IR 05000341/1993027
| ML20059B976 | |
| Person / Time | |
|---|---|
| Site: | Fermi  |
| Issue date: | 12/17/1993 |
| From: | Jorgensen B, Phillips M NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION III) |
| To: | |
| Shared Package | |
| ML20059B964 | List: |
| References | |
| 50-341-93-27-EC, EA-93-294, NUDOCS 9401040314 | |
| Download: ML20059B976 (61) | |
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h U.S, NUCLEAR REGULATORY COMMISSION
REGION III
t Report No. 50-155/93027(DRP) j Docket No. 50-341 License No. NPF-43 l Enforcement Action No.93-294 .
Licensee: The Detroit Edison Company 6400 North Dixie Highway Monroe, Michigan Meeting Conducted: December 14, 1993 Meeting At: Region III Office, Lisle, Illinois l Type of Meeting: Enforcement Conference Inspection Conducted: Onsite at Fermi 2 Nuclear Plant, Occober 12 l
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through November 10, 1993 Inspectors: R. Twigg W. Kropp K. Riemer
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Reviewed By: ~p / 2f/7/ 72 ,
M. PT PEillips, Chief Date -
Reactor Projects Section 2B ,
Approved By: @ b k ,rcm/1- # 3 B. L.\d agensen, or Acting Chief Date Reactor Projects Branch 2 Meetina Summary Enforcement Conference on December 14. 1993 (Report No. 50-341/93027)
Areas Discussed: The apparent violation and areas of concern identified during the inspection were discussed, along with corrective actions taken or i planned by the licensee. The enforcement options pertaining to the apparent violation were also discussed with the licensee. The apparent violation concerned the failure of the corrective action system to correct long-standing !
deficiencies with the abnormal lineup sheet process, work control process, and recurring personnel errors, that culminated in an event on September 17, 1993, ;
where three maintenance mechanics were burne ,
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9401040314 931220 PDR ADOCK 05000341 G PDR
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DETAILS I
, Persons Present at Conference !
Detroit Edison Company D. Gipson, Senior Vice President, Nuclear Generation i R. McKeon, Plant Manager .;
R. Stafford, Manager, Nuclear Assurance .;
J. Plona, Superintendent, Operations !
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G. Pierce, General Supervisor, Work Control j
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L. Goodman, Director, Nuclear Quality Assurance R. Newkirk, Director, Nuclear Licensing i P. Marquardt, General Attorney .
J. Nolloth, Superintendent, Maintenance l T. Bradish, Supervisor, Quality Assurance Audits C. Cassise, General Supervisor, Mechanical Maintenance :
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P. Wiltse, Supervisor, Mechanical Maintenance K. Burke, Nuclear Assistant Shift Supervisor D. Breidi-9, Nuclear Supervising Operator .l M. Thrift, Nuclear Supervising Operator D. Bergmooser, Supervisor, NSSS, Technical Engineering ;
J. Nyquist, Supervisor, Safety Engineering 1 J. Tibai, Principal Compliance Engineer ;
e Atlas Consultino l J. Crews, Executive Consultant i
Illinois Power j ;
G. Baker, Consultant to Senior Vice President .
f Toledo Edison l J. Moyers, Manager, Quality Assessments ,
i U.S. Nuclear Regulatory Commission ,
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J. Martin, Regional Administrator, RIII E. Greenman, Director, Division of Reactor Projects, RIII ;
M. Phillips, Chief, Reactor Projects Section 2B, RIII :
R. DeFayette, Director, Enforcement and Investigations Staff, RIII B. Berson, Regional Consul, RIII .
. W. Kropp, Senior Resident Inspector, Fermi Site 8 T. Colburn, Project Manager, NRR ,
R. Twigg, Reactor Engineer, RIII
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Rt Gardner, Chief, Plant Systems Section, RIII S. Burgess, Team Leader, RIII ,
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p Enforcement Conference An Enforcement Conference was held in the NRC Region III office on December 14, 1993. This conference was conducted as a result of the preliminary findings of the inspection conducted on October 12 through Novembcr-10,.1993, in which apparent violations'of NRC regulations were identified. Inspection findings were documented in Inspection Report No. 50-341/93022, transmitted to the licensee by letter dated-December 2, 199 The purpose of this conference was to-(l) discuss-the apparent violation, the causes, and the licensee's corrective actions; (2)
determine if there were any escalating or mitigating circumstances; and (3) obtain any information which would help determine the appropriate enforcement actio Following an introduction by the Division of Reactor Projects Division'
Director, the apparent violation was presented, along with a discussion of NRC concerns and assessment of the root causes. The licensee's representatives did not contest any of the material presented in the conference or the associated inspection report and were in agreement
.with the NRC's understanding of the areas of concern, which are outlined in the NRC's handout provided at the conference (Attachment 1). The licensee's representatives discussed the apparent violation, including root causes and corrective actions taken and planned. A summary of the licensee's corrective actions and a brief description addressing the-escalation and mitigation factors were included in the attached handout that the licensee provided at the conference-(Attachment _2).
At the conclusion of the conference, the licensee was informed that they would be notified in the near future of the final enforcement actio Attachments: NRC Handout- DECO Presentation Materials
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4 4 U.S NUCLEAR REGULATORY COMMISSION
- ENFORCEMENT CONFERENCE DETROIT EDISON COMPANY FERMI 2 DECEMBER 14, 1993 1:00 PM (CST)
REPORT NUMBER 50-341/93022 EA NUMBER 93-294 REGION Ill OFFICE 801 WARRENVILLE ROAD LISLE, ILLINOIS
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FERMI UNIT 2
ENFORCEMENT CONFERENCE !
l AGENDA l I
T INTRODUCTION AND MEETING PURPOSE:
Edward G. Greenman, Director, Division of Reactor Projects
SUMMARY OF APPARENT VIOLATIONS R. L. Twigg, Corrective Action Program Breakdoss71
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LICENSEE PRESENTATION AND DISCUSSION l Detroit Edison Company l
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NRC CONCERN .
t THE NRC HAS CONCLUDED THAT THE FERMI CORRECTIVE ACTION PROGRAM WAS INADEQUATE BASED.ON FAILURE TO TAKE EFFECTIVE AND TIMELY CORRECTIVE ACTION i e TO PRECLUDE REPETITION OF DEFICIENCIES IN THE AREAS OF ABNORMAL LINEUP SHEETS, WORK . AUTHORIZATION, AND PERSONNEL ERROR * TO CORRECT SELF IDENTIFIED WEAKNESSES IN THE CORRECTIVE ACTION PROGRAM
THE BREAKDOWN OF THE CORRECTIVE ACTION PROGRAM HAS ,
ALLOWED CONDITIONS TO EXIST FOR OVER A YEAR THAT HAVE ;
IMPACTED PLANT PERFORMANCE AND COULD HAVE SIGNIFICANT IMPACT ON FUTURE PLANT OPER.ATIONS
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n WOR.K AUTHORIZATION
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- SEPTEMBER 12, 1992,- LICENSEE REMOVED BOLTS ON THE
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SOUTH SUPPRESSION CHAMBER (TORUS) HATCH WITHOUT PROPER PLANT CONDITIONS
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- FEBRUARY 1993,- NRC INSPECTION REPORT IDENTIFIED WORK .
PACKAGE CONTROL ISSUE
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- EXAMPLES OF INEFFECTIVE WORK PLANNING IDENTIFIED IN JANUARY, MARCH, AND JUNE 199 l t
- SEPTEMBER 17, 1993 - LICENSEE REMOVED ACTUATOR ON-PRESSURIZED SYSTEM WITHOUT PROPER PLANT CONDITIONS
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t EERSONNEL FRRORS
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IDENTIFIED BY HUMAN PERFORMANCE EVALUATION SYSTEM (HPES) SEPTEMBER 1991. CAUSAL FACTORS:
- VERBAL AND WRTITEN COMMUNICATIONS
- WORK ORGANIZATION AND PLANNING r
- SUPERVISORY AND MANAGERIAL METHODS INSPECTION REPORT IDENTIFICATION OF CONCERNS WITH COMMUNICATION PROBLEMS AND PROMULGATION OF MANAGEMENT EXPECTATIONS SINCE OCTOBER 1991: :
- INSPECTION REPORT NO. 50-341/93007
- INSPECTION REPORT NO. 50-341/93011
- INSPECTION REPORT NO. 50-341/93013
- INSPECTION REPORT NO. 50-341/93016 L
MULTIPLE PERSONNEL ERROR EVENTS WITH SIMILAR CAUSAL '
FACTORS SINCE SEPTEMBER 199 !
- APRIL 1992 - HCU LOCKWIRE MISSING
- JUNE 1992 - SGTS INOPERABLE -
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- SEPTEMBER 1992 - TORUS HATCH REMOVAL
- NOVEMBER 1992 - PAM RECORDER INSTALLATION
- DECEMBER 1992 - RADWASTE TANK OVERFLOW ,
- APRIL 1993 - WRONG RECORDER IN CONTROL RM ,
- JULY 1993 - EECW INITIATION
- SEPTEMBER 1993 - BREACH OF HIGH PRESS BOUNDARY REACTOR SCRAMS DUE TO PERSONNEL ERROR ,
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- NOVEMBER 1992 - WRONG VALVE MANIPULATED
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JANUARY 1993 - WRONG TEST EQUIPMENT CONNECTIONS
- APRIL 1993 - WRONG CONNECTORS USED DURING MOD
AUGUST 1993 - TAPE REMOVED FROM INSTRUMENT LINE !
- SEPTEMBER 1993 - RESPONSE TO SEPT 17 EVENT
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SELF ASSESSMENT OF CORRECTIVE ACTION
LICENSEE AUDITS AND NRC INSPECTIONS IDENTIFIED NUMEROUS INSTANCES OF:
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- UNTIMELY OR INEFFECTIVE CORRECTIVE ACTION
LACK OF COORDINATION BETWEEN ORGANIZATIONS TO RESOLVE PROBLEMS
- JNSTANCES DISPLAYING A LACK OF TEAMWORK.
- DER REPORTS CLOSED PRIOR TO COMPLETION OF CORRECTIVE ACTIONS l
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F ROOT CAUSE '
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THE PRIMARY ROOT CAUSE OF:
- THE INADEQUATE CORRECTIVE ACTION PROGRAM P
THE RECURRING CONDITIONS ADVERSE TO QUALITY IN THE AREAS OF THE ABNORMAL LINEUP SHEET (ALS) PROCESS, WORK AUTHORIZATION, AND PERSONNEL ERRORS WAS A LACK OF COORDINATION BETWEEN DEPARTMENTS WITHIN THE FERMI ORGANIZATION AS EVIDENCED BY:
POOR COMMUNICATIONS (WRITTEN AND VERBAL)
- LACK OF TEAMWORK '
- LACK OF MUTUAL ACCOUNTABILITY
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SUMMARY OF APPARENT VIOLATION
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10 CFR PART 50, APPENDIX B, CRITERION XVI, " CORRECTIVE ,
ACTION," REQUIRES, IN PART, THAT MEASURES BE ESTABLISHED TO ASSURE THAT CONDITIONS ADVERSE TO QUALITY ARE i PROMPTLY IDENTIFIED AND CORRECTED. IN THE CASE OF SIGNIFICANT CONDITIONS ADVERSE TO QUALITY, THE MEASURES ,
SHALL ASSURE THAT THE CAUSE OF THE CONDITION IS DETERMINED AND CORRECTIVE ACTION TAKEN TO PRECLUD REPETITIO CONTRARY TO THE ABOVE, FROM SEPTEMBER 1991 UNTIL SEPTEMBER 1993, THE LICENSEE FAILED TO ESTABLISH MEASURES TO ASSURE CORRECTIVE ACTIONS WERE TAKEN TO PRECLUDE I REPETITION OF SIGNIFICANT CONDITIONS ADVERSE TO QUALITY IN THE FOLLOWING AREAS:
- ABNORMAL LINEUP SHEETS
- WORK AUTHORIZATION
- PERSONNEL ERRORS
- CORRECTIVE ACTION PROGRAM
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ABNORMAL LINEUP SHEET (ALSJ
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May 1992 AUDIT CONCLUDED DISCREPANCIES HAD BEEN A RECURRING PROBLEM AND WERE SIGNIFICANT...AND INDICATED '
THAT "A PERFORMANCE PROBLEM EXISTED IN THE ' TAGGING AND PROTECTIVE BARRIER' PROCESS..."
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- ALS DISCREPANCIES IDENTIFIED SINCE MAY 1992:
2/93 NRC Violation 3/93 SURVEILLANCE 93-0302 ,
4/93 DER 93-198 5/93 AUDIT 93-0119 6/93 NRC Unresolved Item 9/93 SEP7' 7,1993 EVENT l
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l Enforcemerr Conference . December 14,1993 I l02 Agenda l
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Introduction - Mr. J. B. Martin i Regional Administrator O
. NRC Overview Mr. E. G. Greenman l Director, Division of Reactor Projects ,
n Summary of Apparent Viola 1lons Mr. R. L. Twigg . O NRC Inspector
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Detroit Edison Opening Remarks Mr. D. R. Gipson ) Senior Vice President, Nuclear Generation lo Abnormal Lineup Sheet Process Mr. J. H. Plona , Superintendent, Operations
' Work Control Process Mr. G. G. Pierce I General Supervisor, Work Control Process O
Previous initiatives Mr. R. B. Stafford ;
: Corrective Action Program Nucleo. Assurance Manager Personnel Error Reduction Program O Enforcement Policy Considerations Mr. R. A. Newkirk Acting Director, Nuclear Licensing Detroit Edison Closing Remarks Mr. D. R. Gipson Senior Vice President, Nuclear Generation O
NRC Follow-Up Questions
! Closing Remarks Mr. J. B. Martin Regional Administrator ! !
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Enforcemen~ Conference 1 December 14,1993 1 to ABNORMAL LINEUP SHEET PROCESS ; INTRODUCTION
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.O e Summary of Problem
. New Review of the DER / Audit Database Initiated O
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Adherence to Administrative Controls l
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Untimely Independent Verification
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Incorrect Implementation of Abnormal Lineup Sheets 0 - Coordination of Protection and Work Scope
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PREVIOUS CORRECTIVE ACTIONS , _ j . Improved Adherence to Administrative Controls -
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Procedure Changes Made l - Training on Self-Checking
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Periods of increased Supervisory Oversight to Monitor Compilance and Provide immediate Feedback . O <
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Revised Independent Verification Procedure
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Training Provided
. Improve implementation of the Abnormal Lineup Sheets ! j
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En"orcemerr Conference : December 14,1993 j
ABNORMAL LINEUP SHEET PROCESS (continued) ! l . PREVIOUS CORRECTIVE ACTIONS (Continued) . O . Improve Coordination of Protection and Work Scope i l 1
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Tagging and Work Control Procedures Revised to l Strengthen Control and Provide Better Coordination of : Protection and Wor j O i
" CORRECTIVE ACTIONS TAKEN SINCE SEPTEMBER 17 l . Tagging Procedure was Revised to Strengthen Controls and '
lo Provide Better Coordination with the Work Control ; j Procedur ,
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l ; * Training Provided to Personnel on These Procedure Change q 10 : ; LONG-TERM CORRECTIVE ACTIONS ! l l
' * Develop Training l
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Practical Exercises .!
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Expect to implement by March 1994 I - Periodically Administered i
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O * Review Abnormal Lineup Sheet Process ,
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Monitor for Additional Lessons Learned i l
4 Feedback from Operations and Maintenance l Personnel I l
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j l' Enforcemen- Conference' l , December 14,1993 o- ; ABNORMAL LINEUP SHEET PROCESS (continued) i
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1.ONG-TERM CORRECTIVE ACTIONS (Continuedy i .
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Independent Assessment of Tagging Process by Failure l Prevention, Inc., International to identify any Other Poten11al Enhancements
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- O V Results Expected by End of January 1994 -]
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Evaluate In-House and Failure Prevention,Inc., j International Results and Make Appropriate Changes
- O SUMMARY )
l The Corrective Actions Discussed will Result in Effective Long- j
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Term Performance ] O \
* The Superintendent-Operations is Responsible for the :
Abnormal Lineup Sheet Process; However, the Detroit Edison . Team will Play a Key Role in the Improvement of the Process j l l l
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l WORK CONTROL PROCESS
[lNTRODUCTION I
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. Summary of Problem O ! ) . Ongoing Review of Work Control Process , . Results - Three Categories of Problems v
O [ - Lack of Operating Experience Input to Work Control
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Administrative Control of Work Packages 0 - Lock of Coordination Across all Groups
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l PREVIOUS CORRECTIVE ACTIONS O [
[ . Improve Operating Experience input to Work Control
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Five NRC Licensed IndMduals were Added to the Work Control Group O jl l
,, . Improve Administrative Control of Work Packages l -
Further Defined Requirements for Work impact Statements
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O CORRECTIVE ACTIONS TAKEN SINCE SEPTEMBER 17 1 l a i
" . Improve Administrative Control of Work Packages i g -
Work Requests impact Statements were improved 0 0 - Work Requests will be Written Without the Need for
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The Sequence of the Plan of the Day will be Followed i s 1 i , O ! h L w e n ja ! O i i Jin1! 2 , 1
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Enforcemen~ Conference December 14,1993 ) l0 WORK CONTROL PROCESS (continued) CORRECTIVE ACTIONS TAKEN SINCE SEPTEMBER 17 (continued) lO jl . Improve Coordination Across all Groups j
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Group Meetings 1 l
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Execution of Safety System Outages (Commenced May j 1 1993) i
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, LONG-TERM CORRECTIVE ACTIONS ,
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* Independent Assessment of Work Control Process by Failure
- o l Prevention, Inc., International to identify any Further Enhancements.
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Review Expected by the End of January 1994 l lo i . Evaluate In-House and Failure Prevention, Inc., International Re-i suits and Make Appropriate Changes l SUMMARY
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. Although There have been Problems Noted with the Work Control i Process, We Believe that the Corrective Actions Discussed Today '
will Provide a Satisfactory, Long-Term Solution. The Success of
; these Corrective Actions is the Responsibility of the General l Supervisor-Work Control; however, the Detroit Edison Team will O i Play a Key Role.
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!s December 14,1993 .
PREVIOUS INITIATIVES HPES 91-05 i O l
* Most Recommendations implemented and Successful f -
Expand PRIDE (Quality Circles) to include all Nuclear Production
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More Supervisor Participation O l - Conduct Meetings with Employes l - Improve Maintenance Shift Turnover l
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Qualify More Personnelin Conducting HPES Reviews
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Provide Controlled Drawings for Fermi 1 o ( - Establish Self-Checking Program a e Less Than Adequate In t
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Improving Procedure Review Process ! O - Improving Procedures in I&C i'92 CORRECTIVE ACTION IMPROVEMENT INITIATIVE
o q e Resulted from Third Party Audit e Six of Ten Corrective Actions initiated Successfully
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Improve Root Cause Analysis and Ability to Detect Adverse , O. ? Trends
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Lower the Threshold for Events Requiring Root Cause Analysis f - Develop Guidelines for Preservatbn of Evidence
j - Increase Awareness of DER Data Base
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Train Personnel on Root Cause Analysis .O h
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Communicate Management Concerns on ineffective e Resolution of Problems
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! December 14,1993 i O l 1 !
l PREVIOUS INITI ATIVES (Continued) ]l l j'92 CORRECTIVE ACTION IMPROVEMENT INITIATIVE (continued) O t ? n 1 i . Less Than Adequate in I
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j - Corrective Action Program Bi-Weekly Report on l 0 ) j - Implementation Problems Corrective Action Review Meetings
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Documented Support on Problem Resolution Between jl Organizations [( j - Departmental Accountability Meetings ! O . E(CAUSES l
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I l j . Incorrect initiatives ! !
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a! i : O . Lack of Proper Indicators for Measuring Progress ( l lj i j . Insufficient Management Involvement ) j ! l CORRECTIVE ACTIONS l 0 j l l . Contained in " Corrective Action Program" Handout L i il s D f L
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'? j Detroit Edison Perspectives 8 l on Apparent Violation and l i NRC Enforcement Policy l 3 ! ',' 8 j 3 . SEVERITY (App. C, Supplement I, Example C.7) #
$ !# } -
A breakdown in the Control of Licensed Activities l Involving a Number of Violations that are Related (or,if ; n " @ Isolated, that are Recurring Violations) that Collectively j Represent a Potentially Sianificant Lack of Attention or l
@ Carelessness Toward Licensed Responsibilitie l:
1 l j DECO PERSPECTIVE O , l
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Specific Examples included in the Report are of
Concern to DECO, but the Safety Significance of L g the Individual Events is Relatively Minor (i.e., When 3 i Considered in the Context of License Compliance j o g and Risk to the Health and Safety of the Public.) y 1 i;
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Overall Significance, and Thus the Severity Level of [
] any Enforcement Action, Should be Based on D l Whether or not a Corrective Action Program [
O { Breakdown has Occurre I
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l - Significant Number of Actions have been l Successfu I i O - Many Corrective Action Program initiatives Taken ! j to improve the Program Over the Past 2 years (not y 4 a Lock of Attention). i t t
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l - Actions Cited in the Inspection Report, while e l Examples of Less than Successful Efforts, do not Q
Constitute a " Breakdown".
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f Detroit Edison Perspectives ; on Apparent Violation and '
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.O l l . SEVERITY (App. C, Supplement I, Example C.7)
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A breakdown in the Control of Licensed Activities
[ Involving a Number of Violations that are Related (or,if O l Isolated, that are Recurring Violations) that Collectively l Represent a Potentially Slanificant Lack of Attention or j Carelessness Toward Licensed Responsibilitie T l DECO PERSPECTIVE O ! ! -
Specific Examples included in the Report are of
; Concern to DECO, but the Safety Significance of i i the Individual Events is Relatively Minor (i.e., When '
Considered in the Context of License Compliance O ; and Risk to the Health ana $afety of the Public.)'
! ; -
Overall Significance, and Thus the Severity Level of I any Enforcement Action, Should be Based ~on
] Whether or not a Corrective Action Program O j Breakdown has Occurre j l -
Significant Number of Actions have been l Successfu l ~O - Many Corrective Action Program Initiatives Taken il j to improve the Program Over the Past 2 years (not I a Lack of Attention).
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Actions Cited in the Inspection Report, while O ;! Examples of Less than Successful Efforts, do not
[ Constitute a ' Breakdown'. ;
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f Detroit Edison Perspectives ly on Apparent Violation and l NRC Enforcement Policy (Continued) 3 . civil PENALTY ADJUSTMENT FACTORS (VI.B.2) I l - IDENTIFICATION -- Problems with Corrective Action l Program were Self-identified as Noted in the Repor '3 I l
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CORRECTIVE ACTION -- Comorehensive Efforts to Improve Corrective Action Program, as Discussed Toda , J } l l l 3 i, a a ~ h
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- o INTRODUCTION O
Identifying problems, determining root cause, and implementing . appropriate corrective action, is perhaps the single most important : O element in the overall achievement of excellenc The significance of this statement is acknowledged by the fact that it has been made a requirement for the licensing of nuclear power plant O The Corrective Action Program has been recently criticized because of a number of cases where ineffective corrective action was determined to be the cause of recurring events. In addition, personnel errors continue to occur at an unacceptable rat O "A Ppropriate" corrective action will be required to re-establish credibility of the program and to ensure a positive trend toward achievement of excellence. Actions are being undertaken in four areas: I CORRECTIVE ACTION IAIPROVEAIENT a O : l PL'RSONNEL ERROR REDUCTION EQUIPA1ENT IA1PROVEAIENTS O PROCEDURE RE-ENGINEERING The following pages contain a description of the improvements that have been implemented or are planned to regain credibility of the program. Additionally, information is provided about programs for resolving personnel errors, equipment concerns and procedure related issue O
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l0 II. CORRECTIVE ACTION IMPROVEMENT O Title 10, Code of Federal Regulations, Part 50, Appendix B, XVI, describes the requirements !
'
for Corrective Actio O. It states that measures shall be established to assure that conditions adverse to quality, such as failures, malfunctions, deficiencies, deviations, defective material and equipment, and non-conformances are promptly identified and corrected. In the case of significant conditions adverse to quality, the measures shall assure that the cause of the condition is determined and corrective action taken to preclude repetition. The identification of the significant condition adverse to quality, the cause of the condition, and the corrective action taken shall be O documented and reported to appropriate levels of managemen Implementation of the regulation is through Fermi Management Policy, FMD CA1,
" Evaluation and Corrective Action", which establishes requirements for the identification, documentation, notification, evaluation, and correction of conditions adverse to quality that may impact Ferrni l-O Each Nuclear Generation organizational unit, other Detroit Edison organizations and site
'
contractors shall identify, document, notify, evaluate and correct conditions adverse to quality in accordance with Fermilnterfacing Procedure FIP-CA1-01," Deviation and Corrective Action Reporting".
. Several improvements to increase the effectiveness of the Correction Action Program have already been implemented, while preparations for other improvements are in progres :o Management involvement
! The requirements for organizational unit heads to review and approve the results of the evaluation process were strengthened. This will assure an increased management involvement in the resolution of problems. (COMPLETE)
iO 12 The Manager-Nuclear Assurance and Supervisor-Safety Engineering reviewed management expectations for the Corrective Action Program with the Organization- , Unit Heads and their direct reports. (COMPLETE) i The Manager-Nuclear Assurance is assessing the quality of Deviation Event Report [
=O (DER) closures until the credibility of the Corrective Action Program has been re-established. This action is in progress and will continue until the objective is met. (IN PROGRESS)
.
W O Il-1 ,
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1A Management and Organizational Unit Head level personnel will periodically assess performance of DERs. DERs will be assigned to selected managers and organization O l unit heads for assessment. They, in turn, will assess effectiveness of DER related issues such as adequacy of evaluations, proposed corrective actions, implementation of corrective actions, performance achieved, etc. (Target: Implementation first quarter 1994) l
.
O Performance Based DER Closures l Validation of corrective action will be made by ensuring performance objectives are achieve DERs that are identified for validation will be tracked as a special group until corrective ction validation has been completed. Final DER closure will be made following validatio I O Performance based DER closure will ensure that corrective action has been effective in i resolving the problems. (Target: Implementation December,1993; JF/FEA)
,
: Continued Effectiveness of Established Corrective '
O Action ' Periodically, a sample of previously implemented corrective actions will be evaluated for .: continued effectiveness. In addition, a performance measurement will be developed for 0 trending the continued effectiveness of established corrective action. A methodology for ! implementing this process will be developed and implemented. (Target: December,1993; { FEA) !
!
: Reinforcement of Expectations j
.o . !
: Expectations for implementing the Corrective Action Program will be achieved by .j reinforcing responsibilities and accountabilities related to DERs. These expectations !
will be presented to personnel qualified to perform DER evaluations. The primary areas to be addressed are- I : O DER Initiation O Documentation O Problem Description O Closure i O Root cause Analysis O Summary 0 Corrective Actions O Follow-up ) Reviewed, approved, and published expectations will be issued. (Target: December, 1993; FEA) l ) ! 11- 2 l
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- - - . . - -. . -
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_ ______ __ . __ __ . _ . _ _ . . _ _ . I .2 Some DERs require a coordinated effort from more than one organization to resolv concerns and to implement corrective action. However, the priorities of the individual O , organizations may vary greatly which can result in an untimely response to a given DER. A methodology will be developed to resolve the organizational coordination .
"
concerns. (Target: Complete first quarter 1994; FEA) g Root Cause Training f To aid in identifying training needs, a list of Specific Corrective Action Program weaknesses identified in the last two years was compiled. QA reports, inspection reports, DER sorts, etc. were canvassed to identify weaknesses. The intent was to identify the generic weaknesses that must be resolved.
- O
:
The NRC Inspection Reports for 1991,1992 and the first half of 1993 and the 1991 and 1992 QA Audit Reports of the Corrective Action Program were reviewed. The review .
identified inadequate DER evaluations as the dominant weaknes ! o- Other actions described in this section are expected to resolve these concern .2 Extensive training has been provided on problem analysis techniques. Significant among these are: ; O Management Oversight and Risk Tree (MORT) O O Vendor provided Problem Analysic (K-T, BPI, Alamo, etc.) ; O Human Performance Enhancement System (HPES)' O Root Cause Training for Nuclear Power Plants (Failure Prevention, Incorporated) O Site Specific Root Cause Analysis .3 To improve DER evaluations, the training strategy for personnel performing root cause determinations will be re-evaluated since the needs of each organization varies depending on the type of problem being analyzed. In addition, guidance on techniques for the proper documentation of DER analyses would be considered.' (Target: Re-evaluation complete by December,1993; FEA)- O- There are 440 personnel qualified to perform DER root cause determinations. It is believed that more accountability and ownership can be achieved by identifying a small core group to perform the evaluations. Nuclear Generation Organizations have _i l concurred and have agreed to identify a core group of less than 170 individuals, (Target: Implementation of the new core group is planned for the first quarter 1994; FEA) O O' 11- 3
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a o t Corrective Action Program Performance o 6.1 Selected personnel at all levels of the organization were interviewed w ith the objective to determine the following: O The perceived weaknesses of the Corrective Action Program
- o O The perceived strengths of the Corrective Action Program O Suggested improvements should be made to the program The survey has been completed and the results have been reviewed and prioritize Selected improvements have been identified for implementation. (Target: First quarter 1994; FEA)
o 6.2 One element of the above survey noted that there are no consistent or uniform priority systems for allocation of resources to DERs based on problem significance. A trial prioritization system has been implemented. An evaluation of trial period results will be made by the end of the first quarter 199 o' Priority Equation - The following equation will be used to determine priority: RATING WEIGHTING PRIORITY O CATEGORY MULTIPLIER FACTO 8 OFCA Nuc Safety x 5 = Indust Rad / Safety x 5 = Regulatory x 3 = Efficiency / Reliability x 3 = Mgmt. Discretion x 2 = .0-PRIORITY OF DER = The rating multiplier can vary from 0 - 5 and establishes the importance of each category as related to the DER. The sum of the individual category priorities determine - the priority for the DER. Establishing the priority of the DER will enhance the ability to allocate resources.
O 6.3 In the past, much emphasis was placed on reducing the average age of open DER However, it is time to shift the focus to improving the overall quality of DERs as a first priority and to maintain timeliness of corrective action as the second priority. The shift . in focus is being implemented by Senior Management. (IN PROGRESS) D 6.4 Starting in September 1993, a new effort was initiated to provide a quality indicator of evaluations and corrective action determinations. This measure is expected to assist in > D: 11-4
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o Repeat Problem Detection O Corrective and preventive maintenance work request data, deviation event report data, maintenance histoiy data and other key information is stored in multiple computer database An initiative has been undertaken to develop the capability to perform " integrated data ! trending" of information stored in these databases. The capability to perform " integrated i O data trending" will improve detection of repeat problems, identification of potential problem areas, and provide for improved root cause and corrective action analyses. (Target: Implement the initiative by the first quarter 1994; BH/FEA) Third Party Reviews ! O It is planned to initiate third party reviews of selected DERs. Third parties, such as an oversight committee or an off-site consultant, are being considered. The expectation is to achieve a broader perspective of the quality of evaluations, corrective actions, and their effectiveness. (Target: Implement first quarter 1994; FEA) O Procedure improvements Procedure FIP-CA1-01," Deviation and Corrective Action Reporting" was revised to O achicve an overall streamlining of the procedure. This ensures that the requirements for identifying and correcting conditions adverse to quality are clearly state (COMPI.ETE) A survey of selected site personnel conducted during September,1993 revealed a g concern associated with the current forms used to process DERs. An initiative to re-engineer the DER forms will look at improving the layout of DERs for a more effective method of recording DER information. (Target: Complete first quarter 1994; FEA/JF) In addition to re-engineering the layout of the DER forms,it is planned to input the forms into the new computer network. This would allow organizations to word process 9 the DER forms which is expected to improve the physical quality of the DER documentation. (Target: Complete second quarter 1994; FEA /BH) 10. Significant Conditions Adverse to Quality (SCAQ) e A logic type flow chart was added to the corrective action procedure to improve the method for identifying significant conditions adverse to quality. As a result,it is expectei that more formal root cause evaluations will be performed. The next revision of FIP-CA1-01 will include reinforcement for the requirement to use the logic flow chart. (Target: First quarter e 1994;JF) 11- 6 I
. . . - - . - - - - _ .
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i ~ 11. O'rganizational Review Checklist o A checklist was added to the corrective action procedure to enhance "self-checking" It is
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expected that evaluations and associated corrective action by responsible organizations will improve. (COMPLETE) O Questions regarding the Corrective Action Program should be directed to the Supervisor, Safety Engineering 44218). - . O-
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Ill. PERSONNEL ERROR REDUCTION t
.
O : Several initiatives have been implemented or are being planned to reduce the personnel error rate. These initiatives focus on safety first, performing work correctly the first time and taking time to achieve a quality resul . Self-Checking Program 1 Self-checking techniques were introduced to all Fermi 2 personnel beginning in 0 February,1992, during the " Operation Self-Check Fermi 2" campaign. The."S-T-A-R" - ,
(Stop,Ihink, Act, Review) and "7-Step" (Stop, Locate, Touch, Verify, Anticipate, Manipulate, Observe) techniques were presented during this campaign which included training, self-checking posters, implementation follow-up, and self-checking ,
promotional items. Prior to 1992, self-checking training had been limited to Operators O nd Nuclear Instrument Repairmen _l 1 Self checking continuing training was provided to all Fermi 2 personnel as part of the ! Personnel Error Reduction Program. This " case study" based training reinforced the ; need for personnel to use self-checking and reviewed self-checking techniques. The ;
"S-T-A-R" acronym was made the only Fermi 2 self-checking acronym to reduce i O confusion. The initial training for the Personnel Error Reduction Program ran from ;
April to August,199 .3 The use of self-checking is monitored by supervisors, Quality Assurance (during audits l
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and surveillances), and the HPES Coordinator during follow-up surveys. The effectiveness of self-checking in reducing personnel errors is monitored by the quarterly O Deviation Event Report (DER) Causal Factor Analysis Report, j Self-checking is continuously promoted by the use of posters, video and other electronic l medi : Self-checking techniques are intended to prevent human performance problems. Such O- techniques can identify a potential human error befcre it occurs. Ultimately, the benefits realized from the use of self-checking include improved plant and personnel , safety, reliability, and exposure reductio ! O O III-1
- _ -
__ . . . .
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: Enhanced Personnel Error Reduction Training !
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1 Enhanced Personnel Error Reduction training presented the elements important to I enhancing human performance, in an interactive training environment, utilizing a " case study" approach. The principles and techniques for preventing human errors were ;
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reinforced through discussions of lessons learned from in-house and industry experience.
.O The training was unique in that it pulls together operating experience and effective error reduction techniques from both the aerospace and nuclear industries. A video + from Delta's " Crew Resource Management Program", that looks at personnel error : during airline flight operations, was presented. Through examination of airline ; O ccident causes, the need for an environment that promotes open and honest vertical communications was emphasized. Prairie Island Nuclear Plant's " Aim for Zero" video was used to emphasize how written communications can set up (or trap) personnel , causing them to make errors. Self-checking techniques were reinforced by the students solving a puzzle and working in teams to analyze a Fermi 2 scram event. Philosophies ; and recommendations from SOER 92-01, " Reducing the Occurrence of Plant Events - ! O Through Improved Human Performance" were emphasized throughout the trainin , This training was completed in August 199 l t Training for new hires and contractors who arrived on site subsequent to completion of l the " Enhanced Personnel Error" training in August,1993; is being conducted in December,199 ; O !
! Future Personnel Error Reduction Training !
r , ! Enhancement of supervisory skills to establish an error free environment and other personnel l O error reduction principles have been selected as subjects to be addressed in future initial and ! continuing training programs. Personnel Error Reduction Initial and Continuing Training is ! intended to reinforce personnel error reduction concepts and addresses weak areas as j determined from the analysis of events and the review of personnel error data. A training ; lesson plan has been prepared and is in the review and approval cycle. Training will begin l O with the first re-qualification class which is scheduled for January,199 ; Supervisor and Work Observation Program j The Supervisor Observation portion of the program encompasses the selection, I O development, and observation processes needed to produce superior performing Maintenance and Modifications supervisors at Fermi 2. It emphasizes areas such as oversight, coaching, intervention, and improved field performance.
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- The Work Observation portion of the program outlines how to conduct performance : based field observation of a work group or first line supervisors at Fermi 2. It O establishes a systematic means to determine the adequacy of program implementation based on established acceptance criteria. Each supervisor is observed and evaluated by l second line and/or General Supervisors. The observation results are discussed with the l Organizational Unit Head as well as the observed supervisor. The objective is to ' improve the performance of the individual supervisor and thereby improve the collective performance of the entire organizatio .3 This program is presently being utilized by both the Maintenance and Modifications j organizations. Feedback from Maintenance has been positive and the program is being ; evaluated for extending to additional area , O Error Reduction Fundamentals , b Generic error reduction fundamentals are being incorporated into site training programs. As training materials are prepared or revised, Nuclear Training personnel , 'O re adding instruction (when appropriate) that emphasizes the use of self-checkin .2 The intent is to reinforce these techniques with plant personnel whenever possibl Emphasis is being placed on system interrelationships to ensure that consequences of actions are realized by individuals prior to task performance when manipulating , system components. (IN PROGRESS) O
. Personnel Error Reduction Campaign ! The Detroit Edison Industrial Safety Program has been very effective at maintaining
- O accident rates at levels below industrial averages. Since accidents are frequently due to i
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personnel errors of the same form, a personnel error reduction program, based on the key concepts of the Industrial Safety Program is being investigated, A personnel error reduction committee has been selected to prepare plans for a personnel error reduction t
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campaign. ( Targeti Implementation in the first quarter 1994)
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O The benefits of forming a standing committee, at the corporate level, to oversee a' Company wide initiative to reduce personnel errors is being evaluated. Power ' Generation, EM&D and Fermi would become charter members of such a committe ; The function of the committee would be similar to the Corporate Industrial Safety l Committee which has been very successful in reducing industrial safety accidents. If
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the evaluation results are favorable, a proposal for implementing a Corporate Personnel O- Error Reduction Committee will be submitted. (Target: Submit by First Quarter 1994)
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O Performance Monitoring O
' To increase overall awareness to the rate of personnel error, expanded performance measures and improvement goals will be establishe .
The following personnel error performance measures are planned: ; O O Personnel Errors Per Hours Worked : O Personnel Error trends by Organization O LERs and Notices of Violations Caused by Personnel Errors O Personnel Errors - Accumulated Mr To Date-O These personnel error performance measures will be reported on a periodic basis. It is , expected that a healthy, competitive environment will be created between organizational units by posting personnel ermr rates for each of the major organizations, (Target: Implement first quarter 1994) , The performance measure for Personnel Errors Per Hours Worked (Personnel Error O Rate) has tentatively been established as the [ number of personnel error related DERs x 10,000 hours] divided by [ person hours worked (overtime and straight time)]. For comparison, the " Personnel Error Rates (PER) for 1991,1992, and 1993 were determined to be:
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Year 1991* 1992* 1993 O P. .73 1.55 1.24 ,
* Refueling Outage year The improvement goal established for 1994 is to achieve a 20% reduction in the Personnel Ermr Rate for Nuclear Generation. (Target: Implement first quarter 1994)
O In addition, the performance measures for Personnel Errors Per Hours Worked will be calculated for each major site organization. The calculation used will be the same as above except that it will be based on the subject organizations personnel error and hours worked data. (Target: Implement first quarter 1994) l O Goals for monitoring personnel errors related to LERs and NOVs have been establishe The 1994 target is not to exceed a total of six LERs and NOVs related to personnel errors. A special award of significant value for all site personnel is being considered if zero LERs or NOVs related to personnel errors are achieved. (IN PROGRESS) JO l
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! Communications / Team Building ,
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.O Effectiveness of communicatioris and its role in achieving team success is recognized as a ,
dominant factor in improving human performance. Severalinitiatives have been implemented or are planned which are intended to instill communications effectiveness and ; team success concepts into the Fermi 2 culture. Following are some of the key initiatives being %plemente O PRIDE (People Really Involved Develop Excellence) - PRIDE is a viable program that functions in a manner similar to " Quality Circles" in -
- " Focus Groups." Employs groups within organizations and in some instances, inter- i LO organizational participation for the identification and resolution of problems affecting l work performance. PRIDE groups typically involve individuals from working through supervisory levels. This activity promotes communications and contributes to team ,
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' Dialogue Survey iO !
This initiative involves a survey instrument to help understand organizational strengths' } and weaknesses in areas such as: O organizational Climate f 0 Communications Flow iO O Decision Making Practice j
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., O Concerns for People O Team Building Survey results are then evaluated by participating work groups and organizations. Key
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10 issues are defined, action plans developed to address the issues with performance measures and goals; and progress toward improvement is monitored and fed back to - the participants. Effectiveness of improvement actions is also evaluated through i follow-up surveys and comparisons with earlier results. Participation in the initiative is ;
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expected to encourage communication and contribute to intra- and inter-organizational team buildin !
:O l This initiative was implemented starting at the Second Level Supervisor and up in 199 .;
it will be expanded to include all levels of the organization in 199 ;
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; AdditionalInitiatives
;O Other actions intended to ;mprove communications, team building, and our ability to focus on appropriate issues include: l
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O Plant problems and activities are reviewed each weekday by manager level ; personnel to provide oversight and coordination. The oversight and , coordination is provided by the Plant, Technical, and Assurance Managers, the j
.O Directors of QA and Training and a Licensing representative. The purpose is to ,
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ensure that the significant problems are being resolved and that site resources are coordinated and focuse !
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O The Operations, Maintenance, Technical Engineering, and Work Control Organizational Unit Heads review mutual activities on a weekly basis. The O purpose is to ensure that problems are being resolved and that coordination : problems between organizations are being resolve O Business Plan Performance Review meetings regarding important subjects t O O Plant Manager periodic meetings with representatives from all levels of ; organizations reporting to hi O Proposed Modifications Review Group (PMRG) that performs an inter-organizational review of proposed modifications.
!O Because of the significance of communications and team building to organizational performance, Fermi 2 will be pursuing other methods for achieving effective ~ communications and team success.
'O Heighten Individual Awareness of Personnel Errors Several methods are being used or will be developed to maintain a focus on personnel error reduction. Following are brief descriptions of the methods planned or currently implemente I
;O I " Innovations":
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" Innovations"is Detroit Edison's new employe suggestion program and is designed to reward employes for their ideas with points that can be cashed in for valuable
- merchandise. The Innovations program will include bonus rewards for ideas to reduce
- personnel errors.
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! Newsletter: ;o The " Operating Experience Newsletter", highlighting the causes of personnel errors at Fermi 2 and other nuclear power stations is being sent quarterly to all site personne The news _ letter heightens the awareness of the seriousness of personnel errors. The-event information is taken from Nuclear Network and site specific report .3 Moderator:
O Special editions of the Fermi 2 newspaper, "The Moderator", are issued to heighten awarcness of specific events and their causes. Additionally, articles by senior management discussing human performance and error reduction topics periodically : appear in the " Moderator".
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: .4 Schedule Adherence Video Tape
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The Senior Vice President of Nuclear Generation presents Senior Management's expectations for schedule adherence in this video message. It stresses the need to work through emerging problems instead of around them to satisfy the schedul :O
- Fission Vision l
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- The site closed circuit television system, " Fission Vision", is used regularly to promote i j the reduction of Personnel Error , i .
- O Training Program Enhancement:
A representative from Nuclear Training attends all lessons learned meetings that are j held with the Plant Manager to ascertain if there are any concerns related to performance problems that need to be addressed in the training progra ) i I 'O '
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Questions regarding Personnel Error Reduction. should be directed to the Supervisor, f Safety Engineering (64218). ,
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_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - _ _ - _ _ _ _ _ - _ . O I EQUIPMENT IMPROVEMENTS O The resolution of equipment concerns and recurring problems is also a major element of the Corrective Action improvement effort. Fermi Management Directive FMD RE1 specifies and _ requires implementation of a performance problem resolution process to describe, identify the O basis for, track, and report progress in resolving hardware performance concerns or degraded condition FMD RE1 states that the scope of these performance concerns should include those discovered through routine and diagnostic assessments. Other hardware performance concerns, regardless of discovery method, may be addressed by this process if they have the potential to O significantly affect system or component availability or reliability, or consume excessive maintenance resource The FMD further states that periodic reviews of problem resolution progress, corrective action timeliness, and effectiveness shall be performed and documented. Concerns or issues requiring increased management attention shall be reported to the appropriate organizational O unit head . Equipment Concerns / Technical issues Reports i o To achieve the objectives of FMD RE1, an Equipment Concerns Report and a Technical Issues Report have been developed. The Equipment Concerns Report is a combined list of
" Equipment Concerns" and " Plant Recurring Problems" that is published weekly by the Inservice Inspection / Performance Evaluation Group. The Technical Issues Report, a monthly report also issued by the Inservice Inspection /III-7 Performance Evaluation Group,is a O summary of significant engineering, licensing, and performance issues that the Organization is pursuing. The TechnicalIssues Report dedicates a separate section to the ten most significant hardware performance issues. This treatment assures all organizations focus on the highest priority problems for timely resolutio O Equipment Concerns / Recurring Problem Review Board An Equipment Concerns / Recurring Problem " Review Board" has been established. The Review Board is responsible for reviewing the Equipment Concerns Report on a monthly O
basis to assure actions being taken to address problems are timely with respect to the O IV-1 .
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, ? s i significance of the issue, that problems are prioritized correctly, that actions scheduled are i being executed on time, and that resolution progress is acceptable with respect to the O significance of the individual issue. Members of the review board are the General Supervisor, l ISI/ PEP (Chairman), Operations, Maintenance and Technical Superintendents and the Supervisor Mechanical Systems group of Plant Engineer"g.
I ! Predictive Monitoring Prograrn .O ,
l The Predictive Maintenance Program of the Maintenance and Technical Engineering ! organizations is used to identify equipment performance problems through trending of i equipment performance data and diagnostic testing. When degrading trends or test results 3 indicate a problem, appropriate personnel are notified, a work request or supp'emental
- 0 monitoring is initiated, and the problem is considered for inclusion in the Equipment
! Concerns Repor . Component Experts 3 Personnel with specialized technical skills or component knowledge are a valuable asset to the plant. These individuals can make substantial contributions to the resolution of problem .2 The Organization is in the process of identifying in-house expertise as well as visiting other plants to determine what type and level of component expertise the staff should possess. This process will be complete by the Spring of 1994. An implementation schedule for additional tra mg or identification of outside resources will then be develope The overall objectives are to identify and document equipment problems, establish priorities for the concerns, and systematically resolve the concerns according to the established priorit Questions regarding Equippent improvements dhould be directed to the C eral Svugrvisor, l'il/ PEP (M848L
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; PROCEDURE RE-ENGINEERING O
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Procedures are an important element in assuring the successful operation of Fermi 2. A Procedure Improvement Team has been established and has the three following objectives: O Changes to the Procedure Hierarchy The Administrative Procedures hierarchy will be restructured in a fashion designed ar und the needs of the end-user. The proposed hierarchy is limited to three tiers: a O policy statement, conduct manuals, and technical procedure .2 The policy statement will house a brief discussion of the programs to be implemented in the " Conduct Manuals", as well as the Senior vice-president's strategies and pohcies ; for operating the plan O The conduct manuals will be modeled on the best attributes of the current Conduct of Operations, Training, and Radiation Protection manuals as well as information and ideas identified through visiting other utilities who have successful procedure programs. The conduct manuals will cover twelve topical areas. ney are: O O Operations O Maintenance O Engineering Support O Radiation Protection O Emergency Preparedness 0 Training l 0 Quality Assurance O Work Control ) O Materials Management O Licensing and Safety Engineering l O O General Administration O Chemistry and Environmental Monitoring j Chemistry and Environmental Monitoring has been selected as the pilot rnanual and is expected to be in draft fann by December 199 .5 Specific goals for upgrading technical procedures will be set in the future. At a minimum, the team will view the number and application of technical procedures, the level of detail, and the utihty of the procedur O l
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, Revise The Current Revision Control Process !
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A The team recommends re-engineering the revision control process to streamline the ;
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review and approval process and to limit reviews to those necessar Recommendations include:
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A Pproval requirements tied to degree of complexit I O O Cosmetic changes (publication errors, date on form, titles of organizations,
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production errors, obvious typos, etc.) may be made with the approval of first line supervisors or the Supervisor,Information & Procedures. (This requires a Technical Specification change).
O r O Allowance of unique event exceptions for review and approval. (Single review and approval of multiple procedures). .l 0 On-line procedure change control and DER processes (including commitment changes).
O All procedures available on-line to users with a text search software package to i
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facilitate research of procedures. This will reduce man-hours for modification imr aementation and improve product qualit O Review and approval by OSRO only for changes that require a safety evaluatio ! O (Requires a Technical Specification change). !
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O Define when Preliminary Evaluations (pes) are not required for procedure changes so that pes are performed when necessary rather than for all revision ! t i O The team has developed a method for embedding commitment detail within the text of ; the procedure. This will assist procedure authors in commitment reviews as well as highlight portions of procedures that are of particular importance. Initial implementation of this feature will be in the pilot conduct manua m
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- management of the procedures. Information system needs defined by the team to date are as *
follows: O Must capture program bases, address RACTS and IDT commitments, and provide ,O-
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cross-reference at the subsection or action statement of the affected procedur ; O Must include common library services (Text search and retrieval, Document Manager) for the procedure t i O O Requirements must be captured in an on-line relational data system, linked to the hierarchy in a statement-specific manne ' O A network based forms package with work flow routing (on-line procedure review and j approval process).
'O O On-line procedure change control and DER processes (including commitment changes).
, O All procedures available on-line to users with a text search software package to facilitate research of procedures. This will reduce man-hours for modification implementation and improve product qualit ' O
0 Capability to print controlled work copies of procedures on-lin l . e I The expectation for this ;cocedure initiative is to reduce the number of procedure tiers to
- o three. This consolidation will reduce the amount ofinformation that must be controlled and ,
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- provide more information in one location. This is expected to reduce the potential.for personnel errors related to procedure use. A second expectation is to reduce the .
administrative burden for review and approval requirements and place them at the proper j organizational levels.
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- Supervisor, information & Procedures Management 44058). ,
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i VI. SUMMARY 'O
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CORRECTIVE ACTION PROGRAM Improvements have been implemented or are planned for the resolution of the Corrective Action Program concern Performance measures have been established or are planned to monitor the effectiveness of i these improvements. When sufficient baseline data becomes available, quantitative goals will O be established for the performance measure _ l
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PERSONNEL ERROR REDUCTION i O t Several initiatives have been implemented or are planned to reduce the personnel error rat , Performance measures have been established and more are planned to increase the overall . awareness of the personnel error rate and to monitor the effectiveness of the improvement ; i initiative ; O EQUIPMENT IMPROVEMENTS .
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An Equipment Concerns initiative is in place to prioritize and resolve equipment problem i Additionally, an initiative is planned to establish a resource of " component experts". The 0 expectation is that these initiatives will reduce the number of equipment concerns and improve plant reliabilit I
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PROCEDURE RE-ENGINEERING !
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A procedure re-engineering initiative is in progress to reduce the number of procedure tiers, to consolidate information , and reduce the administrative burden in the procedure proces t a
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Once fully implemented, it is believed that the above improvements will re-establish the
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Month PER/ MONTH PER/QTR Jan Feb 1.26 Mar 1.53 1.36 Apr 2.14 May 1.35 Jun 1.02 Jul 0.83 Aug 1.12 Sep 1.06 1 Oct 0.82 l
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- DER Cause Trends , l 100-- Goal: Improving Trend ! 80-- 1 I I I 4th Qtr 1992 1st Qtr 1993 2nd Qtr 1993 3rd Qtr 1993
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Description: Trend Personnel Error Decreased Document Deficiencies increased i Hardware Deficiencies increased
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NOTE - Effective Corrective Action is defined as the number of YTD Corrective Actions found effective divided by the number of YTD Corrective Actions audited Month Number Number Percent YTD Reviewed Accepted Accepted to YTD Reviewed Jan 10 6 60 Feb 10 7 65 Mar 15 8 60 Apr 20 19 73 May Jun Jul Aug Sep Oct Nov Dec
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