B15881, Provides Addl Info Re to Juma & Provides Nuclear Committee Advisory Team Independent Assessment of Root & Contributing Causes for Decline in Performance of Millstone Unit 3
| ML20117J490 | |
| Person / Time | |
|---|---|
| Site: | Millstone  |
| Issue date: | 09/04/1996 |
| From: | Feigenbaum T NORTHEAST NUCLEAR ENERGY CO., NORTHEAST UTILITIES SERVICE CO. |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| Shared Package | |
| ML20117J494 | List: |
| References | |
| B15881, NUDOCS 9609100353 | |
| Download: ML20117J490 (40) | |
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l "Y Ne.bt . 107 8dd"" 8'"8'd"*C " 6887 j j
- Utilhies System no tuse secompany s P.O. Box 270 j ;
Hartford, CT 06141-0270 j (203) 665-5000
,i i l EP -4 1996 l 1 :
l Docket No. 50-423 B15881 4
i U.S. Nuclear Regulatory Commission Attention: Document Control Desk Washington, DC 20555 Millstone Nuclear Power Station, Unit No. 3 Submittal of Additional Information Reaardina Millstone Recovery Activities Reference (a): T. C. Feigenbaum letter to U.S. Nuclear Regulatory Commission, Initial Results of Millstone 3 Recovery Activities, dated July 2,1996 3 i
in a letter dated May 21,1996, the NRC requested that, within 30 days, Northeast j Utilities (NU) submit, for the first Millstone Unit to be restarted, a detailed description of its plans to respond to NRC letters dated December 13,1995, March 7,1996, and April 4,1996. In the NU response, dated June 20,1996, we provided the NRC with a :
detailed description of our plans and ongoing activities regarding the identification and i correction of design and configuration management deficiencies at Millstone Unit 3.
On July 2,1996, following completion of a substantial portion of these activities, NU submitted [ Reference (a)) the first in what we anticipated would be-a series of submittals that discussed the results of these activities and also discussed other planned and ongoing activities as they became appropriate.
As part of the July 2 submittal, the preliminary results of two ongoing assessments were summarized; the Fundamental Cause Assessment Team (FCAT), and the Oversight Failure Root Cause Evaluation Team. Additionally, the July 2 submittal reported to the NRC that a Joint Utility Management Assessment (JUMA) of the Nuclear Safety and Oversight (NSO) organization was recently performed, and that NU was addressing interim JUMA recommendations while awaiting the team's report.
The purpose of this submittal is to provide additional information with regard to the JUMA, and to provide the Nuclear Committee Advisory Team's (NCAT's) independent ;
assessment of the root and contributing causes for the decline in performance of the .j Millstone Units.
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.9609100353 960904 I' PDR ADOCK 05000423 P PDR 083422 REV.1-94 i
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U.S. Nucirr Rrgulatory Commission B15881\Page 2 Joint Utility Manaaement Assessment The JUMA provides an annual, independent management review of the Northeast Utilities Quality Assurance Program (NUQAP), as required by the NUQAP Topical Report. It is conducted by utility peers, in this case quality assurance professionals from four other nuclear utilities. The latest report, dated July 17,1996 [ Attachment 1),
provides findings and recommendations which are generally consistent with the findings of our other internal and external assessments, including ACR 7007, the Oversight Failure Root Cause Evaluation Team, and the FCAT/NCAT independent analyses of NU's nuclear program performance decline.
The corrective actions taken by NU to address both the JUMA report and similar conclusions from other assessments are comprehensive and wide ranging. First, the Chief Nuclear Officer's (CNO's) expectations for NSO's role in achieving excellence, have been issued [ Attachment 2). This document establishes the standards and behaviors expected of every member of the NU nuclear organization. Second, the new NSO organization, headed by a Senior Vice President, has been given prominence and broad powers to provide the oversight necessary to ensure that the GNO expectations are realized and that the NU nuclear units are operated and maintained safely. New leadership positions have been established in NSO, and NU is pursuing a rigorous selection process to ensure that we fill these key positions with highly qualified, energetic, proven individuals, many of whom are already in place and initiating positive change.
Our July 2 submittal provided to you the NU nuclear group's comprehensive blueprint for achieving long term performance improvement, the Nuclear Excellence Plan (NEP).
Two of the action plans contained within the NEP are particularly significant to achieving an effective oversight function, and in addressing the JUMA and other related assessment findings: OEO 1.2, Effective Nuclear Safety and Oversight, and l OEO 2.1, Corrective Action. Each of these action plans provides expectations for the required results, specific action items to accomplish these results, and identifies the individuals accountable for implementation. Performance measures and detailed, resource-loaded schedules are being developed and progress will be monitored by senior management. It is important to note that, even as these action plans have been in the process of being finalized, we have been making substantial progress. For example, the new corrective action program is near completion and will be fully c implemented across all five NU nuclear units this fall.
While these action plans are comprehensive and long term in nature, we have l identified those actions that we believe to be essential to complete prior to the restart of l Millstone Unit 3. These actions have been designated as " restart" in the action plans, )
and they have been incorporated into the Millstone Unit 3 Operational Readiness Plan.
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U.S. Nuclear Regulatory Commission B15881\Page 3 Nuclear Committee Advisorv Team In April 1996, the NU Board of Trustees created the Nuclear Committee of the Board (NCB) to provide the board with an independent basis for overseeing the safety and effectiveness of NU's nuclear program. The NCB is comprised of six outside members of the Board and is chaired by Dr. E. Gail de Planque. In May 1996, the NCAT was
, formed to advise, assist and support the NCB in the exercise of its responsibilities. The NCAT is comprised of five independent experts who possess special expertise in
- various disciplines involved with nuclear power and is chaired by George W. Davis.
! The NCAT's first responsibility was to perform an independent assessment of the root
! and contributing causes that led to the decline in the performance of the Millstone
! Units. Also in May 1996, the FCAT was formed to assist the NCAT in identifying the
! fundamental causes of the decline in performance of NU's nuclear program. The FCAT
! is chaired by Dr. Mario V. Bonaca, a senior NU manager, and also includes two l consultants with extensive experience in evaluating nuclear power plant performance j and regulatory issues.
l On July 24,1996, the FCAT report was docketed with the NRC. The FCAT identified
- three fundamental causes of the decline in performance in NU's nuclear program.
4 First, the top levels of NU management aid not consistently exercise effective i leadership and articulate and implement appropriate vision and direction. Second, the l nuclear organization did not establish and maintain high standards and expectations.
- Third, the nuclear organization's leadership, management, and interpersonal skills were weak. These fundamental causes were found to be interrelated. For example, executive management vision and direction affected the standards applied in the nuclear organization. Similarly, leadership and interpersonal skills affected the way in which directions and standards were implemented.
On August 15,1996, the NCB accepted and approved the report providing NCAT's independent assessment of the root and contributing causes of the decline in performance of the Millstone Units [ Attachment 3]. The NCAT's report endorses and concurs in the FCAT report, and states its own conclusions about the root and contributing causes of decline in performance of the Millstone Units. As more fully described in the NCAT report, the root cause of the Millstone performance decline was that senior executives at NU, from the CEO to senior nuclear site executives, were ineffective over a number of years in providing vision, direction and leadership necessary for the management of NU's nuclear program. As more fully described in the NCAT report, the contributing causes were as follows: first, a weak nuclear safety culture existed; second, an appreciation of the regulatory role of the NRC was lacking; third, management understanding and leadership skills did not keep pace with the level of change required and taking place in the industry; fourth, nuclear oversight was ineffective; and fifth, problem identification and problem solving methods were not
U.S. Nuciarr Regulatory Commission B15881\Page 4 effective or consistently applied to improve performance.
NCAT is presently involved in performing an independent assessment for the NCB of the Millstone recovery plan.
Finally, effective today, Mr. Bruce Kenyon will become the President and Chief Executive Officer of NU's nuclear operating companies. Mr. Kenyon brings proven leadership skills and extensive experience in the nuclear industry, including the former positions of President and Chief Operating Officer of South Carolina Electric and Gas, and Senior Vice President of the Pennsylvania Power and Light Company.
We look forward to continuing to apprise you of our progress on our improvement initiatives, if you have any questions on matters covered in this submittal, please contact Terry L. Harpster, Director Licensing Services, at (860) 437-5880.
Very truly yours NORTHEAST NUCLEAR ENERGY COMPANY k M/
T. C. Feigen6aum
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Executive Vice President and Chief Nuclear Officer Attachments:1 Joint Utility Management Assessment Report of the Adequacy of the Northeast Utilities Quality Assurance Program 2 CNO Expectations for Oversight 3 Nuclear Committee Advisory Team Report ec: H. J. Miller , Region 1 Administrator V. L. Rooney, NRC Project Manager, Millstone Unit No. 3 A. C. Cerne, Senior Resident inspector, Millstone Unit No. 3 W. D. Lanning, Director, Millstone Assessment Team !
J. P. Durr, Chief, Project Branch l fhM' h 9om8.y Pu6LiC. !
g enwnisGm 4m hl**/*
Docket No. 50-423 815881 Attachment 1 l
Joint Utility Management Assessment Report of the Adequacy of the Northeast Utilities Quality Assurance Program !
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i September 1996
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Report of the Management Review of the Adequacy of the Northeast Utilities Quality Assurance Program
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50M4ARY The scope of this audit was to evaluate the effectiveness of the Northeast Utilities Quality Assurance (QA) Program. The specific objectives of this audit were to evaluate actions taken to address the 1994 and 1995 assessments of the QA organization, evaluate philosophy, guidance, and staff understanding for designation of critical attributes for work activities, review the implementation and effectiveness of the audit and surveillance programs, and to assess the value added to the line organization as a result of QA activities. This review included support provided by upper level QA supervision and management in the implementation of the QA mission. Lists of personnel contacted and documents reviewed are attached to this report.
The audit team consisted of the following personnel:
James Perry - Auditor Cleveland Electric Illuminating Company Marv Hoffmann - Audi*.or Detroit Edision Doug Blair - Auditor Iowa Electric Company Jim Kuhn - Auditor Northern States Power Randall Klinzing - Team Leader Illinois Power Company ASSESSMENT CONCLUSION Based on interviews with line management and QA personnel and review of assessment reports, Adverse Condition Reports (ACRs), and documentation, the conclusion of the audit team is that the audit, surveillance, and inspection programs are not effective in the implementation of their Mission Statement and the resolution of identified problems due to the following reasons:
- Lack of support of the QA organization by executive and line management. Without this support, issues identified by the QA Organization are not resolved.
- Lack of an effective corrective action program. The corrective action program is a vital part of an effective QA progrzm.
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The resolution of identified problems applies to problems within QA and problems in the plant identified by QA. It was evident during interviews and by personnel not, attending scheduled interviews with the audit team that there is little management support of the oversight program.
The Combined Utility Assessment (1994), Yankee Atomic Electric Company Assessment (1995), and an internal assessment performed by the Assessment Services Group (1996) were reviewed during this audit. These reports contained recommendations that would have corrected deficiencies and provided a much stronger and more effective QA organization.
Few of these recommendations have been addressed. This area i is detailed in Assessment Summary 1.
Interviews were conducted with personnel in line management.
These individuals were of the manager, director, and shift supervisor level. It was evident by the responses to the questions posed to these individuals that, in some cases, they did not understand the function, purpose, and value of l the QA organization and appeared not to care. This conclusion is further supported by the fact that some of the unit directors did not attend scheduled interviews and the i results of assessments that were reviewed during this l assessment. The results of the interviews conducted are detailed in Assessment Summary 2.
A review of completed surveillances for 1996 indicated only 18% of the scheduled surveillances for all three Millstone units have been completed to date. This reflects management's attitude toward the value of the oversight function. If the assessment organization was truly valued, surveillance activities would have been significantly increased due to the plants being on the watch list. This is an opportunity for QA to be involved with activities in the plants. The low percentage of completion is due in part i to inadequate staffing. This area is detailed in Assessment
- Summary 3.
2 Selected audits appeared to be effective in identifying meaningful issues. All things considered, e.g., corrective action program weakness, lack of management support of audits, lack of resources in QA., the overall audit process is not effective in the identification and timely resolution of conditions adverse to quality. This ineffectiveness has previously been identified in several Millstone root cause evaluations and self-assessments.
, As a result of this review, the JUMA team initiated two ACRs l in the audit and surveillance area. ACR M1-96-0171 Page 2 of 5
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4 identifies that the 24 month Measuring and Test Equipment (M&TE) audit has not been performed for more than 24 months.
No audits were scheduled. ACR M1-96-0172 identifies that there is no requirement to respond to audit findings within 30 days as required by ANSI /ASME N45.2.12, " Requirements for lhuditing of Quality Assurance Programs for Nuclear P6wer Plants." This area is detailed in Assessment Summary 3.
The designation of critical attr'outes for work activities is weak at best. Interviews with station personnel indicate that critical attributes are assigned without consistency and that line personnel responsible for assigning hold points have not received training on that task. The guidance for establishment of critical attributes provided in procedures C-WPC2 and QAS-4.10 is not adequate to ensure a consistent product.
During interviews with inspection personnel, it was determined that supervision does not have sufficient personnel to support the inspection activities of the three Millstone units. The inspectors and supervisors are frustrated regarding the current lack of direction and state of flux within the QA organization. This statement applies to all areas of the QA organization assessed.
ACR M1-96-0146 was written to identify that contract QC inspectors were performing inspections without having ;
received indoctrination training as required by QAS-4.08.
Supervision was aware of this problem, but had not taken action. This area is detailed in Assessment Summary 4.
Most of the individuals interviewed did not feel that personnel auditing /surveilling their areas had the technical competence or knowledge to do more than evaluate compliance !
issues. However, QA feels it is doing performance-based I appraisals. This difference of how other organizations see QA compared to how QA sees themselves is an area that needs to be addressed by management. This difference also appears to effect the creditability of the QA organization. The most common complaint resulted from ACRs written by QA that did not adequately describe the problem such that the receiving organization could recognize the central issue.
Additional comments suggested this was the result of QA not understanding or recognizing the real issue based on a lack of expertise in that area.
It is interesting that the inspection and surveillance process at Connecticut Yankee is well implemented, and the supervisor is well respected by the inspectors. This plant is part of the same NU QA program. The inspection Page 3 of 5
. .. i activities are well planned. Inspectors are provided a '
weekly schedule of inspections to help them plan their work.
Industry Operating Experience is also factored into l inspection activities. I ltEColeENDATIONS Below is a list of the recommendations provided by the audit team. )
i 96-1.1 QA management needs to hold their supervision j accountable for timely review and correction of weaknesses and deficiencies identified during assessments. ,
96-1.2 The personnel placed into supervisory positions during the reorganization process need to be very knowledgeable of the QA process, willing to '
I make decisions, and have an aggressive attitude.
96-1.3 QA management needs to ensure that resources are available to meet program requirements. i 96-2.1 Corporate management and QA management need to drive line management to support and be responsive to problems identified by the QA organization.
96-2.2 A training program needs to be developed to educated corporate and executive management as to the purpose of the QA Department and QA program.
96-3.1 The Chief Nuclear Officer must drive change by reinforcing expectations for line management to support the nuclear assessment processes and attendance at related meetings (planning, entrance, exit).
96-3.2 Develop specific strategies and an action plan for integration of the audit and surveillance process. Consider SALP functional area approach (i.e., team to perform audit /surveillances of Operations, Engineering, Maintenance or Plant Support). Staff these teams with highly qualified and credible personnel, including some rotational assignments from the line organization.
96-3.3 Issue surveillance reports to the line organization. Issue the reports to all levels of supervision within the surveilled organization.
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96-3.4 Quickly resolve audit report review / approval l problems. i 96-3.5 Consider utilizing NRC inspection modules more
, consistently and proactively in assessment'.
activities. Take the opportunity to self-assess against new and temporary (TI) NRC inspection
, criteria by assembling multi-disciplinary teams led by QAS personnel.
96-3.6 Make entrance meetings optional if all appropriate individuals are notified during the planning process.
96-3.7 Provide verbal feedback to the surveilled/ audited organization at the completion of the activity.
96-4.1 Develop a training program for personnel assigning critical attributes.
1 Along with these recommendations, the audit team concurs with recommendations provided in the reports reviewed during this assessment.
This report has been reviewed and concurred with by the members of the audit team.
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Randall D. Klinzing'* ) )
Audit Team Leader Page 5 of 5 1
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ASSESSMENT SIM4ARY 1 l I. AREA EXAMINED -
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The actions taken by the Nuclear Quality Performance Department to address the issues identified in the Combined Utility Assessment (1994) and the Yankee
. Atomic Electric Company assessment (1995) were reviewed. Included in this review are the results of a self assessment completed February 21,1996, by the Assessment Services Group. This review included steps taken to integrate the oversight activities conducted by both the Plant Quality Services Group and the I Assessment Services Group.
II. ASSESSNENT There has been little, if any, progress during the last ,
two years toward addressing recommendations provided '
during the above referenced assessments. The recommendations provided in these assessments would have helped correct deficiencies and provided a much stronger and more effective QA organization.
III. OBSERVATIONS i
Below is a list of the recommendations provided to QA by the three reports referenced above and their status, j 1994 ASSESSMENT 94-1.1 The suggested document that summarizes various commitment documents and their sub-elements was never developed.
94-1.2 The resources were never applied to reduce the backlog of audit findings and unresolved items. Instead, the decision was made not to follow-up on most findings initiated by the QA.
94-2.1 No known a. . ion.
94-2.2 No known action.
94-2.3 There is a schedule of surveillances that are to be performed. As of the date of this assessment, 18% of the scheduled surveillances have been completed.
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- I 1995 ASSESSMENT A No style of QA oversight has been established. This is partially due to the continual changing of QA l management. Senior management is not holding their i personnel accountable for the timely and effective ,
resolution of problems. This conclusion is supported I by the 1996 Corrective Action - Adverse Condition
' Report Program audit.
i B. As stated above. !
C. No action D. No rotation program has been established.
E. A guideline for writing audit reports has been established. The audit reports reviewed were of good quality. However, the surveillance reports quality varied greatly.
1996 SELF ASSESSMENT
- 1. Completed, Revision 8 was issued 5/9/96.
- 2. No action
- 3. There is a proposed plan to address part of ;
recommendation. l
- 4. The NRC receives the audit reports through the Licensing Coordinator. The other parts of this I recommendation were not address or were not implemented.
- 5. In process, not reviewed
- 6. In process, not reviewed
- 7. Completed l
- 8. No action
- 9. Action completed. Based on interviews with line management, the actions taken were ineffective. It was evident from the interviews that line management's perception is that QA personnel are not taking the time to understand their side of an issue.
- 10. No action Page 2 of 3
- 11. No action
- 12. Some items addressed. Based on interviews with line management, the actions were ineffective. Not everyone in the line organization is receiving the reports that think they should.
- 13. 'No action
- 14. No action i 15. No action
- 16. Completed, not verified
- 17. No action 1
IV. ACR's ISSUED None V. RECOMMENDATICNS ,
96-1.1 QA management needs to hold their supervision accountable for timely review and correction of weaknesses and deficiencies identified during assessments.
96-1.2 The personnel placed into supervisory positions during the reorganization process need to be very knowledgeable of the OA process, willing to make decisions, and have an aggressive attitude.
l 96-1.3 QA management needs to ensure that resources are available to meet program requirements.
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ASSESSMENT StA44ARY 2 4
I. AREA EXAMINED ,
Services the Nuclear Quality Performance Department
- provides to the line organization were evaluated for added value.
II. ' ASSESSMENT The conclusion reached by the auditors during the interview process was that the QA organization's function and value is not understood by line management.
III. OBSERVATIONS Through interviews and document reviews, it was determined that differences of opinions exist as to the services QA provides to the line organizations. Each summary listed below is the conclusion reached by the auditors through interviews.
Nine questions were asked during interviews with line management. The following is a synopsis of the results.
- 1) What was the last QA Assessment in your area? What were the results? Was the team / person technically qualified?
The people that could remember when the last assessment was performed did not clearly remember the results.
One person said that QA tended to tell you about problems that were already known. He needed to know "before the bomb goes off," not that it had. There is a problem with communication of assessment results with line management. Many of the people interviewed did not know the result of the assessment until a report was issued. The results of technical competency varied. Maintenance and Operations were unimpressed with the people assessing their areas. The results also varied greatly by who performed the assessment.
Overall, QA needs to communicate better and utilize more technically qualified personnel to perform assessments.
- 2) Did you have input before the assessment?
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j Most people answered yes. A few said they did not know about the assessment until the exit meeting was scheduled. ,
- 3) Is QA looking at the right things and to the proper i
. depthi - !
4 The answers were generally no. It was pointed out that
- QA is lacking resources and technical knowledge.
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- 4) How do you respond to QA recommendations?
Answers here were generally canned. Most said that they respond. The Site Fire Marshall said he got good recommendations from the audit of his area and made many changes as a result.
- 5) Can you explain the difference between audit / surveillance / inspection?
Three of fifteen people interviewed knew. One of these i had a QA background. The majority could describe only one of the three. Two people had no concept of the differences or how to define any of the three.
- 6) Do you receive and/or use the Monthly Report?
Many managers did not receive the report or if they had, they could not recall receiving it. Mixed responses were received when asked if they used it to evaluate their departments. Responses ranged from discussions at meetings within their organization to only reviewing for applicability. The monthly report would benefit greatly if it was presented in person and was expanded to provide more detail. An unit one person said it was worthless because he did not know the details behind the statements made. A person from unit two had his monthly report presented in person.
This allowed for good dialog.
- 7) What is one thing that you would change about QA?
Normally, technical expertise in the area of review was the answer. Knowing a problem was developing prior to it becoming a problem was also discussed.
- 8) Who is your primary interface with QA Assessment?
Everyone knew their contact if,they were in a position to have one.
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l 9) What is your perception of the QA program, is it getting better/ worse / status quo? - J i
l Most did not have an answer due to the changes in
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staff. A common answer received from long term ,
personnel was it depends on the assessor. 1 Below is additional information that was provided during interviews that is applicable to this line of questioning.
Most of the individuals interviewed did not feel that personnel auditing /surveilling their areas had the technical competence or knowledge to do more than evaluate compliance issues. However, QA feels it is doing performance-based appraisals. This difference of how mther organizations see QA compared to how QA sees themselvec is an area that needs to be addressed by management. This difference also appears to effect the creditability of the QA organization. The most common complaint resulted from ACRs written by QA that did not adequately describe the problem such that the receiving organization could recognize the central issue. ;
Additional comments suggested this was the result of QA not l understanding or recognizing the real issue based on a lack i of expertise in that area and root cause training.
Interviewees were asked about QA participation in the Morning Meeting. The responses varied from value added, depended upon the individual attending, mostly just a presence with no input, and walked on by management when the individual provided input. It can be concluded from these responses that the QA presence at the Morning Meeting is not well received by all persons attending the meeting.
Some individuals did not realize that QA could be requested to support issues raised by line management. Others knew this avenue was available, but had not used it. A few managers had requested and received support from'QA on resolving issues.
The individuals interviewed were asked if anything was done to educated management that QA is an oversight organization and what it's purpose is. The majority of individuals responded that nothing had been done to address this subject. They also felt it would help them better understand the QA function and purpose if they were trained.
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i IV. ACR's ISSUED None .
V. REColeENDATIOt4S 96-2.1 Corporate management and QA management need to drive line management to support and be responsive
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to problems identified by the QA organization.
96-2.2 A training program needs to be developed to educated corporate and executive management as to the purpose of the QA Department and QA program.
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ASSESSMENT SIDOOAY #3 I. AREAS EXAMINED l
- - Review the Nuclear Quality Performance Departme$t i Surveillance Program implemented by Plant Quality Services and Assessment Services, and evaluate the
' process for effectiveness, reporting mechanisms, l identification of deficiencies through the Adverse
- Condition Reporting system, tracking of corrective j actiorw, follow-up activities, and the added value to the line organization.
Review the audit process used by the Assessment i
Services group and evaluate the process for
- effectiveness, reporting mechanisms, identification of j deficiencies through the Adverse Condition Reporting i system, tracking of corrective actions, follow-up j activities, and the added value to the line
! organization.
II. ASSESSMENT
- Selected audits appear to be effective in identifying
! meaningful issues. Examples include the MP2/MP3 i Technical Specification Audit (A60582) issue on l application / interpretation of containment isolation j valve technical specifications (ACR 8849/LER 96-026)
. Containment Isolation Valve Issue and the Document Control Audit (A60582) issues on maintenance of design l basis documents as quality related design documents
. (ACR 8845). However, when considering the weaknesses
! in significant supporting attributes of the internal
! audit process (i.e. Millstone corrective action program L weaknesses, lack of strong management support for the audit process, and insufficient QAS resource l application), the overall audit process is not
, effective in the identification and resolution of
. conditions adverse to quality in a timely manner. This ineffectiveness has previously been identified in several Millstone root cause evaluations and self-l assessments. Continue efforts to resolve identified issues are needed to effect turnaround.
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In the Fall of 1995, the surveillance program underwent some significant changes. As a result, an integrated j surveillance schedule was developed. A review of
- completed surveillances for 1996 indicated only 18% of j scheduled surveillances for all three Millstone units Page 1 of 8 I
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i 4- l I (plants on the watch list) have been completed to date.
This reflects Millstone management's attitude toward
} the,value of the oversight organization. If the j assessment organization was truly valued, the
, surveillance activities would have been significantly j increased. Currently, the surveillance organization is J
not adequately staffed to perform their intended
, function, and the program is not effectively
- implemented.
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- III. OBSERVATICt48
! In addition to reviewing the effectiveness /value added of the internal audit and surveillance programs, the team also assessed the audit and surveillance process 3
- reporting mechanisms, use of the ACR process, tracking
! of corrective actions and associated follow-up
) activities, j
A review of 12 audit reports and the associated audit
- files was conducted. These included:
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- ' Maintenance Activities (A60585)
- 'MP2/MP3 Tech Spec Corrective Action (A60606) i-
- Document Control (A60562) i ' Integrated Safety Evaluations (A60581)
' Station Blackout (A30338)
- ' Control of Engineering Programs (A60580)
' Corrective Action - ACRs
, (A21077/A22077/A23077/A25120) i ' Adverse Condition Reports
! (A25110/A21072/A22072/A23072)
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- Fitness for Duty Program (A30333) i
- Fitness for Duty - 1995 (A60597) l ' Corrective Action - NOV's j
! (A25105/A21070/A22070/A23070)
'CY 1995 Outage Audit (A62001)
\
- In general, audit reports were well written with an i j appropriate level of detail. The audit teams appeared
' sufficient, both in size and qualification, for the l scope of the audits. One arguable exception could be i the " Control of Engineering Programs" audit. This j audit was performed as a one man " team". 'Although the
- person is highly skilled and certainly qualified to
- assess' engineering programs, the assessment would have j benefited,from some diverse, direct engineering program 1 implementation experience. 'As it was, the audit report j
had a " compliance" versus a " performance of 4 i
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- . i effectiveness of the actual control of the engineering j program theme." l l After reading the sampled audit reports, it w'as not j
{ always clear as to the effectiveness of the audited !
! . program. Statements included in the reports included l
! " generally adequate" or "in the opinion of the !
auditor." The 1994 Fitness for Duty Program audit j
- (A30333) contained the following statement; "It is the !
j opinion of the Lead Auditor that the NU FFD Program ,
- will be effective after acceptable corrective actions j
- to the findings of this audit are implemented and :
i unresolved issues are appropriately resolved." The !
- JUMA audit team interpreted this statement as l
! rating the FFD program as ineffective. QAS did not l perform follow-up surveillances or audit activities on
! this ineffective program until its next regularly
! scheduled audit (12 months later) . This lack of ,
follow-up may have been caused by the unclear l j effectiveness statement, j ..
i Distribution of the audit reports to management seemed !
l appropriate to the audit team. Interviewr, conducted .
- indicated there still may be a problem with the report i i getting to personnel in the plant. A few personnel i j indicated they are not receiving the reports they think j they should. The audit team strongly feels that the l
- Nuclear Regulatory Commission should be included on the l l' distribution. ,
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- Generation, review, and approval of audit reports j l within QAS needs attention. There have been multiple j i occurrences within the last six to eight months where J
- j. audit reports have not been issued within the required j i 30 days of the exit meeting. ACR 7073, issued in '
l November, 1995, addressed the issue, but was j immediately closed based on the issuance of management i expectations to issue reports within 14 days of the i exit meeting. These corrective actions were
! insufficient, and the problem recurred resulting in
! another ACR in June, 1996. Discussions with audit l staff and supervision indicate this is a fairly complex
- issue and that it warrants thorough investigation and
,- resolution by QAS management in a timely manner, f Verbal repcrting (briefs and entrances / exits) j effectiveness for audits appears mixed based on interview results and review of meeting attendance records. Line management support for and participation j in the internal assessment processes appears very weak Page 3 of 8
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! in many areas. Radiation Protection Management has I been very active in working with QAS to establish i schedules and scope to the benefit of all parties. l 9 This relationship could be a model for the other i j functional areas. _ i
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I i Use of the ACR process to report and resolve findings !
[ is a good idea and consistent with movement within the !
! industry. However, effectiveness problems with the ACR !
!- process only compound problems with the audit and !
- surveillance process. Interview results suggested that !
, the use of the ACR process for findings was less than f
, optimal due to ineffective communication surrounding l the ACR process (i.e. when was an ACR actually issued, timeliness of overdue notifications and awareness, l etc.). The significance level determination process l l could benefit from stronger participation by QAS !
management. For example, ACR8844 (Failure to Verify Closed Containment Isolation Valves) and related ACR l 8849 (Relaxation of NRC-approved requirements) were ,
processed as significance level "C". Interviews with 'l' the responsible audit staff indicated that these issues were recommended to be processed ar. Level "B". Level l "B" significance, per NGP 2.40, includes " events or !
issues which are expected to occur infrequently but i need to be minimized for the company to achieve its safety and business goals...". Level "B" issues also !
require a full root cause determination versus a casual i factor determination for a Level "C". It would appear ;
that NRC reportable technical specification I implementation failures of the nature discussed in '
these ACRs should receive a full root cause analysis I and also meet the threshold definition for Level "B".
As previously stated, the surveillance program underwent some significant changes in the Fall of 1995.
As a result, the decision was made to no longer issue a written surveillance report to the surveilled organization. The information is passed to the line organization via verbal briefs. The acting PQS Manager stated too much time was being spent writing the surveillance report, taking time away from actually performing surveillances. Additionally, the decision to no longer issue written surveillance reports was thoroughly discussed with line management by QAS management. Interview results of line management conducted by the JUHA audit team revealed not all personnel are receiving surveillance results verbally. i One example is a Shift Supervisor that stated he saw a surveillant reviewing control room activities, but was Page 4 of 8
never appraised of the results. Due to the layers of management at Millstone, as well as the numerous changes in the line management, the audit team recommends surveillance reports be issued to the line organization. In addition to issuing the surveillance reports, immediate verbal feedback to the line ~
management would help improve QA's creditability with management. Issue the reports to all levels of
' supervision within the surveillance organization.
A review of 15 surveillance reports / implementation plans was conducted. The written quality of the reports varied from excellent to poor. In some cases, the reports were not easily understood by the auditors.
The scope of the reports / plans varied from in depth vertical slice type assessments of an area to a narrowly focused scope to assess a particular activity j or program element. This range in assessment scope is
{ what is expected from the surveillance program.
l The surveillance program at Millstone does not satisfy Section X of the Topical Report. Surveillances are not :
being performed as scheduled. For 1996, only 18% of the scheduled surveillances at Millstone have been >
performed to date. Conversely, at Connecticut Yankee ;
(CY) nearly all surveillances scheduled for the first and second quarter of 1996 have been completed. ,
NU Quality Assurance Program Topical Report,Section X states that the use of surveillances of processing methods is an alternate when inspection is impossible, inaccessible, or not applicable. Six personnel are assigned to perform surveillance activities at Millstone. Surveillances are scheduled quarterly for both Millstone and Connecticut Yankee. The following table depicts the number of surveillances scheduled versus those performed for the first and second quarter of 1996.
First Quarter Scheduled Completed Millstone Unit 1 18 3 Millstone Unit 2 22 8 Millstone Unit 3 25 5 CY 28 28 Page 5 of 8
Second Quarter Millstone Unit 1 19 4 ,
j Millstone Unit 2 29 0 Millstone Unit 3 27 5 j
'CY 26 18 In addition, the surveillances performed at Millstone do not reflect those planned. Examples:
Surveillance No. Planned Area Actual Area i 96-10 I.3.b I.3.a 96-28 B.2.a or c B.3 96-29 D.2.b D.3 96-33 D.1.c or D.2.a D.2.b 96-35 B.2.b or B.3 or B.4 B.1 Effectiveness of the trending and follow-up of audit and surveillance related ACRs is mixed due to resource limitations within QAS and the lack of timely response ;
to ACRs from the line organizations. A review of ACR '
< packages and interview results suggest that the overall !
process, identification to closure, is inefficient, and ~
needs to be enhanced to meet the needs of all affected players.
Two ACRs were issued to identify problems associated l with the audit program. ACR M1-96-0171 identified that
, the 24 month Measuring and Test Equipment (M&TE) audit j has not been performed for more than 24 months. No audits were scheduled. A comparison of Section 6 of each unit's Technical Specification was completed.
Differences in required audits was noted. Other required audits may have been missed due to the poor tracking mechanism being used to track audit. A complete list of audits should be compiled for each unit.
ACR M1-96-0172 identifies that there is no requirement in RP4, " Adverse Condition Resolution Program," to respond to audit findings within 30 days as required by Page 6 of 8
A ANSI /ASME N45.2.12, " Requirements for Auditing of Quality Assurance Programs for Nuclear Power Plants."
A review of selected training-files for certified lead-auditors indicates that this process is being '.
. effectively implemented. -
Past efforts to better integrate the audit and surveillance processes have not been totally effective.
Significant barriers still exist to effective integration. Although the front line staffs have made efforts to integrate their assessment activities, the organizational and physical barriers have made their integration very difficult.
The organizational structure (separate-PQS and audit groups) has detracted from the team approach to assessment.- A previous assessment recommended that the two functions be better integrated.
Consistent, effective use of the Performance Assessment Manual (PAM) was not evident in the audit and surveillance activities. Some of the QAS personnel appear to be very familiar with, and consequently use, i PAM. However, the-inconsistent use of PAM would suggest the lack of, or ineffective implementation of, i QAS management expectations for the use of this
, relatively expensive assessment tool.
IV. ACRS ISSUED M1-96-0171 An M&TE audit has not been conducted within the past 24 months M1-96-0172 There is no procedural requirements to respond to audit finding within 30 days as required by ANSI /ASME N45.2.12 V. RECODMENDATIOtG 96-3.1 The Chief Nuclear Officer must drive change by reinforcing expectations for line management to support the nuclear assessment process and attendance at related meetings (planning, entrance, exit).
96-3.2 Develop specific strategies and an action plan for !
. integration of the audit.and surveillance processes. Consider SALP functional area approach (i.e. team to perform audit /surveillances of Page 7 of 8 )
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Operations, Engineering, Maintenance or Plant Support). Staff these teams with highly qualified and credible personnel, includ,ing some j rotational assignments from the line organization.
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3.3 Issue surveillance reports to the line organization. Issue the reports to all levels of supervision within the surveilled organization.
96-3.4 Quickly resolve audit report review / approval problems. Potentially volatile situation. ;
96-3.5 Consider utilizing NRC inspection modules more consistently and pro-actively in assessment activities. Take the opportunity to self-assess against new and temporary (TI) NRC inspection criteria by assembling multi-disciplinary teams led by QAS personnel.
96-3.6 Make entrance meetings optional if all appropriate individuals are notified during the planning process.
96-3.7 Provide verbal feedback to the surveilled/ audited organization at the completion of the activity.
4 Page 8 of 8
ASSESSMENT 51294ARY 4 I. AREA EXAMINED .
Evaluate the philosophy, guidance and staff ,
understanding in the designation of critical attributes for work activities. Determine the adequacy of which
,they are verified and by whom it is documented (QC inspected, self-verified, dual verified, etc.)
II. ASSESSMENT Management has not provided clear, concise direction regarding the involvement of QC personnel at the Millstone site. Supervisors do not have sufficient i personnel to support the inspection activities of three l units. Inspectors and supervisors are frustrated regarding the current lack of direction and state of flux within the organization. Supervisors are over burdened with. meetings. In addition, supervisors are l reluctant to make decisions.
III. OBSERVATIONS Guidance for the establishment of hold points is delineated in procedure C-WPC2, "AWO Preparation and Work Scheduling."
At Millstone units one, two and three, hold points are I assigned by line personnel. In addition to an l individual assigning hold points within work orders, !
several work procedures contain hold points for specific activities, e.g., Raychem, Hilti Bolt Installation, etc.. Interviews with station personnel ;
indicated that hold points are assigned without '
consistency and that line personnel responsible for assigning hold points receive no training in performance of that task. Interviews with station personnel indicated that guidance for the establishment of hold points is provided in procedures C-WPC2 and QAS-4.10. However, the guidance provided is not consistent between the two. A review performed by the auditor revealed the guidance provided in these procedures is consistent. Line personnel use C-WPC2 to assign hold points and QC personnel use QAS-4.10. QC does not have a good reputation with line personnel because QC management is constantly changing directions regarding the use of hold points and the role of QC.
Page 1 of 3
s .
) A QC inspector is assigned as the focal point
! '(dispatcher) for inspections each week. He is notified of inspections and assigns an inspector to perform the them. In addition, several contract inspectors are
- assigned to the dispatcher at this time. Some of the
- contract inspectors performing inspections had not received indoctrination per QAS 4.08. Adverse Condition Report M1-96-0146 was issued regarding this
" observation. Another inspector is assigned to the unit
, one work control unit to support the preparation of 3
work orders. Inspectors do not perform surveillance activities or write inspection reports at Millstone.
! Conversations with supervisors and inspectors indicate i that operating experience (CE) for the industry and
- l. Millstone are not factored into inspections.
Millstone has seven inspectors and three supervisors
! for three units. Inspectors are assigned to specific
! units and report to one of the three supervisors.
] However, the inspectors work in all three units, 4 reporting to the supervisor for the unit in which they 1
are working at the time. While it is advantageous for the inspectors to support all units, reporting to supervisors with different expectations adds confusion to the inspection process.
Conversely, Connecticut Yankee (CY) has four j inspectors. One inspector is assigned to the work '
control unit each week for the purpose of assigning hold points to work orders. Some work procedures also contain hold points. CY inspectors perform surveillances when not performing inspections. The supervisor is respected by the inspectors and he is actively involved in day to day inspection activities.
Each inspector receives an assignment sheet weekly l which delineates the activities that he is responsible l for in the coming week. Inspectors do not write ;
inspection reports. However, industry OE is factored !
into inspection activities by the site's Independent Safety Engineering group.
IV. ACR's ISSUED M1-96-0146 Several contract inspection personnel have not received indoctrination training as required by QAS 4.08. They have been performing inspections.
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V. RECCteENDATIONS 96-4.1 Develop a training program for personnel assigning critical attributes. ,
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Docket No. 50-423 B15881-l I
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i Attachment 2 CNO Expectations for Oversight l
September 1996 I
.~r .g..--. 9 _ -.- ip.,
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l August 1,1996 i
TCF-96-120 TO: Nuclear Vice Presidents, Directors, Managers, and Supervisors l
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-l FROM: Ted C. Feigenbaum j
SUBJECT:
CNO Expectations for Oversight ,
1 One of my most important responsibilities as Chief Nuclear Officer is to clearly communicate my expectations for the behaviors that we must all embrace to achieve Nuclear Excellence. In June, I l'
' introduced Va/ues for Exce//ence to the entire organization as the core values I expect to see demonstrated by every member of the Nuclear Group.
- Today, I want to talk with you about my expectations for the relationship l expect to see between our Nuclear Safety &
Oversight Group and the rest of the Nuclear organization.
As you review'our Values for Excellence booklet, you'll see many_
references to the importance of self-assessment and critical self-evaluations. And these references encompass nearly all of our core values. The message is clear: to be successfu/in achieving > -l Nuclear Excellence we must have a strong commitment to oversight and se/f-evaluation.
In recent reports on our Millstone operations -- ACR 7007, JUMA, j etc. -- our. past Oversight capability and commitment were l
criticized. We have been taking actions to correct these problems, and you've seen Oversight positions filled first to get l
, this critical part of our organization up and operating at peak 4 efficiency.
e As part of our revitalization of Oversight, I wanted to make sure that my expectations are clearly defined and communicated to everyone in NU Nuclear. 'One of my major responsibilities at Seabrook was to head up the Quality organization. In that hands-on role, I saw just how valuable an effective quality focus can be to the success of the whole organization.
i i urge you to read the attached expectations carefully, and make {
a special effort to talk with your people about the critical importance of an effective Nuclear Oversight organization. i We'll.all know that we're on the way to long-term success when !
we see a combination of critical self-assessment at the i department level, and strong, effective Oversight from our NS&O I orgenization. This partnership of the Line and Oversight is an essential part of the foundation we must build together to achieve t Nuclear Excellence.
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The Role of Oversight In Achieving Excellence i
inherent in achieving our goal of excellence is the need for strong i and competent oversight organizations. I believe that foremost ;
among these is Nuclear Safety and Oversight (NS&O) which provides the means for continual, enlightened, critical assessment of: (a) organizational effectiveness; (b) programs and processes; i (c) end-products and services; and (d) self-assessment. NS&O is to support and assist the effective implementation of all NU
- Nuclear functions, but its role and responsibilities are distinctly different from that of the Line organization.
The Line is to define, implement and verify the correctness of its activities. Problems or deficiencies that may exist are to be l promptly identified and corrected by each worker -- i.e., the first '
2 level of defense. Should that level not detect a deficiency, I expect supervision and management to detect the deficiency and take appropriate corrective action as the second level of defense.
A deficiency identified by NS&O reflects the weakness of the Line
- in fulfilling its responsibilities. And needless to say, should a i
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condition adverse to quality be identified by external organizations, such as NRC or INPO, it means we have all been unsuccessful in fulfilling our responsibilities. ;
I expect NS&O to support the Line organizations by providing critical feedback in a constructive and professional manner i through coaching, advising, and consulting. This feedback should not only address matters of compliance, but it also needs to highlight items that are predictive in nature, such as weaknesses, trends or vulnerabilities that, if not promptly addressed, may lead to major problems or events. Most importantly, NS&O needs to facilitate a culture of continuous improvement by helping each organization identify its own weaknesses through critical self-assessments and, where possible, by offering suggestions for improvement. In turn, the Line organizations must value the oversight function, and respond to NS&O's input with the priority and importance due a full partner in the quest for excellence.
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- i In pursuing this mission a number of expectations need to be i reinforced including- 1 i
i e Regulatory Compliance is Vital - make no mistake about the importance I place on being in compliance with our licensing basis at all times. Should the Line or NS&O detect that we are not, or may not be, in compliance with either the spirit or the l;
{
l letter of regulatory requirements or commitments, I expect the Line to take immediate corrective action. Remember our standard is excellence and not minimum compliance with regulatory requirements.
- Potential Vulnerabilities Must Be Promptly identified - through independent assessment, with a vigorous and comprehensive 4
key performance indicator program, and by reviews, audits and observations, I expect NS&O to keep management fully i informed on the status of quality, significant trends, and any threats to quality. Nuclear safety is always first priority. At the i same time, there is also an important need to independently
- assess our programs and processes to ensure they are. highly-effective.
t e High Standards Are Necessary - I expect NS&O to reflect the l highest standards of integrity, objectivity _ and competence.
- This will require highly-experienced professionals, trained and j qualified for this important function. To help maintain these i high standards, I expect rotations between the Line and NS&O l as an integral part of development training and promotional
- consideration. NS&O should strive for excellence in all facets ,
of its activities, as well as promote and facilitate ever- !
- j. improving standards through interaction with other elements of j
- the NU Nuclear organization. !
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e Line Management Resnect Must Be Earned - I expect NS&O, as l a member of the NU Nuclear team, to raise meaningful issues l in a timely, clear and professional manner. Such issues should i
! be communicated factually with a clear message of urgency I
and significance. I expect such contributions to be highiy valued by the Line and to result in prompt and effective corrective action. When discussing opporturiities for improvement, or NS&O suggestions for alternative action, a
" Win-Win" approach should be pursued.
. Teamwork is Essential - I expect cooperation and close communication between Line organizations and Oversight to be j a matter of routine. "No surprises" is the standard. A close working relationship is desired, balanced with the need to !
protect the independence and objectivity of NS&O. A joint Line/NS&O team should assess unexpected events, such as NOV's or major operating problems, in order to identify lessons I learned for both Line organizations and Oversight. i e Self Assessments Are inherent To Imorovements - I expect routine self-assessments by all NU organizations leading to continuous improvement and rising standards of excellence.
NS&O should seek to learn through self-assessments how it I can be more effective. Further, NS&O should monitor and !
assist the Line in performing critical self-assessments and -- if j problems or deficiencies are identified -- in initiating corrective i actions, both specific and generic, to prevent reoccurrence. l I
e Emplovee Concerns Will Be Promotiv Resolved - I expect the entire NU organization to establish and sustain an environment that is openly conducive to raising and resolving employee concerns. Inherent in our Core Values is the need to consider all issues which may have safety significance and to resolve these issues promptly. Proven diagnostic measures should be used by NS&O to identify and measure areas where additional ac+ inns may be warranted.
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- Further, the Employee Concerns Program must remain an effective option for those individuals not wishing to resolve their concern through the Line organizations.
e A " Power Of Five" Persoective Is To Be Maintained - the continued long-term success of our nuclear units depends on i efficiencies and economies from common programs and initiatives. I expect that duplication and unwise or unnecessary use of resources will be eliminated. New opportunities should be identified by NS&O for achieving economies consistent with achieving operational and organizational excellence goals.
I e ftSAB/NSARC And SORC/PORC Are Imoortant To Oversight Effectiveness - I expect NSAB/NSARC and SORC/PORC to be aggressive, pro-active and demanding in pursuing their responsibilities for safety. NSAB/NSARC should become more independent in make-up and viewpoint, and provide leadership in identifying how NU organizations, and particularly NS&O, can better perform their responsibilities. In addition, I want to j be involved and informed on situations of concern before they become major problems.
There is no docht in my mind that an effective, strong and j involved NS&O will help detect and force resolution of those i factors that limit the effectiveness of NU organizations. As a result, I view NS&O as an integral and vital ingredient to achieving nuclear safety, operational excellence, cost-i effectiveness and regulatory credibility.
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Docket No. 50-423 l B15881 i
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Attachment 3 Nuclear Committee Advisory Team Report >
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September 1996 :
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l l Nuclear Committee Advisory Team
}. 22 July 1996 i
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} George W. Davis, Chairman
] John S. Carroll
! Robert B. McGehee Dominic J. Monetta ,
j Thomas E. Murley i
i From: Nuclear Committee Advisory Team
- To
- Nuclear Committee of the Northeast Utilities Board of
{ Trustees a
j Subj : Cause Assessment for the Decline in Millstone Performance
! Encl: Report of the Fundamental Cause Assessment Team i dated 12 July 1996 i
Purpose:
! The purpose of this letter is to endorse and fo dard the
! report of the Fundamental Cause Assessment Team (FCAT) and to l provide the Nuclear Committee Advisory Team's (NCAT's) final
- independent assessment of the root and contributing causes for i the decline in performance of the Millstone plants 1
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Background:
The Nuclear Committee Advisory Team (NCAT) was formed in j May 1996 and was requested, among other things "To perform an J
independent assessment for the Nuclear Committee of the Northeast Utilities (NU) Board of Trustees of the root and contributing ,
j causes that lead to the decline in performance of the Millstone j units". In its efforts to independently assess, the NCAT membars ,
j have read pertinent documents on NU's nuclear operations covering l j the past decade, including INPO audits; NRC letters, l investigation reports, SALP reports and other assessments; ,
j financial reports and assessments; and Company letters, i assessments, plans, responses to regulatory queries, audits, i etc. The NCAT members have individually interviewed employees, I both past and present; regulatory agents; INPO personnel with cognizance of NU activities; and NU contractors, both past and i
l present. Collectively, the team members have visited all i Millstone units and met with members of the current Nuclear l Organization management. The Fundamental Cause Assessment Team's t (FCAT's) report has been reviewed and discussed. After i considerable individual thought and collective deliberation,
- the NCAT has reached the conclusions contained in this letter.
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> Root Cause:
Senior executives at Northeast Utilities, from the CEO to senior nuclear site executives, were ineffective over a number of years in providing vision, direction, and leadership necessary for the management of the NU nuclear power program.
- This senior management failed to provide the nuclear organization clear direction and oversight in several key areas, including performance standards, station priorities, and management expectations. Conflicting messages, particularly those relating to production costs over safety and compliance issues, were conveyed by senior management.
- Many of the more important initiatives and activities intended to address identified issues, such as employee concerns, design bases and configuration control, and correction of backlog deficiencies, did not receive consistent and clear management direction and support nor did they have adequate owner accountability.
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- Key performance issues, such as an effective corrective l
action program, licensed operator qualification standards, and critical self evaluation processes were j not fully appreciated by senior management even after l
they were identified by outside industry and regulatory agencies, j
j - Senior management did not ensure effective communications with the regulators and throughout the nuclear l
organization, did act recognize the existence of the 4
horizontal and vertical barriers to the two way exchange d
of information and were unaware of or ineffective in i reversing the loss of trust and confidence at the l Millstone station that resulted. Further, top management 4 discouraged information that contradicted their j understanding of the nuclear organization, whether this information came from internal critics, " whistle-blowers",
1 or external regulators
- Top management did not establish a cooperative and supportive team atmosphere among groups competing for resources and recognition. This was particularly true of the operations and engineering organizations where an appreciation of each other's role and importance to plant safety was lacking
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l Contributing Causes and Rationale:
A weak nuclear safety culture existed.
- Management tolerated and unintentionally encouraged a weak nuclear safety culture by discouraging self criticism, diminishing the effectiveness of quality assurance and other oversight activities, being unresponsive to employee complaints and concerns, overemphasizing cost and production, and deferring repairs.
An appreciation of the regulatory role of the NRC was lacking.
- During the early years of Millstone operations (before 1987), NU had built up a substantial reservoir of regulatory margin through good operation and, more importantly, by their good engineering and excellent safety analysis capabilities. Since the late eighties, that margin has been eroded through a legalistic approach to regulatory compliance, a lack of openness, and tolerance of non-conservative decision making.
Management understanding and leadership skills did not keep pace with the level of change required and taking place in the industry.
- There was a lack of appreciation of the inherent l
relationship among operating performance, cost l
effectiveness, and safety, which resulted in a failure l
in direction and vision for the NU nuclear program. The
' focus on cost reduction (i.e. deferred repairs) and production (i.e. CH 442) was at the expense of conservative decisions. INPO CEO conference discussions on this subject showed the correlation-between high safety achievement and low production cost.
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- The use of experience and lessons learned from others in the nuclear industry was inadequate. Discouragement of travel reduced interactions on various committees and attendance at important conferences. The management I team, particularly at the senior levels was largely inbred !
and viewed as insular. As a result, NU was unaware of l the growth and improving trends in the industry and the l standards of performance being expected and achieved. ;
- Lack of senior management leadership and direction resulted in inconsistent standards being applied i throughout the nuclear organization, even within the l same site. Each manager or group of managers provided l
j their own standards and goals. This resulted in confusion on expectations and direction of the nuclear organixation and led to a general lack of teamwork as well as a general
satisfaction with average performance of the nuclear plants.
Nuclear oversight was ineffective.
- Quality Assurance activities were limited to the minimum necessary to meet regulatory requirements. , l The Independent Safety and Engineering Group (ISEG) issued only 11 reports between 1987 and 1994, indicative of the low level of this oversight function. The Nuclear Review Board was manned by line management and did not exercise the scope of its responsibilities in challenging !
the performance standards being achieved at Millstone l or assuring the effectiveness of the QA function.
- The standards of the Plant Operations Review Committee (PORC) did not prevent non-conservative decisions or foster safe nuclear operations. (i.e. CH 442 valve, l inadvertent draindown of the reactor vessel, etc.) ;
l Problem identification and problem solving methods were not effective or consistently applied to improve performance.
- The corrective action programs failed to encourage the identification of deficiencies, weaknesses or conditions adverse to quality or assure prompt resolution.
- Self assessments and inspections were not critical and did not identify some significant problems.
- Engineering support for operations was underutilized and, at times, was ineffective.
Acknowledgment:
The Nuclear Committee Advisory Team fully endorses and concurs with the Fundamental Cause Assessment Report enclosed with this letter. The NCAT believes the report accurately l
identifies and describes the factors that led to the decline in performance of Northeast Utilities' nuclear program and the historical context in which that decline took place. The findings are in substantial agreement with those contained in this report f l &
George . Davis m