Full compliance was achieved when training was provided in August 2014. To ensure future continued compliance, the 10 CFR 50.59 training module will be updated to include a discussion of the fundamentals of GDC compliance and the importance of identifying and reviewing the impacts of design changes upon the licensing basis, including the FSAR.

Additional Information:

The SLOD system was owned by the transmission system owner, NU. Removal of SLOD was a result of a major transmission line upgrade project to improve grid reliability by separating lines and towers leaving the MPS switchyard. This separation allowed NU to eliminate SLOD, which they no longer considered reliable or secure.
So the instrumentation was getting unreliable and obsolete...just rip it out without telling the NRC.  
The upgrade, as it was presented, reduced risk to MPS and improved grid reliability to MPS.
Why wasn't the NRC invited to a meeting?  
Representatives of DNC and NU participated in multiple Nuclear Plant Interface Meetings (NPIMs) coordinated by ISO New England (the transmission system operator). These meetings, which began several years in advance of the actual physical modifications, included discussions of proposed changes to the transmission system.

The transmission upgrade project by NU involved rerouting the transmission lines from four lines on two towers to four lines on four separate towers. The removal of SLOD was presented in the aggregate as an improvement in grid reliability, conforming to present transmission system standards. According to the North American Electric Reliability Corporation standard on special protection systems (SPSs), SPSs such as SLOD carry with them unique risks including, risk of failure on demand and inadvertent activation, and risk of interacting with other SPSs in unintended ways. Thus, at the time, DNC,
I bet you the overarching ideal was to yank this gear out of the system before it caused an inadvertent trip on fault.  
ISO New England, and NU believed that separation of the towers/lines removed the vulnerability which SLOD was installed to mitigate and represented an improvement in grid reliability. Therefore, following tower line separation, SLOD was disabled and eventually removed. DNC recognizes that during the design development for the modified transmission circuits, there were opportunities to understand that the Millstone licensing basis was impacted by the removal of SLOD and that a 10 CFR 50.59
What about worrying about the collapse of the Pennsylvania and New York grid on past documents?  
evaluation would be required. DNC accepted the changes proposed and approved by NU, ISO New England, and the Northeast Power Coordinating Council without adequately considering the impact to the MPS licensing basis. The complexities associated with the specific technical issue, multiple responsible entities involved, and understanding of the licensing basis all played a part in the failure to recognize the impact of the change on the licensing basis.

The 10 CFR 50.59 screen failed to consider that the removal of SLOD was an adverse change relating to DNC's compliance with GDC 17, and therefore did not conclude that a 10 CFR 50.59 evaluation was needed. It was the belief that the tower and line separation project, including SLOD removal, was undertaken by NU for the sole reason to enhance grid stability and reliability, providing a more stable source of offsite power to MPS. That belief resulted in the DNC mindset that the removal of SLOD references from the FSARs did not require further evaluation. Following the May 25, 2014 event, DNC recognized that SLOD was credited for GDC 17 compliance and its removal should have been considered an adverse change requiring a 10 CFR 50.59 evaluation.

Extensive engineering analysis, including consideration of potential design modifications, is ongoing to address DNC's compliance with GDC 17. Upon completion of this work, a LAR will be submitted to the NRC requesting review and approval of licensing basis changes to the MPS2 and MPS3 FSARs for GDC 17.

As noted in the response to Question 3, improving sensitivity to the license basis and the 10 CFR 50.59 requirements is being addressed by training to prevent future similar situations.
Of Interest:


"After filing the motion, however, the group learned that the plant’s final safety analysis report, a document required by the plant’s license, had been changed last year, altering the methodology for measuring seismic safety and stating that the plant can withstand shaking up to .75 times the force of gravity. Such a fundamental change, the group argues, requires amending the operating license itself, a process in which the commission must give the public the opportunity to comment.

Report not public

Instead, the revised safety analysis report wasn’t available to the public on the commission’s website. When Friends of the Earth requested a copy, they received a redacted version.

Commission spokeswoman Uselding said information related to nuclear plant safety is often released to the public on a case-by-case basis, after a commission staff member has reviewed the request to address national security concerns."
They needed 50.59 for this in July 2001 and then not to rip the whole thing out in 2012. Who cares if they screwed Pennsylvania and New York by 2012?

"The Severe Line Outage Detection (SLOD) system is designed to prevent instability and loss of all generation at Millstone Station. Besides avoiding unit instability, a distribution system casualty with generation above 1300-1400 MW at Millstone Station could have severe, adverse consequences on Pennsylvania and/or New York grid reactive and thermal operating conditions. The SLOD system is continuously armed and avoids instability and loss of all generation at Millstone by tripping only pre-selected units when certain conditions exist. The tripping logic associated with the SLOD system was modified to remove all trips associated with Millstone Unit No. 1. The Double Line and Breaker Failure Detection Unit Rejection Special Protection System (DBURS), two more Special Protection Systems (SPS) used to trip pre-selected units at Millstone, were deleted and removed since their functions were no longer needed due to the loss of Millstone Unit No. 1 generation. CRP-909 was connected to the master supervisory panel in the 345-kV switchyard via a new fiber optic cable. Switches on CRP-909 for control of Millstone Unit No. 1 switchyard circuit breakers and motor operated disconnects were removed."
"Summer Readiness of Offsite and Alternate Alternating Current (AC) Power Systems
a. Inspection Scope

The inspectors performed a review of plant features and procedures for the operation and continued availability of the offsite and alternate AC power system to evaluate readiness of the systems prior to seasonal high grid loading. The inspectors reviewed Dominion’s procedures affecting these areas and the communications protocols between the transmission system operator and Dominion. This review focused on changes to the established program and material condition of the offsite and alternate AC power equipment. The inspectors assessed whether Dominion established and implemented appropriate procedures and protocols to monitor and maintain availability and reliability of both the offsite AC power system and the onsite alternate AC power system. The inspectors evaluated the material condition of the associated equipment by interviewing the responsible system manager, reviewing condition reports (CR) and open work orders, and walking down portions of the offsite and AC power systems including the 345 kilovolt (KV) switchyard and transformers. Documents reviewed for each section of this inspection report are listed in the Attachment." 
t.

Virus have infected my computer

Virus have infected my computer...I have been dealing with it since sat morning. Cloud 7 something or other. I think I just cleared it up. I couldn't use my computer all weekend long.

I was thinking of throwing my computer against the wall a few times it got me so  mad and then running over it with my car!!!

Sunday, October 26, 2014

NRC OIG's San Onofre Inspection Quotes


Basically the quotes from all the NRC employees in the NRC OIG inspection. 

You notice we don't have quotes from the San Onofre organization employees"

Every sentence in this could be a talking point in its own right.  
Team Leader

"The Team Leader described her role as the administrative coordinator of the inspection but with some technical oversight."

"She did not view herself as an authority on the team, and said team members were "pretty much even."

"The Team Leader thought existing 10 CFR 50.59 guidance could be improved."

"She recalled that each region interpreted the inspection procedures differently."

"Additionally, the Team Leader said there was no specific training for 50.59."

"She thought NRC has a good 50.59 inspection program, but it needs to be revamped to eliminate these discrepancies."

Team Member 1

"OIG learned that the team member who was assigned to review the replacement steam generator evaluation as part of the 2009 50.59 inspection was a Region IV DRS Reactor Inspector, and the 2009 SONGS 50.59 inspection was approximately his second 50.59 inspection."

"He said the team "pulled the screen, which was very large, for the 50.59 for the Unit 2 steam generators and went line by line to ensure that there was no adverse impact pertaining to installation of the new steam generators at SONGS Unit 2."

"He said while neither he nor any of the other team members was an ABAQUS or ANSYS "guru," they would have asked to see evidence that this statement was supported."

"He said if he were doing the inspection now and came across UFSAR items indicating a methodology change that was not captured in the screen, he would question the licensee." 
   
"Team Member 1 told OIG that training for 50.59 inspections could be improved."

"He went into this inspection right out of college and said it would have been helpful to have had more training."

"At the time of this inspection, regional inspectors were not involving the headquarters technical experts, like they do now."

"Team Member 1 also thought the 50.59 guidance available to inspectors is too vague."

"For example, he said At the time of this inspection, regional inspectors were not involving the headquarters technical experts, like they do now."


"For example, he said "more than a minimal increase" should be defined by a specific value in 1O CFR 50.59. (OIG notes that "more than a minimal increase" is the terminology used in several of the 1O CFR 50.59(c)(2) screening criteria.)"

"Furthermore, he noted that an inspector's knowledge and background influences the conclusion of an inspection."  

"He said, "I could read it one way, [you] could read it a completely different way," and subsequently come up with a different conclusion."

"He added that inspector "skill sets are to determine and ask appropriate questions that could lead us to potential issues."

Team Branch Chief

"A Region IV DRS Branch Chief told OIG that during the 2009 integrated inspection at SONGS that included the 10 CFR 50.59 review of the SONGS replacement steam generator, he was in a 3-month rotational position acting as the Branch Chief responsible for the Region IV DRS Engineering Branch that did the SONGS 71111.17 inspection."   

"The Branch Chief did not work with the inspectors on the scope of their work or provide any oversight of their onsite inspection activity, but he said he would have looked at the results they brought back and would have approved the "feeder'' report that they prepared for inclusion in the integrated inspection report."

Interviews of NRC Subject Matter Experts

"Although the purpose of any 50.59 process should be to evaluate changes to the facility as described in the FSAR, the SONGS _evaluation rarely discusses the actual changes to the FSAR. You cannot tell from the evaluation what exact statements were changed."

"For a document that is supposed to evaluate adverse changes to "license and design basis" functional requirements, there is little mention of what the actual design and license basis requirements are."
"This displays a significant lack of understanding of the 50.59 process and requirements at the plant."

There are a number of general statements in the screen that are never supported. Just stating these types of conclusions does not make it so; this is a large, involved screen that, after dissected, lacks substance.   Examples cited regarding the comparison of the original steam generators (OSG) against the replacements include the following:

''These differences represent a vast improvement over the OSG materials in terms of corrosion, erosion-corrosion and wear resistance."

"These differences also represent functional improvements over the OSG components."

"There are some instances where the licensee and their contractor appear to have deviated from NRG-approved guidance and, as a result, failed to perform 1O CFR 50.59 evaluations related to portions of the steam generator replacements." 

"The most prevalent deviation from guidance involves areas where reanalysis was completed to demonstrate that all required safety functions and design requirements were met. NRG-approved guidance states that in these circumstances, the change is considered to be adverse and a 1O CFR 50.59 evaluation is required."

Another area of deviation from guidance involves the licensee's understanding and use of guidance related to changes to one or more elements of evaluation and changes from one method of evaluation to another.  Each discussion related to methods of evaluation is incomplete or flawed.  In general, these discussions lack adequate detail to support the stated conclusions.

"Review of this document would take substantial effort by an inspector. There really are not enough hours allotted within the baseline 50.59 inspection to perform a good review. It would take a tremendous amount of time just to get the required documents to support the licensee's conclusions, if such documents exist."

"One of the Branch Chiefs noted in his review that 10 CFR 50.59 is an administrative process to determine if facility changes can be implemented without prior NRC staff approval by way of the license amendment process of 10 CFR 50.90. He wrote, "Errors in executing the 10 CFR 50.59 process do not directly impugn the ultimate acceptability of the design and analysis associated with the proposed change."

"The Branch Chief also told OIG that training was an area that needed improvement and that the quality of a 10 CFR 50.59 inspection is dependent on the inspector's knowledge, experience, and background."

"He said the guidance is complex and there is a lot of judgment that is applied in using it."

"The Branch Chief said the only way to provide effective oversight is to make sure the inspectors have the tools and training to effectively execute the inspection procedures."

"He said that currently, the only training people get on conducting 50.59 inspections is through the inspector qualification process and that it would be much better to have some kind of recurrent refresher training or lessons learned."

 "The Branch Chief said some regions do more than others in that regard."

"The Branch Chief also noted that NRC 50.59 inspections generally occur after the fact and it is the licensee's responsibility under the license to complete this process properly, using their procedures, and our inspection activity is reviewing that and aimed at holding them accountable on a sampling basis for the quality of the projects they produce and adherence to their procedures." 

"He said while there may be an opportunity - if an inspector reviews something while it is being worked on - to identify something that can change the course of the licensee's path, but typically the activities are already done in the field, or on their way to being done, before NRC starts looking."

"The other Branch Chief told OIG that the 50.59 regulation is complex and NRC inspectors need clear guidance, specific training on the 1O CFR 50.59 inspection process, and increased hours to perform the inspections."

"In his opinion, the NEI 96-07 guidance is too vague, allows for too many judgment calls, and needs solidifying of definitions."

"From his experience, the licensee and NRC routinely get into disagreements because of interpretation of the guidance."

"This Branch Chief told OIG that had he reviewed the SONGS 50.59 in 2009, he would have come to the conclusion that, without additional documents, he would have absolutely no reasonable assurance that SONGS could pass a 50.59 inspection." 


"He would have told the licensee that their documentation was inadequate and not documented properly, and the licensee may have had time before the install to produce adequate documentation."

"The Branch Chief said he would have expected the 2009 inspectors to ask questions and follow up on the unsupported general statements made by the licensee in the 50.59 documents; however, he could not determine from the documentation he reviewed whether a license amendment was needed."

"He said while there may be an opportunity - if an inspector reviews something while it is being worked on - to identify something that can change the course of the licensee's path, but typically the activities are already done in the field, or on their way to being done, before NRC starts looking."

"The NRR Program Manager also commented that inspectors can watch an activity every month - for years even - and then a different inspector will come in and find something the others never identified."

NRR Response to OIG Questions About Methodology Changes

"According to the memorandum, it was not unexpected that NRC did not have on hand all the information needed to answer OIG's questions "based on NRC Inspection Manual 2515, 'Light­ Water Reactor Inspection Program,' which states, '[t]he NRC inspection program covers only small samples of licensee activities in any particular area,' and 'individual inspectors are expected to exercise initiative in conducting inspections, based on their expertise and experience."'

Interviews of NRC Region IV Management

Former Deputy Regional Administrator

"Regarding the 50.59 inspection process, the fundamental question is to understand whether or not the licensing staff, NRR, needs to conduct a review before a change is permitted to the licensing basis of the plant."

"He said that samples are taken to see if the licensee comported with criteria of the regulation."

"He believed that in hindsight, SONGS needed a license amendment based on what was known today (2013), however, he could not speak to what was known in 2009 or 2010."

"He believed that in hindsight, SONGS needed a license amendment based on what was known today (2013), however, he could not speak to what was known in 2009 or 2010."

"The former Deputy Regional Administrator explained that the design, as built, was fundamentally flawed and would not have been approved under any conditions."

"The overall design was unacceptable because of the adverse thermal-hydraulic conditions and the upper tube structure support being inadequate."

"Regarding inspection guidance procedures relevant to the 50.59 process, the former Deputy Regional Administrator stated that the inspection guidance appears to be focused on the updated FSAR, and provides some practical guidance."

"However, it does not address the issue of why a change might need to have pre-approval."

"The inspection guidance does not cover the details of the rule, why each of the 50.59 criteria exists, and how to interpret them."

"According to the former Deputy Regional Administrator, the inspection guidance can be improved."

"He noted that he has heard from staff members that they are dissatisfied with NEI guidance."

"The challenge is that there are so many different types of components, structures, and systems and it is hard to write a procedure that captures all those different circumstances."  

"Having a detailed inspection plan that allows one to probe into the important areas is part of inspection preparation and for an effort like the steam generator replacement, which is like inspecting a system, there would need to be more individuals involved, more resources, more time, and more preparation."    

"He added that the steam generator replacement inspection guidance is focused on a number of activities including opening up containment, removing the old generators, placing new generators, patching the containment and verifying containment integrity."

"The guidance allocates 350 hours for this activity and only approximately 60 hours are devoted to design, including the 50.59 review, which is not very much time to actually delve into a complex component such as steam generators."

"The former Deputy Regional Administrator said that the agency has to decide if it is important enough to inspect every one of these (steam generators) as they come along, and that inspections are funded and adequately supported."   

The program guidance needs to be reviewed and could be enhanced and the resource allocation needs to be reviewed.   

"The former Deputy Regional Administrator added that guidance for inspecting in-service steam generators experiencing tube degradation provides a lot of insight, but has not been updated in 18 years."

"Some of the guidance is out of date and some needs to be strengthened."

"The former Deputy Regional Administrator said that there are not many findings that result from [steam generators or 50.59] inspections."

"When the staff initially started conducting steam generator replacement inspections they were a huge deal and the inspection plan was discussed at the branch, division, and regional administrator's level and there was a lot of communication with the other regions."

"However, in his view, over time these inspections have become routine."

Former Regional Administrator

"Although these reviews are never 100 percent because they are done through sampling, his expectations are that the inspectors look hard and that they challenge."

"The former Regional Administrator wants them to be as thorough as they can be, but their time is limited."  

"So they can never look at everything."  

"The former Regional Administrator told OIG that inspectors review the important functions of the important systems and components that are being changed and the evaluation behind the change to see if it is justifiable that it is not increasing the risk - not triggering those criteria from the 50.59 rule."

"He said that knowing what they know now, "the steam generators as designed were basically unlicensable."  
"We wouldn't approve them."

"The former Regional Administrator advised 50.59 could be strengthened with explicit instruction to the inspector in preparation for their inspections."   

***"He mentioned a limiting factor with 50.59 is that a lot of information contained in the licensing basis is not contained in the FSAR and may not be reviewed under 50.59."

"The former Regional Administrator felt the NRC should consider excluding some design changes from 50.59."  

"He said it is worth the time and effort for the NRC to do a license amendment on a major reactor coolant system component."  

"He said a license amendment would not accomplish design validation, but it will get to a certain set of criteria and, in the case at SONGS, it would have caused reviewers to ask good questions to determine."

'What's behind it?"

"For example, he said that based on guidance in the Standard Review Plan,26 one item that certainly would have been questioned by reviewers was the acceptance criteria of 95 percent (void fraction27), because no other plant in the industry is over 90 percent."  

"Some reviewer would have said that this is an outlier and we need to understand that."

***"The former Regional Administrator stated to leave the review of such a large and broad component with the scope and depth of engineering of the steam generator with the inspection oversight program may be risky."  

***"The inspection program will miss things because it is not encompassing enough to review to the level of detail or scrutiny as does the Standard Review Plan."

Current Region I V Deputy Regional Administrator

"When asked to interpret the differences of opinion from the 2009 inspection to the subject matter expert reviews during this inquiry, the current Region IV Deputy Regional Administrator said he did not know the amount of time taken in 2009 as compared to the AIT and AIT followup and any additional reviews."

"He said the different outcomes could reflect the level of experience of inspectors."

"However, he added the fact that the AIT cited SONGS for a couple of minor violations, indicates the 2009 inspection team did not conduct a proper 50.59 evaluation."

"The RIV Deputy Regional Administrator commented that if two 50.59 inspectors have the same information and come to different conclusions, we need to take a look at our guidance and make sure that it is clear and more objective."   

"He advised based on what he knows about the SONGS issues, the agency may benefit from a different inspection approach to do some kind of screening and determine if a more detailed design-type review for major component replacement inspections is necessary. " 

"This issue is being addressed with the lessons learned review."  

"Additionally, he believes there could be improvements in training and guidance, as evidenced by the subject matter experts having different observation in reviewing the SONGS replacement steam generator evaluation. " 

***"And if experts have different views, inspectors with less experience may have more variability in their conclusions."

Interviews of NRC Headquarters Managers

"However, he said that inspectors do not look at everything and are trained to sample."

 "NRC does not have the resources, including time or manpower, to review everything and so inspectors sample."

"The former NRR Director said that the problem with the SONGS steam generators was a design issue."

"The 50.59 process would not have prevented the steam generators from leaking and this is not the purpose of the 50.59 process."

"The 50.59 process is not going to stop a licensee from buying bad equipment, or from operating a plant incorrectly.  It is not NRC's job to make sure that a licensee buys good generators."  

"The NRC's job is to protect public health and safety."

"The former NRR Director told OIG that the 50.59 process is a threshold as to whether a licensee can take a particular action without NRC approval."

"According to the former NRR Director, this information indicated that NRC was reviewing the 50.59s and that mistakes were being made; however, none of these findings were particularly safety-significant."

"Consequently, based on this data, he does not believe that he has a lot of problems
with the generic use of 50.59 by licensees or a problem with NRC oversight of the 50.59 process."

"According to the former NRR Director, if there were problems with the 50.59 process, it would have manifested itself in many more issues than just the steam generator issue."

"The former NRR Director added that NRC has not had an issue with the approximately 53 nuclear power plants that have changed their steam generators under the 10 CFR 50.59 process."

"According to the former NRR Director, based on the information provided by OIG pertaining to methodology changes, it appeared that NRC may have done a bad job of reviewing the SONGS 50.59 during the 2009 inspection; however, one should be careful before concluding that this was a broader problem than SONGS."

"He did not have data to conclude that NRC needs to do a larger inspection sample.  What happened at SONGS was not particularly safety-significant."   

"It was a good question to ask whether the NRC was doing enough of a review of the 50.59s being conducted.  

"Nevertheless, as the NRR Director responsible for the operational safety of 100 nuclear power plants and research and test reactors, he has limited resources."

Deputy Executive Director for Reactor and Preparedness  Programs

***"Safety of the plant is the licensee's primary responsibility, and NRC relies on licensees to implement technical specifications and the conditions of their license."

"A licensee may make changes in their facility without obtaining a license amendment only if they meet the eight criteria in 1O CFR 50.59."

"Also, he said, "We're only going to be able to sample, and you always want to make sure that you're sampling the items with the highest likely safety significance input."

"His main concern is that the process is not overly driven by subjectivity and judgment."

"NRC staff and is not intended to pick up problems with design flaws like 10 CFR 50.90 (i.e., license amendment requests) reviews; however, it could."  

Also, he said, "We're only going to be able to sample, and you always want to make sure that you're sampling the items with the highest likely safety significance input."

"The Deputy Executive Director commented that the high frequency with which licensees use the 50.59 process coupled with the relatively low frequency of issues identified by NRC suggests to him that training could be a factor."  

"He believes that if we look at training in a broad sense - qualification training, on-the-job-training, and experience - we may be able to understand how training influenced inspectors' decisions made or should have been made differently."  

***"For example, communications with external stakeholders will be an area that NRC improves and possibly areas with the 50.59 process and how it gets implemented."

"They screwed it up and we didn't pick it up."

"Turns out we didn't look at it in detail because they did a 50.59 review - didn't believe they needed to get us to look at [a license amendment request]."

"ISSUE 2: AIT Review of SCE's 10 CFR 50.59 Evaluation

Interviews of AIT Participants

Former Division of Reactor Safety Director

"He recalled that the Region II Senior Reactor Inspector used NEl's NRG-endorsed guidance (NEI 96-07, Guidelines for 10 CFR 50.59 Implementation ) to review the 50.59 screens and evaluations and determine whether a license amendment was needed."

"We had a lot of stuff to look at. ..We didn't look at everything."

"The AIT was focused on the tube degradation."   

"Furthermore, the AIT inspection is an incident based inspection; he explained it is not a 50.59 inspection but questions arose regarding the adequacy of 50.59 and the AIT did more work to address those questions."

"The AIT Team Leader explained the AIT cited SCE with a thermal hydraulic modeling design violation of (10 CFR Part 50) Criterion Ill, (Design Control), which resulted in Region IV issuing SCE an apparent white violation."  

"He said, Region IV concluded that they did not believe the velocity information was available at the time (during the 50.59 process), like it is now." 

***"Had the information been available, SCE would have had to do something differently from a 50.59 perspective."   

"He advised that, collectively, the team thought if SONGS had done a more thorough evaluation, ·they potentially could have identified the problem if they had checked the adequacy of some of the information that they had questions on, specifically questions regarding velocities and questions concerning design control."

 Region II Senior Reactor Inspector

"The Senior Reactor Inspector said the decision to review the licensee's 50.59 evaluation arose after the AIT member from the Office of Nuclear Regulatory Research ran an independent thermal-hydraulic model of the replacement steam generators and identified some inconsistencies between his model and the licensee's model."

"He said that 1O CFR 50.59 specifies that if the licensee departs from the methodology as described in the FSAR, then a license amendment is needed."

"However, because the FSAR did not contain what was used for the original steam generators, there was no basis to conclude a departure from methodology had occurred."
(Catch 22)  "He said, "if the methodology is not in the FSAR, they didn't depart from it."
"So legally, by 50.59, they don't meet that criteria."
"He said the AIT's determination was - based on review of the FSAR, the engineering change package describing the new design, the 50.59 screen and evaluation, and other items - there was no indication that the licensee needed a license amendment."

Office of Nuclear Reactor Regulation Project Manager

"The Office of Nuclear Reactor Regulation (NRR) headquarters specialist to whom the AIT Team Leader referred was an NRR Project Manager assigned as the 10 CFR 50.59 Program Manager since 2009.
He was not told how to conduct the review and he was not an official member of the AIT."

"He said that reviewing the 50.59 entails reviewing a sampling and based on his years of experience as an inspector, he said, "you don't expect 100 percent of everything, but you review it. . . and you dig deeper into things that don't sound right."

"He said that all inspections are done by sampling."

"ANSYS with ABAQUS, he said this was a methodology change and the regulation is clear: If you use a new method, you have to justify it based on whether the NRC has previously approved that method for the intended application."

"He communicated to Region IV AIT followup team members that if ABAQUS had not been previously approved by the NRC for the specific application, a license amendment would be needed."

(SONG Chief Engineer Gary J Kline)

"The Project Manager recalled this was an item the licensee objected to because they said it was a revision to an existing method, and not a new methodology, whereas he believed it was a new methodology." 
"He was not sure what information the licensee provided to the AIT followup inspectors, or to what extent the NRC inspectors looked for where NRC had previously approved this method, but that the region closed the item out."

"He said he reviewed it and went with the region's judgment."

"The Project Manager acknowledged the methodology changes discussed in Issue I of this report (i.e., steam generator related methodology changes reflected in the UFSAR that were not mentioned in the licensee's 10 CFR 50.59 screen)."  

"He said he did not notice this during his review (he checked the UFSAR to see that changes mentioned in the evaluation were reflected, but did not do a reverse comparison to see if all the changes to the UFSAR were reflected in the 50.59), but the licensee should have included them in the description of changes."

"However, he said, "just because they should have included that, and therefore they did not evaluate . . . does not mean it would have resulted in the need for prior NRC approval.  It just means they didn't completely document it."

"The purpose of 10 CFR 50.59 is not to identify design deficiencies but to determine whether prior NRC review and approval is required."

"He said design deficiencies should be picked up through licensee quality assurance programs and potentially through NRC oversight of licensees' design control process through inspection, which is accomplished through a sampling process."

AIT Followup Team Member

"After discussion with OIG about the 10 CFR 50.59 provision concerning the need for NRC approval for the "intended application" when changing from a method of evaluation concerning methodology changes described in the FSAR to another method (10 CFR 50.59 (1)(2)(ii)), the Senior Project Engineer said the inspection plan was "probably flawed" because they did not look for explicit approval by the NRC for the intended application."

"With regard to the second area of concern within this URI, the Senior Project Engineer said that it was not a change in methodology because they went from using STRUDL and ANSYS to using just ANSYS to analyze a limiting event."

"However, when OIG discussed the use of a manual calculation to replace STRUDL, he said the regulatory basis for closing this area was probably not" adequate, based on the rule."

Review of Closeout Justification by Subject Matter Experts

"The other Branch Chief told OIG that NEI 96-07 guidance states that licensees who cite approved methodology from another licensee need to document their review of the method, approved application, safety evaluation report, and related documentation and verify that applicable terms, conditions, and limitations are met and to ensure the method is applicable to their type of plant."

SONGS Special Project Branch Chief

"A Region IV Branch Chief with oversight responsibility for SONGS since 2009 who also served as Branch Chief of the SONGS Special Project Branch told OIG, in hindsight, if NRC were to go through the 50.59 questions now, some of those screening questions would have to be answered yes and would require NRC approval."  

"But back then [2007- 2009], NRC did not know and SONGS did not know what NRC knows now [regarding the FIT-Ill thermal-hydraulic model], and an [NRC Office of Investigations] investigation was ongoing [as of February 2013] to determine what information was available."   

"He advised all indicators are that SONGS was not aware of the failure of the code error (used with the FIT-Ill) and SONGS could not have predicted it."

Former Deputy Regional Administrator

"According to the former Deputy Regional Administrator, SONGS' 50.59 did not meet the criteria 50.59 (2)(c)(ii) because design changes resulted "in more than a minimal increase in the likelihood of occurrence of a malfunction of a structure, system or component important to safety previously evaluated in the Final Safety Analysis Report as updated."    
"He noted that this issue was not pursued because of the 2.206 petition submitted to the NRC Petition Review Board by the Friends of the Earth."

"The former Deputy Regional Administrator said that while he and some of the staff members involved in the AIT believed that SONGS violated 50.59 (2)(c)(ii) during its' implementation of the 50.59 process, other staff members did not share this view."

"According to the former Deputy Regional Administrator, the staff's focus and emphasis was not so much on whether one could point to a single criteria, but whether or not it (the violation) was fair and reasonable and met the standards for discretion."

"As noted under Issue 1, the former Deputy Regional Administrator said in hindsight, he believes that SONGS should have requested a license amendment from NRC prior to making the change."

"He also believes the steam generator design was fundamentally flawed and would not have been approved as designed."

Former Region IV Regional Administrator

"The former Region IV Regional Administrator told OIG that because the event surrounding the SONGS steam generator tube degradation was unprecedented in the industry, Region IV immediately established an AIT."

"The AIT may have conducted a focused 50.59 because NRC rarely, if ever, conducts a 100-percent review."

"Consequently, the AIT could have very easily selected items they viewed as important aspects to review to determine if the licensee reached the right conclusion."

 "In his view, the AIT focused on design issues and the 50.59 process is not intended to identify design issues."

"He was aware that the AIT has raised methodology-type questions because some of it surfaced in the AIT report and that the team considered methodology changes."

"However, if the region missed some of the methodology changes it was because inspections have always been no more than a sampling."

"If the AIT did not focus on the methodology changes, it was because there was something about their approach, plan, and scope of review, coupled with guidance they received that took them in the direction they took.  It was not malevolent or intent, but a part of the mentality and process of how inspectors pick their sample and selection process."

Current Region I V Deputy Regional Administrator

"The current Region IV Deputy Regional Administrator said that based on what the NRC looked at during its inspections, the agency made definitive statements that the licensee did not require a license amendment."

"However, he acknowledged there could be other aspects of the 50.59 that were done incorrectly that would require or would have required a license amendment.  He said that without additional inspection, NRC does not know the answer."  

"He said to make a definitive decision on whether a license amendment request was required, the agency would have to talk about the resources needed to accomplish that."  

"He said, "It comes down to a prudent use of resources to go back and accomplish that.""

"He does not believe the licensee's 50.59 evaluation would have picked it up."

"He also doubts the NRC license amendment review process would have picked this up. If the licensee explains the model used and reports the value reached, NRC may accept the output."

The NRC review process is not going to identify an error that the licensee made in either the modeling or the inputs to the modeling or the assumptions that went into the modeling."

Former NRR Director

"The former NRR Director noted that whether the NRC should have conducted a much more thorough review because of external stakeholder interest is a different question and should have been a management decision."

"However, from a safety significant standpoint, the answer would have been that it did not warrant a more thorough review. He noted that there was no release offsite that was consequential to anyone."

Interview of NRR Acting Director

"The Acting NRR Director told OIG the region does not have latitude to deviate from the 50.59 rule [similar versus intended use]."

"But, in this case, it is NRC's job to have the licensee provide the justification, as the licensee is responsible for doing the 50.59 evaluation."


"The Acting NRR Director informed OIG that the examples cited by the licensee in the AIT followup report (as described in footnote 32), which included three NUREG contractor reports, are reports of research that have been done for the NRC Office of Nuclear Regulatory Research and do not constitute NRC approval."

"They were examples of how the NRC used the code for a vessel head, and dissimilar welds, which are good uses of ABAQUS, but they are not steam generator tube bundle interactions with tube support plates."

"His inference in reading the next paragraph of the AIT followup report was that inspectors looked at Comanche Peak's FSAR and recognized SCE's examples were not NRC approvals and they looked for another analog and presented the Comanche Peak analysis of ABAQUS." 

"He stated it is debatable if Region IV found the best application to cite in closing the open URI 10 issue."

"He said the trigger to require a license amendment is intended to focus on safety and not necessarily to avoid a bad investment by the licensee."

"The safety outcomes of this event were well within the licensing basis of the facility and were a low-consequence event in terms of public exposure impacts."

"he result was not a significant safety impact.  In the end, SONGS had a tube leak that was well within the design basis accident analysis."

"And it was not clear to him that the analysis that supported the design would have driven the NRC to a conclusion that would have identified and anticipated the wear identified in the secondary side."

"The Acting NRR Director said that industry has replaced the vast majority of steam generators on pressurized water reactors. under 50.59 from the late 80's and early 90's forward, and up until SONGS, these replacements have occurred without issue."

Deputy Executive Director for Reactor and Preparedness Programs

"The Deputy Executive Director told OIG that the complex issues with the SONGS replacement steam generators are problems the NRC has not previously witnessed."  

"Had SCE submitted an amendment for review, the NRC would have touched those issues that resulted in the flaws in that generator (which experienced the tube leak)."

"He further explained that a 50.59 review (inspection) is not a safety review and that the design problem should have been found by the licensee."

"Hypothetically, he stated the NRC could have potentially found the problem in the licensing review process; but the 50.59 would not be the process to find that."

"The Deputy Executive Director told OIG the 50.59 process is utilized to determine if the NRC is required to review a change proposed by the licensee or if the NRC relies on the licensee's review of the change."

"With regard to the closeout of URI 10 concerning the use of ABAQUS, the Deputy Executive Director stated it is ultimately the region's responsibility to close out the URI."

"The inspector determined the NRC had approved ABAQUS for the reactor coolant system structural integrity analysis and without more information he could not provide an answer regarding the adequacy of the region's closure."

ISSUE 3: NRC Oversight of SONGS UFSAR

OIG Review of NRR Oversight of Other Updated UFSAR Submittals

"To conduct the review, the Project Manager pulled all license amendments from 2002 forward, took a random sampling, and compared them to the FSAR. (Random or risk informed or smart)"

 "The Project Manager said that the UFSAR reviews by project managers are a low priority and he was not sure if they could be given a higher priority because project managers have a lot of work already."

"Although he remembered receiving the 2009 and 2011 FSARs from SONGS, he did not remember doing a review for either one. He was not aware if the SONGS Project Manager before him reviewed or documented a review."

"He said that even if there is some guidance to project managers on these reviews, it was his impression from talking to peers, that the UFSAR reviews were not consistently performed."  

"He thought the review was considered a low-value activity."

"As far as the 50.59 summary document submitted by the licensee, this Project Manager described the reports as being brief and containing a summary of the licensee's basis for determining that the change can be made under 50.59."

Former Region I V Deputy Regional Admini strator

"The former Deputy Regional Administrator told OIG that during the AIT, Region IV staff reviewed the original SAR and noted that the licensee had made many changes to the steam generators over a 25-year period, which were no longer reflected in the UFSAR or consistent with the original SAR."

"When a licensee then goes to replace the steam generators, they are then comparing to whatever existed just before the replacement."

"All the changes have already occurred and were never updated [in UFSAR."

Current Region IV Deputy Regional Administrator

"The current Region IV Deputy Regional Administrator, stated that his general expectation is that all material submitted to the NRC from a licensee would be reviewed by headquarters staff."

Former NRR Director

"The former NRR Director advised OIG that he expected project managers to review revisions the UFSAR submitted by licensees under the 10 CFR 50.71(e) process and verify that changes made by licensees through various processes such as the 50.59 evaluations, license amendments,  and licensee commitments, have generally been updated into the UFSAR."

"Regarding OIG's observation that the SONGS FSAR was reviewed twice during an 11- year period and that review of the 2011 submittal was completed in December 2012, the former NRR Director acknowledged that this was unacceptable to go for such a long period of time without FSARs being reviewed."

"Regarding the NRR staff's review of FSARs submitted by other nuclear power plants, the former NRR Director said NRC should either change the requirement to complete such reviews within 90 days or do a better job to accomplish the requirement."

"The FSAR review is a self-imposed requirement and if the agency was not meeting its own internal guidance, then the agency should change the guidance and consider what really makes sense based on safety significance."

"The former NRR Director said that the project manager's review of the UFSAR is an administrative task. 
He noted that this review is a bookkeeping exercise and it is not a technical exercise."

Deputy Executive Director for Reactor and Preparedness Programs

"The Deputy Executive Director told OIG that NRC oversight of 10 CFR 50.71(e) is critical since it enables the NRC to know whether or not a plant is in compliance with its licensing basis."

 "He added the purpose of 10 CFR 50.71(e) is to ensure that changes either approved by NRC or made by licensees made under 1O CFR 50.59 process are captured in the UFSAR."


"He considers it a priority to review the UFSAR."