Text

Forwards Root Cause Analysis Summary, Unsatisfactory Licensed Operator Requalification Program, Resulting from Failure of Two Crews & Three Operators During Requalification Simulator Exam Retakes on 910605 & 06
	ML17286B016
Person / Time
Site:	Columbia
Issue date:	08/20/1991
From:	John Baker, Oxsen A, Sorensen G; WASHINGTON PUBLIC POWER SUPPLY SYSTEM
To:	Martin J; NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION V)
Shared Package
ML17286B017	List: GO2-91-156, Forwards Root Cause Analysis Summary, Unsatisfactory Licensed Operator Requalification Program, Resulting from Failure of Two Crews & Three Operators During Requalification Simulator Exam Retakes on 910605 & 06; ML17286B021;
References
	GO2-91-156, NUDOCS 9108290092
	Download: ML17286B016 (12)
	v • d • e

WASHINGTON PUBLIC POWER SUPPLY SYSTEM P.O. Box 968

~ 3000 George Washington Way

~ Richland, Washington 99352 Docket No. 50-397 G02-91-156 August 20, 1991 J. B. Martin, Regional Administrator U. S. Nuclear Regulatory Commission Region V 1450 Maria Lane, Suite 210 Walnut Creek, CA 94596 r?

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Dear Mr. Martin:

Subject:

NUCLEAR PLANT NO. 2, OPERATING LICENSE NPF-21 UNSATISFACTORY LICENSED OPERATOR REQUALIFICATION TRAININGPROGRAM - ROOT CAUSE ANALYSIS

Reference:

1.

Letter, J. B. Martin to A. L. Oxsen, Confirmatory Action Letter V-91-01, Revision 3, dated June 14, 1991 2.

Letter, A. L. Oxsen to J. B. Martin, Corrective Action Plan, Revision 7, dated August 16, 1991 In accordance with Item 6 ofthe Confirmatory Action Letter, Revision 3 (Reference 1), attached for your review is a copy of the Supply System's root cause evaluation of the circumstances which resulted in the failure of two crews and three operators during the requalification simulator exam retakes on June 5 and 6, 1991. As required, this root cause evaluation describes why our May 16 licensed operator training program corrective action plan was not effective in identifying and preventing the problems which occurred in the retake examinations.

A copy of our corrective action plan (Revision 7) was submitted to you on August 16 (Reference 2).

In addition to the formal root cause evaluation, in the aftermath of the recent requalification examination failures at WNP-2, Supply System senior management conducted a critical self-evaluation of their performance prior to and immediately after the failures to try and understand why our process failed. The followingsummary of that evaluation is intended to provide a more global perspective as a supplement to the formal root cause analysis.

The formal root cause analysis looked at processes and organizational responsibilities in seeking to determine the root cause and I believe the process identified those organizational and process failures which, when corrected, willresult in a satisfactory licensed operator requalification

J. B. Martin, Regional Administrator August 20, 1991 Page Two NUCLEAR PLANT NO. 2, OPERATING LICENSE NPF-21

'NSATISFACTORY LICENSED OPERATOR REQUALIFICATION TRAININGPROGRAM - ROOT CAUSE ANALYSIS program.

Because senior management was a part of the environment in which these organizational and process breakdowns occurred, we felt it necessary to ask ourselves why we were not effective at changing the performance of our staff. In performing this assessment, we found that senior management did not clearly establish standards of performance and hold personnel accountable to the expected standards.

In addition, when elements of our process were challenged, we did not always react constructively to comments.

While there were many areas of less-than-adequate performance which contributed to the failures, we consider the following to be especially significant from a management perspective:

1)

The process used to develop our emergency operating procedures (EOPs) was not structured properly.

A small task force of technical specialists developed the philosophical position and drove the procedure preparation without appropriate management direction.

A task of this magnitude should have had project status with appropriate formal management reviews of strategy, schedules, resources and outside expertise.

Sensitivity to developing a compliance strategy which placed WNP-2 outside the mainstream did not receive adequate management review. Itis worth noting that the tendency to address similar initiatives on an ad hoc basis relying on our strong technical capability to achieve success is not restricted to this issue and we plan to review these other areas to assure corrective actions are taken.

2)

When the adequacy of our EOPs was first challenged in the NRC EOP inspection in late 1990, management became very defensive, initially refusing to accept many of the findings as valid.

Rather than checking the quality of our EOPs against what was the norm among our peers in the industry, we attempted to justify our product internally, which wasted a great deal of time and ultimately did not improve our position.

Again, there was a lack of sensitivity to being outside the mainstream and then trying to defend that position.

3)

When the initial failures occurred, senior management realized there was a significant misalignment between our level of performance expectations and that of the NRC.

We had not taken appropriate measures to assure our staff was informed of changing industry standards in this critical area.

After it became known that several other utilities had suffered major setbacks resulting from failures in their requalification programs, little was done to determine ifWNP-2 had the same exposure.

Management did not require that such an evaluation be performed.

J. B. Martin, Regional Administrator August 20, 1991 Page Three NUCLEAR PLANT NO. 2, OPERATING LICENSE NPF-21 UNSATISFACTORY LICENSED OPERATOR REQUALIFICATION TRAININGPROGRAM - ROOT CAUSE ANALYSIS 4)

Initial senior management reaction to the first round of failures was to blame everyone but the Supply System; i.e., someone changed the rules; too much artificial stress; the exam was unreasonable, etc.

Only after a preponderance of data was reviewed indicating that many of our peers were successfully handling the more challenging exam scenarios did senior management begin to aggressively move in the right direction.

The process of evaluating senior management's contribution to the WNP-2 exam failures has been a painful but important learning experience for the Supply System.

We are convinced that our training process and our operator ability to handle severe accidents have been greatly improved as a direct result of this experience.

We are committed to ensuring that the generic lessons learned are internalized such that these mistakes are not repeated in other areas.

It is apparent senior management must make fundamental changes in its decision making processes for these types of major issues.

In the short term, we are planning on several management meetings to be sure we effectively communicate lessons learned to our staff.

As we make the necessary improvements in our processes to preclude similar exposure in the future, we willcontinue to keep you apprised of our progress.

We view this recent experience as a temporary setback in our overall improvement program. Itis the intent of the Supply System to be recognized as a nuclear utility committed to superior performance.

Very truly yours, A. L. Oxsen Deputy Managing Director GCS:ALO:lg Enclosure CC:

PL Eng/NRC LP Miller/NRC NS Reyolds/Winston Ec Strawn NRC Resident Inspector/901A Document Control Desk/NRC DL Williams/BPA/399

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ACCESSION NBR:9108290092 DOC.DATE: 91/08/20 NOTARIZED: NO DOCKET FACIL:50-397 WPPSS Nuclear Project, Unit 2, Washington Public Powe 05000397 AUTH.NAME AUTHOR AFFILIATION OXSEN,A.L.

Washington Public Power Supply System SORENSEN,G.C.

Washington Public Power Supply System BAKER,J.W.

Washington Public Power Supply System RECIP.NAME RECIPIENT AFFILIATION MARTIN,J.B.

Region 5 (Post 820201)

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SUBJECT:

Forwards Root Cause Analysis Summary,'Unsatisfactory Licensed Operator Requalxfication Program," resulting from failure of two crews

& three operators during requalification simulator exam retakes on 910605

& 06.

DISTRIBUTION CODE:

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TITLE: Operator Requalification Program NOTES: 58'~ fp+D D

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1 1

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NOTE TO ALL"RIDS" RECIPIENTS:

PLEASE HELP US TO REDUCE WASTETH CONTACT THE DOCUMENT CONTROL DESK, ROOM Pl-37 (EXT. 20079) TO ELIMINATEYOUR NAMEFROM DISTRIBUTION LISTS FOR DOCUMENTS YOU DON'T NEED!

TOTAL NUMBER OF COPIES REQUIRED:

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AG Hosier/955 SL Washington/988U DR Kobus/1028 CM Powers/1023 DW Mazur/387

" SL McKay/927S RL Webring/988U RL Koenigs/981G Docket Files/955 Docket No. 50-397 GO2-91-156 JW Baker/927M JE Rhoads/956A LT Harrold/927M RB Barmettlor/1028 ALO/LB/1023 GCS/LB/280 August 20, 1991 J. B. Martin, Regional Administrator U. S. Nuclear Regulatory Commission Region V 1450 Maria Lane, Suite 210 Walnut Creek, CA 94596

Dear Mr. Martin:

Subject:

NUCLEAR PLANT NO. 2, OPERATING LICENSE NPF-21 UNSATISFACTORY LICENSED OPERATOR REQUALIFICATION TRAININGPROGRAM - ROOT CAUSE ANALYSIS

Reference:

1. Letter, J. B. Martin to A. L. Oxsen, Confirmatory Action Letter V-91-01, Revision 3, dated June 14, 1991

2. Letter, A. L. Oxsen to J. B. Martin, Corrective Action Plan, Revision 7, dated August 16, 1991 In accordance with Item 6 ofthe Confirmatory Action Letter, Revision 3 (Reference 1), attached for your review is a copy of the Supply System's root cause evaluation of the circumstances which resulted in the failure of two crews and three operators during the requalification simulator exam retakes on June 5 and 6, 1991. As required, this root cause evaluation describes why our May 16 licensed operator training program corrective action plan was not effective in identifying and preventing the problems which occurred in the retake examinations.

A copy of our corrective action plan (Revision 7) was submitted to you on August 16 (Reference 2).

In addition to the formal root cause evaluation, in the aftermath of the recent requalification examination failures at WNP-2, Supply System senior management conducted a critical self-evaluation of their performance prior to and immediately after the failures to try and understand why our process failed. The followingsummary of that evaluation is intended to provide a more global perspective as a supplement to the formal root cause analysis.

The formal root cause analysis looked at processes and organizational responsibilities in seeking to determine the root cause and I believe'the process identified those organizational and process failures which, when corrected, willresult in a satisfactory licensed operator requalification "Goi2G hVHiOR:

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WASHINGTON PUBLIC POWER SUPPLY SYSTEM P.O. Box 968

~ 3000 George Washington Way

~ Richland, Washington 99352 Docket No. 50-397 G02-91-156 August 20, 1991 J. B. Martin, Regional Administrator U. S. Nuclear Regulatory Commission Region V 1450 Maria Lane, Suite 210 Walnut Creek, CA 94596

Dear Mr. Martin:

Subject:

NUCLEAR PLANT NO. 2, OPERATING LICENSE NPF-21 UNSATISFACTORY LICENSED OPERATOR REQUALIFICATION TRAININGPROGRAM - ROOT CAUSE ANALYSIS

Reference:

1.

Letter, J. B. Martin to A. L. Oxsen, Confirmatory Action Letter V-91-01, Revision 3, dated June 14, 1991 2.

Letter, A. L. Oxsen to J. B. Martin, Corrective Action Plan, Revision 7, dated August 16, 1991 In accordance with Item 6 of the Confirmatory Action Letter, Revision 3 (Reference 1), attached for your review is a copy of the Supply System's root cause evaluation of the circumstances which resulted in the failure of two crews and three operators during the requalification simulator exam retakes on June 5 and 6, 1991. As 'required, this root cause evaluation describes why our May 16 licensed operator training program corrective action plan was not effective in identifying and preventing the problems which occurred in the retake examinations.

A copy of our corrective action plan (Revision 7) was submitted to you on August 16 (Reference 2).

In addition to the formal root cause evaluation, in the aftermath of the recent requalification examination failures at WNP-2, Supply System senior management conducted a critical self-evaluation of their performance prior to-and immediately after the failures to try and understand why our process failed. The followingsummary of that evaluation is intended to provide a more global perspective as a supplement to the formal root cause analysis.

The formal root cause analysis looked at processes and organizational responsibilities in seeking to determine the root cause and I believe the process identified those organizational and process failures which, when corrected, willresult in a satisfactory licensed operator requalification

J. B. Martin, Regional Administrator August 20, 1991 Page Two NUCLEAR PLANT NO. 2, OPERATING LICENSE NPF-21 UNSATISFACTORY LICENSED OPERATOR REQUALXHCATION TRAININGPROGRAM - ROOT CAUSE ANALYSIS program.

Because senior management was a part of the environment in which these organizational and process breakdowns occurred, we felt it necessary to ask ourselves why we were not effective at changing the performance of our staff. In performing this assessment, we found that senior management did not clearly establish standards of performance and hold personnel accountable to the expected standards.

In addition, when elements of our process were challenged, we did not always react constructively to comments.

While there were many areas of less-than-adequate performance which contributed to the failures, we consider the following to be especially significant from a management perspective:

1)

The process used to develop our emergency operating procedures (EOPs) was not structured properly.

A small task force of technical specialists developed the philosophical position and drove the procedure preparation without appropriate management direction.

A task of this magnitude should have had project status with appropriate formal management reviews of strategy, schedules, resources and outside expertise.

Sensitivity to developing a compliance strategy which placed WNP-2 outside the mainstream did not receive adequate management review. It is worth noting that the tendency to address similar initiatives on an ad hoc basis relying on our strong technical capability to achieve success is not restricted to this issue and we plan to review these other areas to assure corrective actions are taken.

2)

When the adequacy ofour EOPs was first challenged in the NRC EOP inspection in late 1990, management became very defensive, initially refusing to accept many of the findings as valid.

Rather than checking the quality of our EOPs against what was the norm among our peers in the industry, we attempted to justify our product internally, which wasted a great deal of time and ultimately did not improve our position.

Again, there was a lack of sensitivity to being outside the mainstream and then trying to defend that position.

3)

When the initial failures occurred, senior management realized there was a

significant misalignment between our level of performance expectations and that of the NRC.

We had not taken appropriate measures to assure our staff was informed of changing industry standards in this critical area.

After it became known that several other utilities had suffered major setbacks resulting from failures in their requalification programs, little was done to determine ifWNP-2 had the same exposure.

Management did not require that such an evaluation be performed.

I,

J. B. Martin, Regional Administrator August 20, 1991 Page Three NUCLEAR PLANT NO. 2, OPERATING LICENSE NPF-21 UNSATISFACTORY LICENSED OPERATOR REQUALIFICATION TRAININGPROGRAM - ROOT CAUSE ANALYSIS 4)

Initial senior management reaction to the first round of failures was to blame everyone but the Supply System; i.e., someone changed the rules; too much artificial stress; the exam was unreasonable, etc.

Only after a preponderance of data was reviewed indicating that many of our peers were successfully handling the more challenging exam scenarios did senior management begin to.aggressively move in the right direction.