ML040150395
| ML040150395 | |
| Person / Time | |
|---|---|
| Site: | Davis Besse  |
| Issue date: | 01/15/2004 |
| From: | - No Known Affiliation |
| To: | Office of Nuclear Reactor Regulation |
| SHea J, 415-1388, NRR/DLPM | |
| References | |
| Download: ML040150395 (84) | |
Text
Open Emails List From DB Communications Matrix Dated 01/10/2004 This document contains a list of open emails and the emails themselves, following the order of the list, that remain on the Communication Matrix.
Paul Blanch Emails:
1.) FW:[DBRVH_LTBL_II] Re: Davis-Besse Update 06/08/03. Requests Grobe confirm statement that Billie Garde asked for 2.) No more requirement to investigate Davis Besse 3.) Rods out during cooldown at Davis Besse 4.) Questions about Commission Meeting 5.) Issues to be resolved in order for Davis-Besse to restart - why was it removed from monthly 6.) Preservation of evidence 7.) Davis Besse LER 2003-010-00 8.) RE: Davis Besse LER 2003-010-00 David Lochbaum Emails:
1.) Davis-Besse / South Texas Project : Same Ol Song 2.) Re: Request for document Tom Gurdziel Emails:
1.) Davis-Besse Valve Position 2.) Davis-Besse LER 2003-009 3.) 10/21/03 Davis-Besse HPI Pump meeting slides 4.) First Energy Serial Number 2973, dated July 30, 2003 5.) NRC Special Inspection of Reactor Coolant System Leak Test 6.) The Journal News 12-24-03 article by Roger Witherspoon
7.) LER 03-010-00, Davis Besse 3rd Party Emails:
1.) For you post panel 1 October 2003 consideration 2.) Fw: Please keep in mind....
3.) Davis-Besse-Donna letter 4.) Davis-Besse nuclear reactor restarting 5.) Fwd: Lingering safety issues are snag at Davis-Besse 6.) Comment/Question 7.) Re: lasting culture change vs. safety environment change 8.) Response from "Contact the Web Site Staff" 9.) Is DB Culture Adequate for DB Restart? What is the Question to Ask?
10.) Followup 11.) Davis-Besse Question -Riccios two questions 12.) telephone call 13.) Davis Besse facility 14.) Island Evacuations 15.) A question for you 16.) Ltr re: OMA@Davis-Besse Actual Open Emails Paul Blanch Emails:
From:
"Paul Blanch" <pmblanch@attbi.com>
To:
<JAG@nrc.gov>
Date:
6/14/03 9:39AM
Subject:
FW: [DBRVH_LTBL_II] Re: Davis-Besse Update 06-08-03
Jack:
I thought you should be aware of these comments. Is there any truth in the statement Billie made asking for blood? I am getting calls from people afraid to raise issues at Davis Besse. I even get calls from some of the people working in the Employee Concerns Program. What should I tell these people? What is being done about the chilled environment created by Andrews termination?
Paul M. Blanch 135 Hyde Rd.
West Hartford, CT 06117 Cell 860-881-6011 Office 860-236-0326 FAX 801-991-9562
Original Message-----
From: Bill Corcoran [1]
Sent: Saturday, June 14, 2003 7:01 AM To: larry.r.foulke@verizon.net
Subject:
[DBRVH_LTBL_II] Re: Davis-Besse Update 06-08-03
- Larry, Thanks for your thoughtful reply.
I am keeping an open mind, since we are not privy to the truth, but only to the interpretations of it that we have been given.
OBTW: I am amazed that Jack Grobe did not hold a press conference and announce that he did not ask for blood. Perhaps he did ask for blood.
Even so, there must have been people in positions of influence at Davis-Besse who knew that targeting Andrew Siemaszko was a high-risk/low return venture. There must have been others that knew that targeting Andrew would create a chilling effect regardless of Andrews guilt or innocence. The bad news from below that would be cut off by targeting Andrew would not justify the commitment to accountability that targeting him would support. The whole outcome to date of targeting Andrew was foreseeable. Why did the knowledgeable people not step forward with the voice of reason? Was the environment already fatally chilled? If any of those knowledgeable people did forward, why were they not heard? Was there a determined mindset that couldnt be unlocked? One of the human performance experts whose ideas permeate INPO publications warns against "sharp end focus", i.e., blaming what goes wrong on the actions of an individual. This world-respected researcher, James Reason, advocates identifying and correcting "latent organizational weaknesses. "Im amazed that INPO did not get involved and provide advice counter to that of Mr. Grobe, if there was such advice. Perhaps the truth will come out.
Best Regards, Bill Corcoran W. R. Corcoran, Ph.D., P.E.
Nuclear Safety Review Concepts 21 Broadleaf Circle Windsor, CT 06095-1634 860-285-8779 Fax: 702-993-2408 Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.
Original Message -----
From: Larry Foulke <mailto:vze284sx@verizon.net>
To: Bill <mailto:corcoran.nsrc@prodigy.net> Corcoran Sent: Friday, June 13, 2003 11:59 PM
Subject:
Re: Davis-Besse Update 06-08-03 Bill, before I file your message, I had another thought after I printed out the Travers letter and read it more carefully. Its a shame that NRC has so much influence with the licensee that when they suggest they want to see some action regarding personnel the utility appears to submit to doing things with their people that seems regrettable. NRC has to be more careful in suggesting corrective actions and the licensee must not be so ready to hand over a "culprit."
Larry Foulke Bill Corcoran wrote:
Please scroll down to read a letter to Bill Travers from an attorney representing one of the players in the tragedy of Davis-Besse.
Would you be so kind as to let me know your opinion of the lessons to be learned without regard to who has the better case?
One of the lessons to be learned from my point of view is that system engineers need to be aware of the requirement to go as high as it takes (10 CFR 50, Appendix B, Criterion I, Sentence 9).
How many nuclear workers get trained in that requirement?
Another of the lessons to be learned is the old researchers saw, "The absence of evidence is not evidence of absence."
FENOC should have QAd its letter to the NRC requesting the delay.
These are small lessons to be learned. What are the big ones?
Best Regards, Bill Corcoran W. R. Corcoran, Ph.D., P.E.
Nuclear Safety Review Concepts 21 Broadleaf Circle
Windsor, CT 06095-1634 860-285-8779 Fax: 702-993-2408 Mission: Saving lives, pain, assets, and careers through thoughtful inquiry.
Yahoo! Groups Sponsor CC:
"DAV_ll" <DBRVH_LTBL_II@yahoogroups.com>
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FW: [DBRVH_LTBL_II] Re: Davis-Besse Update 06-08-03 Creation Date:
6/14/03 9:38AM From:
"Paul Blanch" <pmblanch@attbi.com>
Created By:
pmblanch@attbi.com Recipients nrc.gov ch_po.CH_DO JAG (John Grobe) yahoogroups.com DBRVH_LTBL_II CC (DAV_ll)
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From:
"Paul Blanch" <pmblanch@comcast.net>
To:
<jag@nrc.gov>
Date:
Thu, Oct 16, 2003 6:42 PM
Subject:
No more requirement to investigate Davis Besse Mr. Grobe:
Could you please explain these apparent inconsistencies between the recent article and the statements in NRC monthly update? See below. I am aware of at least 2 investigations that involve alleged wrongdoing by management personnel at Davis Besse.
FirstEnergy says D-B on track NRC not committed to November restart By JENNIFER FUNK Staff writer AKRON -- FirstEnergy officials told financial analysts Wednesday the Davis-Besse Nuclear Power Station remains on track to be ready for restart by mid to late November.
Thats despite several inspections and modifications that still need to be completed at the plant
-- as well as more training on providing a safety-conscious environment there.
Schedule talk dominated the teleconference with analysts Wednesday, however. A top nuclear senior official said, too, that right now there is nothing to indicate a delay between when the plant will be ready for restart and when the Nuclear Regulatory Commission will give the go-ahead.
"We havent identified any at this point," said Gary Leidich, president of FirstEnergys nuclear division, responding to a question after a teleconference presentation. "Do I expect some?
There very well may be some, but we dont have any on our radar screen right now."
The plant has been off-line since February 2002, and staff there have been working around the clock since they found the largest amount of corrosion ever found on a U.S. reactor head. Since then, multiple other issues have been identified with physical faults at the nuclear station, as well as problems with the safety culture.
NRC officials have pegged a lack of questioning attitude among workers and a focus on production over safety as reasons for the problems.
Meanwhile, NRC Region III spokesman Jan Strasma said Wednesday it is still unclear what the timeline would be between FirstEnergys declaration of ready for restart and the NRCs approval.
"But there is a deliberation period there," he added. "Assuming all our inspections are done, there will be a meeting in which FirstEnergy will discuss their readiness for restart.
"The panel will consider all our inspection findings and what they (FirstEnergy) tell us, and make a recommendation to the regional administrator."
Once the regional administrator, who consults with NRC senior management, makes a decision, the plant may restart.
"Certainly theres some number of days in there," Strasma said.
There are still several inspections ongoing and at least three inspections that have not yet begun because plant officials arent ready yet, he added.
During the teleconference, Leidich predicted that three ongoing investigations -- from the NRCs Office of Inspector General, the Office of Investigation and the U.S. General Accounting Office
-- will not hinder restart efforts.
Strasma confirmed that those investigations will continue and the plant does not need them to be completed prior to restart.
Leidich updated analysts during the half-hour long teleconference on the status of a pressure test conducted earlier in the month, during which no leakage was found at the bottom of the reactor head.
He quickly addressed problems with operators during the test, which he called "a couple of human performance issues."
Operators made a handful of mistakes during the test that resulted in a seven-day process taking about eight-and-a-half days.
"We do feel we appropriately addressed those and have improvements in place that will not affect our schedule going forward," Leidich said.
Those errors, however, worried NRC officials who are watching the plant closely not only for progress on correcting physical problems but for sharpening the staffs efforts.
Leidich said the organization has put in place more operating and engineering staff training, as well as updates to procedures and additional oversight.
Meanwhile, U.S. Rep. Dennis Kucinich -- also making a bid for the Democratic presidency ticket
-- asked the NRCs top management to reconsider a denial of his petition to pull Davis-Besses operating license, according to the Plain Dealer this morning.
Kucinich cited flaws in the NRCs own review process and asked that the license be pulled to force a complete inspection of every system in the plant.
From the NRC monthly update July 2003 Issues to be resolved in order for Davis-Besse to restart The NRC Oversight Panel will only consider recommending that Davis-Besse resume operations when the plant has demonstrated its readiness to operate safely. Key elements will include: Davis-Besse management and personnel properly understand the technical, organizational, programmatic and human performance problems that led to the extensive degradation of the plants reactor vessel head. Davis-Besse enhances programs for operating the plant safely, detecting and correcting problems, controlling boric acid corrosion, and is fostering a more safety-conscious environment among plant managers and workers.
Davis-Besse improves the performance standards of its managers and workers, including their "ownership" of the quality of work products and the safety focus of decision-making. The replacement of the vessel head is technically sound and all reactor components are inspected, repaired as necessary, and demonstrated to be ready for safe operation. Plant safety systems inside and outside containment are inspected, repaired as necessary, and have been confirmed to be ready to resume safe operation of the plant. Plant operators demonstrate appropriate safety focus and readiness to restart the plant.
NRC Update: Davis-Besse Reactor Vessel Head Damage June 2003 - Page 8
. Any organizational or human performance issues resulting from the ongoing investigation conducted by the NRCs Office of Investigations are addressed.
. All licensing issues that have arisen as a result of the reactor head replacement have been resolved.
. Resolution of radiation protection issues associated with the radiation exposure to workers during steam generator work and the particle contamination found in offsite locations.
. Modification of the strainer system for the containment sump, which would be the source of cooling water for recirculation in the event of a loss-of-coolant accident.
Paul M. Blanch Energy Consultant 135 Hyde Rd.
West Hartford CT 06117 Home 860-236-0326 Fax 801-991-9562 Cell 860-881-6011 CC:
"DAV_ll" <DBRVH_LTBL_II@yahoogroups.com>
Mail Envelope Properties (3F8F1EAA.458 : 4 : 29784)
Subject:
No more requirement to investigate Davis Besse Creation Date:
Thu, Oct 16, 2003 6:41 PM From:
"Paul Blanch" <pmblanch@comcast.net>
Created By:
pmblanch@comcast.net Recipients nrc.gov ch_po.CH_DO JAG (John Grobe) yahoogroups.com DBRVH_LTBL_II CC (DAV_ll)
Post Office Route ch_po.CH_DO nrc.gov yahoogroups.com Files Size Date & Time MESSAGE 7067 Thursday, October 16, 2003 6:41 PM Part.001 14859 Mime.822 24548 Options Expiration Date:
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"Paul Blanch" <pmblanch@comcast.net>
To:
"Andrea Kock" <ALK@nrc.gov>
Date:
Mon, Oct 6, 2003 4:01 PM
Subject:
RE: Allegation -- Rods out during cooldown at Davis Besse Andrea:
It is fine with me if you provide a response that addresses all the issues cited in the e-mail traffic. It should be very interesting reading and all of us should learn something. Allegation is withdrawn assuming that all questions will be addressed in the inspection report.
I know that many NRC people monitor the YAHOO DB (DBRVH_LTBL_II@yahoogroups.com) and it may be helpful if when these types of questions come up, the NRC simply responds to the YAHOO site.
Thanks for your prompt response.
Paul M. Blanch Energy Consultant 135 Hyde Rd.
West Hartford CT 06117 Home 860-236-0326 Fax 801-991-9562 Cell 860-881-6011
Original Message-----
From: Andrea Kock [2]
Sent: Monday, October 06, 2003 3:34 PM To: pmblanch@comcast.net Cc: Christine Lipa; James Heller; Monte Phillips
Subject:
Re: Allegation -- Rods out during cooldown at Davis Besse Paul:
I have checked with the RIII staff on the issue. Apparently we know all about this and have evaluated the licensees compliance with the Technical Specifications. The staff have told me that an inspection report will be issued within the next 30 days, and they will send you a copy.
What I have been told is that: (1) the NRC had already determined that the licensee complied with its procedures (which specify that the safety rods be pulled during the cooldown process),;
and (2) NRC has reviewed the procedure and it complies with the licensees Technical Specifications. The complete details will be in the inspection report.
Since we already knew about this and actually have a complete answer coming to you, I dont plan on entering this into our allegation system. If you need further details, let me know and I will get you in touch with the inspectors involved who have more information. Thanks for the information.
Andrea Kock USNRC RIII Allegation Coordinator
>>> "Paul Blanch" 10/06/03 12:45PM >>>
Greg:
I am reluctantly submitting this as an allegation to assure that a written response is provided to address the many questions as to why the control rods were out of the core during the recent cooldown at Davis Besse.
For more information see the enclosed series of e-mails.
The allegation is as follows:
FENOC stated that some of the rods were withdrawn simply because its never good policy having them all in at the same time while youre cooling down (if you can avoid it), just in case you need a little extra something to fall back on (i.e. if something were to happen, you wouldnt have anymore rods to insert if theyre all inserted when you start.)
If you follow the e-mail traffic enclosed, it appears that by having the rods latched and withdrawn, Davis Besse appears to have been in violation of the plants license and its Technical Specifications.
No confidentiality is requested.
Paul M. Blanch Energy Consultant 135 Hyde Rd.
West Hartford CT 06117 Home 860-236-0326 Fax 801-991-9562 Cell 860-881-6011 1122893,787506064,2>
3,787506064,2> Add this card to your address book
Original Message-----
From: Paul Blanch [3]
Sent: Monday, October 06, 2003 9:46 AM To: DAV_ll Cc: jag@nrc.gov; cal@nrc.gov
Subject:
[DBRVH_LTBL_II] A few thoughts on Donnas post The following is from an associate who prefers to remain anonymous.
A few thoughts on Donnas post.
Donna should state what source she is quoting - is this a tech spec requirement or is this from a plant operating procedure?
What are the bases for this requirement? If it is a tech spec, it will have a tech spec bases, which will be documented. If it is a plant operating procedure, it would be important to know under what conditions it applies (probably while conducting a normal plant shutdown / cooldown
- as she implies) - which of course would not apply to Davis Besse which was doing a mode 5-4-3 change. I would certainly expect that the RCS must have been borated to a cold shutdown condition prior to refueling the reactor in preparation to the 7-day pressure test.
Of course SOER 94-2 is not available to us mere mortals as it is an INPO proprietary document. So we dont officially know what it says.
My best guess is that this was a one-time change to the normal practice for the pressure test -
just as they had to obtain a one-time exemption from tech specs that required the HPI system to be operable. My guess is that their logic went along the lines of:
HPI pumps were installed and borated water sources were lined up - but officially they were "inoperable" due to the issues involved with the debris clogging the pumps.
The reactor was borated to a cold shutdown condition even with group I safety rods fully withdrawn. They had enough boric acid in the RCS to keep the reactor shutdown even it was cooled down to cold shutdown.
They withdrew group I safety rods to provide a counter to a boron dilution accident - where the boric acid concentration was slowly diluted over a period of time by the introduction of non-borated water. They would use these rods to "provide additional shutdown margin" if a boric acid dilution event removed the pre-existing shutdown margin unexpectedly. (This
explanation also could get into the alternative explanation that I offered about old tech specs and the definition of shutdown margin. This is a complex case that would have to be answered with an analysis of the ECP equations - so I really cant take the time to lay it all out in an email.)
I doubt very seriously that whatever their reason - they understood the real physics of the situation. I suspect (and this is a real reach) that they wanted to demonstrate that they had "compensatory actions" in place to justify the one-time tech spec exemption to not enter mode 3 without an operable HPI system. This was a "compensatory action" that sounded pretty good on paper but really did not provide much real safety.
The only benefit of rod withdrawal is that if a dilution event were to have occurred, they would detect the neutron level increase (due to subcritical multiplication) sooner and have a ready response to counter that increase in scramming the safety rods. After all, if their borated water source was truly "inoperable", they could not take credit for emergency boration to counter a dilution event - even though it would have worked just fine because there would be no debris in the bearing water from a boron dilution event.
The logic seems like a real reach to me. "Lets put the core closer to criticality so we can detect the problem sooner and have a means to take compensatory action." Seems like you are relying on the safety rod scram to work and it would be better to just leave the rods inserted and deal with identifying the dilution event when it first occurs and stopping the dilution. You would be further away from criticality at all periods of time - without relying on a scram of the safety rods.
One additional thought is that the purpose of the test was to determine if there was leakage from the bottom penetrations. This was to be determined by visual observation of boron deposits at the bottom headand around the penetrations. If there was a minimal amount of soluble boron in the coolant, the likelihood of detecting any leakage would certainly be minimized.
Original Message-----
From: Christiansen, Donna M. [4]
Sent: Saturday, October 04, 2003 11:16 PM To: DBRVH_LTBL_II@yahoogroups.com
Subject:
RE: [DBRVH_LTBL_II] Credit where credit is not due Actually, some plants require require shutdown banks be withdrawn prior to commencing a cool down down if the plant does not meet cold shutdown boron requirements:
The shutdown rod banks must be at the fully withdrawn position whenever reactivity is being changed by boron dilution or xenon concentration changes, RCS temperature changes or control bank rod movement unless:
- b. The RCS has been borated to the hot, xenon-free concentration AND is being maintained at no-load Tavg.
SOER 94-2 also discusses Boron Dilution Events in PWRs.
Donna
Original Message-----
From: Paul Blanch [5]
Sent: Saturday, October 04, 2003 08:49 To: Dave Lochbaum Cc: DAV_ll; jag@nrc.gov; cal@nrc.gov
Subject:
[DBRVH_LTBL_II] Credit where credit is not due Dave:
Frank gives you credit for this analysis.
Like Frank said, I have never heard of an intentional cooldown with rods withdrawn.
Note the following words from a very reliable source during an interview with FENOC:
"FENOC stated that some of the rods were withdrawn simply because its never good policy having them all in at the same time while youre cooling down (if you can avoid it), just in case you need a little extra something to fall back on (i.e. if something were to happen, you wouldnt have anymore rods to insert if theyre all inserted when you start)...."
f>
This is a very perverted logic! Maybe the next cooldown they will have all the rods out!
Original Message-----
From: Frank Buckingham [6]
Sent: Saturday, October 04, 2003 12:14 AM To: DBRVH_LTBL_II@yahoogroups.com
Subject:
Re: [DBRVH_LTBL_II] Thoughts on why DB may have had the rods out If DB has an old shutdown margin tech spec as Dave described and they withdrew rods to gain "bogus" SDM then their safety culture has a long way to go. I am also curious why they were cooling down with the rods out, and if they had an RPS actuation in that state than an LER is required for a reactor trip..
Paul Blanch wrote:
- Paul,
I am not familiar with the concept of withdrawing group I safety rods to have "a little extra something to fall back on". But then again, B&W reactors are sometimes a little different. I offer two possible explanations, neither of which are the "right way to fly".
- 1. It is possible that their reasoning considers the availability of a step drop in negative reactivity (caused from tripping the rods) might offset any rapid increase caused by some other problem.
As you may recall, the negative reactivity term comes from two sources - a step drop due solely to the insertion speed of the rods - and a continuous linear decrease caused by the lowering position. They may be thinking that the step drop could be used to counteract any step jump in neutron flux caused by a cold-water additional accident or other similar rapid increase in reactivity. I have never heard of anyone using this approach before.
- 2. There is another (more likely) perspective that is possible. At some older plants, the definition of "shutdown margin" is such that once the rods are fully inserted into the core, they no longer "count" toward shutdown margin (SDM). The amount of shutdown margin is equal to the negative reactivity that remains available to be inserted from the current condition. Rods already inserted are not available to be inserted. Some plants have mode dependent tech spec requirements to have specified amounts of SDM in each operating mode. They normally achieve this requirement in mode 3 by crediting their borated water source. If the source of borated water if inoperable, then they could always "gain back" SDM by withdrawing group I safety rods providing they have enough boric acid in the coolant to maintain subcriticality. They would have to be very careful to ensure that the RPS was fully operable and that the withdrawal was closely monitored for approach to criticality. This would not really improve anything - but it would meet the definition of tech spec shutdown margin and solve the problem in a legalistic sense.
This old definition of SDM was a problem in some of the older, non-standard tech specs back in the old days. Note that this is no longer the "standard definition" of SDM. Today, the "Improved Tech Specs" (ITS) definition of shutdown margin reads:
SHUTDOWN MARGIN (SDM) SDM shall be the instantaneous amount of reactivity by which the reactor is subcritical or would be subcritical from its present condition assuming:
- a. All rod cluster control assemblies (RCCAs) are fully inserted except for the single RCCA of highest reactivity worth, which is assumed to be fully withdrawn. With any RCCA not capable of being fully inserted, the reactivity worth of the RCCA must be accounted for in the determination of SDM; and
- b. In MODES 1 and 2, the fuel and moderator temperatures are changed to the nominal zero power design level.
Davis Besse has not shifted to ITS - they had it in their list of things to get done - like the access ports on the reactor vessel head support structure. Their older tech specs may require
the rods to be "out" in order to "count" toward SDM. This seems pretty counter-intuitive from a safety perspective and not a very smart way to operate these days. But - who knows for sure without hearing the whole story.
Just a guess.
1122893,787506064,2>
3,787506064,2> Add this card to your address book Paul M. Blanch Energy Consultant 135 Hyde Rd.
West Hartford CT 06117 Home 860-236-0326 Fax 801-991-9562 Cell 860-881-6011 CC:
"Christine Lipa" <CAL@nrc.gov>, "James Heller" <JKH@nrc.gov>, "Monte Phillips"
<MPP@nrc.gov>, "DAV_ll" <DBRVH_LTBL_II@yahoogroups.com>, "Gregory Cwalina"
<GCC@nrc.gov>
Mail Envelope Properties (3F81C9F3.544 : 20 : 42308)
Subject:
RE: Allegation -- Rods out during cooldown at Davis Besse Creation Date:
Mon, Oct 6, 2003 4:00 PM From:
"Paul Blanch" <pmblanch@comcast.net>
Created By:
pmblanch@comcast.net Recipients nrc.gov ch_po.CH_DO MPP CC (Monte Phillips)
JKH CC (James Heller)
ALK (Andrea Kock) nrc.gov
owf2_po.OWFN_DO GCC CC (Gregory Cwalina) yahoogroups.com DBRVH_LTBL_II CC (DAV_ll)
Post Office Route ch_po.CH_DO nrc.gov owf2_po.OWFN_DO nrc.gov yahoogroups.com Files Size Date & Time MESSAGE 15148 Monday, October 6, 2003 4:00 PM Part.001 22740 Mime.822 41524 Options Expiration Date:
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Date:
Mon, Feb 10, 2003 3:17 PM
Subject:
Questions about Commission meeting John Grobe John Zwolinski USNRC Last week, I briefly watched the Commission meeting on the Davis Besse SCWE issues.
There was at least one item that somewhat bothered me and that was the FENOC response to a question asked by Commissioner McGaffigan The following is from the actual transcript of the meeting.
COMMISSIONER McGAFFIGAN: She (Dr. Haber) has worked at other nuclear facilities and has a methodology that she is going to use at your facility that she has tried out in other places?
MR. MYERS: Thats correct. Her methodology is a proven, we think, methodology. Its a five-step process. I believe its called convergent validity. And what you do is theres -- you go
through like interviews, you go through questioning, you set in meeting, and you look for common attributes. And when you find those common attributes, you have convergence of an issue. So the model that she uses is the convergent validity approach.
COMMISSIONER McGAFFIGAN: And shes going to interview about 10 percent of your workforce. Shes going to have surveys with the rest of the workforce. I think somebody -- and she has -- she has colors. Everybody has colors -- red, yellow, green, presumably, or some variation thereof.
If she has red findings, youre going to get her report in the March timeframe. How will you deal with that? You know, its a hypothetical, but how do you -- it is conceivable that she will find some real problems. That was the case at Millstone. We had a group there Little Harbor, that, you know, had some things in the red initially, and they were not red by the time restart occurred. So -
MR. MYERS: Well, you know, actually her findings -- thats -- the color code system is our color code system. And her findings -- shell provide findings or issues and areas, and that may cause us to take one of the attributes, for instance in maintenance or operations or chemistry or something, and term one of those attributes red or yellow. Now, our restart -- our process, you know, if you have red findings it requires immediate management attention with a plan to go look at that issue and try to fix it. So no, I wouldnt anticipate that we would start up with any areas that are red.
COMMISSIONER McGAFFIGAN: How do you prevent a focus on getting things done dominating safety? What incentives -- I mean, there has been concern in the past I know that people felt they had to get something done and didnt feel that they were being given the time to do it. Now, my advice to you is to not do that because every one of these plants that have had problems, in our experience, any sort of schedule has proven to be optimistic. But, what incentives are you putting in place, so that people do not feel overly pressed to get a particular job done that particular day, to check off an item on a checklist?
MR. MYERS: You know, there is two or three things. Bob talked about our incentive programs that weve changed already. If you go look at -- were stressing in our 4Cs meetings, which Ive now met with over 500 employees at the plant. And I meet with those employees for about two hours at a time, and we stress consistently, you know, just stop -- you know, really, the fastest way to get the job done and the best way to get the job done is do it correct the first time. And if it takes longer, then one of the attributes in our management model that we look at is the resources. The resources is the right people, right amount of time, and the right equipment.
You know? Youve got to have all of those things to get the job done right. And, you know, recently, you know, weve been looking at fuel load. And as a management team, one of the things we have to do consistently is demonstrate our ability to stop and take corrective actions.
And, you know, we made a decision to go and fix several things prior to this fuel load. We think there was defense in depth by having two trains of decay heat, so we waited to get two trains of decay heat.
Mr. Myers response was that Dr. Haber has conducted similar surveys with the clear implication that these surveys were conducted in the US. In my view, the response to the Commissioners, you know, did not appear to be complete and/or accurate. I am aware that Dr.
Haber has conducted some research on safety culture but I am unable to find any public or ADAMS documents reporting on her surveys.
In contrast, I search ADAMS on other organizations such as Little Harbor, Synergy, John Beck, or Billie Garde, I receive 100s of "hits." I got only one hit on ADAMS when I searched on Dr.
Haber and that was an ACRS transcript where a study by Dr. Haber was referenced. It may be possible that Dr. Haber works for some corporation and therefore I may not be performing the correct search.
I am aware that Dr. Haber may have conducted studies in Eastern Europe; however I dont know the relevance of these culture studies to the SCWE problems at Davis Besse.
Mr. Myer also stated:
Now, our restart -- our process, you know, if you have red findings it requires immediate management attention with a plan to go look at that issue and try to fix it. So no, I wouldnt anticipate that we would start up with any areas that are red.
This statement has the clear implication that the DB restart is dependent upon the outcome of Dr. Habers assessment of the safety culture, an assessment that has no acceptance criteria. I would also like to know if the results of Dr. Habers study are going to be made available to the general public in a similar manner the Little Harbor studies of the Millstone culture.
After the Region III meeting last week, Billie Garde stated that at Millstone it took more the 4 persons more than 2 weeks to assess the SCWE. This is the manpower load stated by either Davis Besse or Dr. Haber for conducting an assessment of the DB culture. I can personally state that it took more than one year at Millstone with more than 4 persons to provide any realistic assessment of this culture.
After reading the RCA of the operations department at DB, my assessment is that the culture at DB is at least as degraded as Millstone at its lowest point. Conversations with people at DB also confirm this assessment.
I have not heard or seen any criteria or measuring tool that Dr. Haber will be using to gauge either the Safety Culture or the SCWE at DB. Maybe this is like some college tests that are scaled after the test such that almost everyone passes. I dont see the NRC asking these questions.
What I see coming is that Dr. Haber will conduct her survey and report that things have improved but more needs to be done (thats the requirement of a good consultant) but everything is just fine and they now have "religion." (Bless me father for I have sinned) Shortly following this declaration, the NRC will review the study and conclude that everything is now OK and can get the keys to the car.
The logical question is why did DB select Dr. Haber to conduct this study when there have been many other well known and experienced organizations who have conducted these surveys on SCWE? These other organizations are Little Harbor, ELI, Synergy, NIC and probable a few more. I think I know the answer but would like to hear it from the NRC.
I would greatly appreciate a list of safety culture studies conducted by Dr. Haber at commercial nuclear facilities in the US.
Paul M. Blanch 135 Hyde Rd.
West Hartford, CT 06117 Cell 860-881-6011 Office 860-236-0326 FAX 801-991-9562 Mail Envelope Properties (3E4808E5.086 : 24 : 32902)
Subject:
Questions about Commission meeting Creation Date:
Mon, Feb 10, 2003 3:15 PM From:
"Paul Blanch" <pmblanch@attbi.com>
Created By:
pmblanch@attbi.com Recipients nrc.gov owf4_po.OWFN_DO JAZ (John Zwolinski) nrc.gov ch_po.CH_DO JAG (John Grobe)
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From:
"Paul Blanch" <pmblanch@comcast.net>
To:
<JAG@nrc.gov>, <CAL@nrc.gov>
Date:
Mon, Aug 18, 2003 10:08 AM
Subject:
Issues to be resolved in order for Davis-Besse to restart Jack:
I have been reviewing the recent Davis Besse monthly updates from the NRC for the past year.
I was pleased to see that the NRC was committed to have the NRCs Office of Investigations (OI) essentially complete its work prior to approving the restart. I also understand that OI has recently launched an additional investigation related to possible wrongdoing and inaccurate information involving one or more of the officers of First Energy.
Additionally in the NRC monthly update to the public, there were promises made to the media and the general public that other issues would be resolved prior to restart.
The following is directly from the July NRC update:
Issues to be resolved in order for Davis-Besse to restart The NRC Oversight Panel will only consider recommending that Davis-Besse resume operations when the plant has demonstrated its readiness to operate safely. Key elements will include:
Davis-Besse management and personnel properly understand the technical, organizational, programmatic and human performance problems that led to the extensive degradation of the plant's reactor vessel head.
Davis-Besse enhances programs for operating the plant safely, detecting and correcting problems, controlling boric acid corrosion, and is fostering a more safety-conscious environment among plant managers and workers.
Davis-Besse improves the performance standards of its managers and workers, including their "ownership" of the quality of work products and the safety focus of decision-making.
The replacement of the vessel head is technically sound and all reactor components are inspected, repaired as necessary, and demonstrated to be ready for safe operation.
Plant safety systems inside and outside containment are inspected, repaired as necessary, and have been confirmed to be ready to resume safe operation of the plant.
Plant operators demonstrate appropriate safety focus and readiness to restart the plant.
Any organizational or human performance issues resulting from the ongoing investigation conducted by the NRC's Office of Investigations are addressed.
All licensing issues that have arisen as a result of the reactor head replacement have been resolved.
Resolution of radiation protection issues associated with the radiation exposure to workers during steam generator work and the particle contamination found in offsite locations.
Modification of the strainer system for the containment sump, which would be the source of cooling water for recirculation in the event of a loss-of-coolant accident.
For some reason this entire section has been inadvertently omitted from the August update. I'm sure this is an oversight and I would appreciate it if the NRC would reissue or amend the August update to include this vital information, especially the commitments related to the ongoing OI investigations.
Paul M. Blanch 135 Hyde Rd.
West Hartford, CT 06117 Cell 860-881-6011 Office 860-236-0326 FAX 801-991-9562 CC:
"DAV_ll" <DBRVH_LTBL_II@yahoogroups.com>
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Issues to be resolved in order for Davis-Besse to restart Creation Date:
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"Paul Blanch" <pmblanch@comcast.net>
Created By:
pmblanch@comcast.net Recipients nrc.gov ch_po.CH_DO JAG (John Grobe)
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Date:
Thu, Nov 6, 2003 3:04 PM
Subject:
Preservation of evidence Mr. Grobe:
There has been significant dialog on the Yahoo Davis Besse web site related to the events that occurred shortly after the discovery of the degraded reactor head.
During discussions between some of the web site members some valid questions arose questioning exactly what happened when the discovery was made. We believe it is important that these questions be addressed such that if a similar event occurs in the future, proper actions will take place such that a complete understanding of the event takes place and that all evidence will be preserved in order to gain a complete understanding of the event.
I volunteered to attempt to obtain the answers to these question from the NRC. I was considering filing a FOIA request but dont believe this to be the best vehicle to obtain this information.
We have not been able to find answers to the following issues and request your assistance.
- 1. We would like to know what the NRCs requirements are for the preservation of evidence.
- 2. We would like to know how the NRC evaluated FENOCs performance in the preservation of reactor vessel head degradation evidence before NRC got involved.
- 3. We would like to know if FENOC met NRCs requirements for the preservation of evidence.
- 4. We would like to know the sequence of events that resulted in the destruction of the "as found" material on and about the "cavity."
- 5. We would like to know what the NRC knew about what was going on and what they did about it.
Thank you in advance.
Paul M. Blanch Energy Consultant 135 Hyde Rd.
West Hartford CT 06117 Home 860-236-0326 Fax 801-991-9562 Cell 860-881-6011 CC:
"DAV_ll" <DBRVH_LTBL_II@yahoogroups.com>
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Preservation of evidence Creation Date:
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"Paul Blanch" <pmblanch@comcast.net>
Created By:
pmblanch@comcast.net Recipients nrc.gov ch_po.CH_DO JAG (John Grobe) yahoogroups.com DBRVH_LTBL_II CC (DAV_ll)
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Date:
Fri, Nov 7, 2003 4:32 PM
Subject:
Davis Besse LER 2003-010-00 Mr. Grobe:
The following LER clearly describes a manufacturing defect along with potential safety implications. Is it safe to assume that Davis Besse has filed a 10 CFR 21 report describing this defect? How may I obtain a copy?
Paul M. Blanch Energy Consultant 135 Hyde Rd.
West Hartford CT 06117 Home 860-236-0326 Fax 801-991-9562 Cell 860-881-6011 CC:
"DAV_ll" <DBRVH_LTBL_II@yahoogroups.com>
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Subject:
Davis Besse LER 2003-010-00
Creation Date:
Fri, Nov 7, 2003 4:31 PM From:
"Paul Blanch" <pmblanch@comcast.net>
Created By:
pmblanch@comcast.net Recipients nrc.gov ch_po.CH_DO JAG (John Grobe)
CAL (Christine Lipa) yahoogroups.com DBRVH_LTBL_II CC (DAV_ll)
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To:
"Christine Lipa" <CAL@nrc.gov>
Date:
Wed, Dec 17, 2003 7:56 PM
Subject:
RE: Davis Besse LER 2003-010-00 So how does the NRC assure that all users of this defective equipment are notified of the defect? I thought this was the main purpose of 10 CFR 21! May I have a copy of the RIs documented assessment please?
Original Message-----
From: Christine Lipa [7]
Sent: Wednesday, December 17, 2003 6:51 PM
To: pmblanch@comcast.net Cc: Anthony Mendiola; Christopher Thomas; John Grobe; John Stang; James Shea; Monte Phillips; Jan Strasma; Viktoria Mitlyng
Subject:
Re: Davis Besse LER 2003-010-00 Mr. Blanch, The Resident inspectors reviewed the CR and associated issues with the valve and determined that no 10 CFR Part 21 report was necessary. The inspectors documentation of the LER closure will be in Inspection Report 2003-022, which should be issued by the end of December.
Christine Lipa, NRC Region III
>>> "Paul Blanch" <pmblanch@comcast.net> 11/07/03 03:31PM >>>
Mr. Grobe:
The following LER clearly describes a manufacturing defect along with potential safety implications. Is it safe to assume that Davis Besse has filed a 10 CFR 21 report describing this defect? How may I obtain a copy?
Paul M. Blanch Energy Consultant 135 Hyde Rd.
West Hartford CT 06117 Home 860-236-0326 Fax 801-991-9562 Cell 860-881-6011 CC:
"Dave Lochbaum" <dlochbaum@ucsusa.org>, <ulrich@ulrichwitte.com>
Mail Envelope Properties (3FE0FB2B.F4A : 17 : 8010)
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"Paul Blanch" <pmblanch@comcast.net>
Created By:
pmblanch@comcast.net Recipients nrc.gov ch_po.CH_DO CAL (Christine Lipa)
ulrichwitte.com ulrich CC ucsusa.org dlochbaum CC (Dave Lochbaum)
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From:
"Dave Lochbaum" <dlochbaum@ucsusa.org>
To:
<SRB3@nrc.gov>
Date:
Mon, Jun 23, 2003 8:36 AM
Subject:
Davis-Besse / South Texas Project : Same Ol Song Good Day:
Attached is a 1995 report by the US General Accounting Office on how the NRC handled the problems at the South Texas Project nuclear plant. In brief, safety problems built up -
undetected by NRC - until the reactors had to be shut down for over a year to fix them all.
Sound familiar?
The number of parallels between that regulatory breakdown then and the Davis-Besse regulatory breakdown now are numerous, including:
- 1) The reactors at South Texas operated for a long time with vital safety equipment inoperable.
"While the risk increased, according to NRC there was little chance of an accident at the site because of multiple safety features in the reactors design." (See Page 2 of the GAO report.)
[NOTE: Apparently, when you make the same mistakes, you can use the same excuses - part of the NRCs efficiency kick.]
- 2) The NRC fined the plants owner $325,000 (see page 3 of the GAO report.) [NOTE: Since the NRC allegedly felt that there was little chance of an accident, wonder what the fine was for?]
- 3) According to page 3 of the NRC report, "NRC was aware of problems with both reactors
[emergency] pumps and of maintenance work taking place on one reactors [emergency diesel]
generators before the plants shutdown." That knowledge did NOT prompt NRC to ask that the reactor be shut down as required by safety regulations.
- 4) According to page 3 of the NRC report, "NRC was aware of other long-standing management and technical problems and a decline in the licensees performance, but it did not know the magnitude of these problems until April 1993." Both reactors were voluntarily shut down in February 1993 by the plants owner. So, the NRC put the pieces together after the damage was done - sound familiar?
- 5) According to page 3 of the GAO report, "NRC found that problems at the plant had been identified repeatedly over a period of years, but the agency had not adequately integrated this information to determine whether the problems indicated systemic weaknesses in the licensees operations. Furthermore, according to NRC it did not ensure that the licensee corrected identified problems." Sound familiar?
- 6) Again on page 3 of the GAO report, "NRC reported that these and other weaknesses in the program resulted in missed opportunities." Does anyone anywhere know of a single opportunity that NRC did not miss? Even a blind squirrel finds an acorn sometimes.
- 7) On page 5 of the GAO report, "In July 1992, NRC had rated the licensee a good performer."
Likewise, Davis-Besse earned, rather got, all GREEN ratings from NRC before the agency learned about the hole in the head.
- 8) On page 6, "NRC has also taken steps to better focus inspections on the licensees efforts to correct identified problems." Yeah, right. And if pigs had wings they could fly.
- 9) On page 25, "...engineering solutions often corrected the symptom - not the cause - of equipment problems. Furthermore, according to the [NRC lessons learned team], the engineers did not adequately apply the operational experience they had gained in both the industry and at the site, leading to avoidable events and repetitive equipment failures at the plant." [Remember, these words were written for South Texas and recycled for use at Davis-Besse.]
- 10) On page 25, the NRC reported to GAO that South Texas "had hired senior level managers -
with proven track records in the nuclear industry - to facilitate improvement efforts." Well, how many new senior managers has NRC hired to help it improve - ZERO.
- 11) On page 28, GAO stated "we found several problems that had been identified as many as 24 times in earlier NRC inspection reports. Although NRC had considerable evidence of long-standing problems at the plant, NRC did not adequately use or integrate the information to determine whether the problems indicated systemic weaknesses in the licensees operation of
the plant." Surprise! Systemic weaknesses in the NRCs oversight prevent the agency from seeing systemic weaknesses on the part of the plant owner. Whod have thunk it?
- 12) On page 29, GAo reported that NRC had sent an information notice to all plant owners about a problem testing emergency diesel generators discovered at the Calvert Cliffs nuclear plant. That same testing problem contributed to the problems at South Texas. Thus, the plant owner failed to heed a warning issued by NRC in 1988. Deja vu - Davis-Besse failed to heed a warning issued by NRC in 1988 about boric acid corrosion. Was any body listening back in 1988?
- 13) On page 33, GAO documents that NRC had cut back drastically on its inspection effort at South Texas in the months preceding the shut downs in February 1993. The average inspection hours per month dropped from 541 to 309. Its dog-gone amazing how many problems you wont find when you dont even look.
- 14) On page 33, GAO reported that NRC instituted a policy in 1989 to have three full-time resident inspectors at two-unit sites like South Texas. But NRC did not implement this staffing policy at South Texas until Jujly 1993 - five months AFTER the shut downs. At Davis-Besse, NRC also staffed the site with fewer inspectors than dictated by agency policy. Amaxingly - the staffing level for the license renewal and new reactor certification efforts dont seem to be shorted at all.
- 15) On page 33, GAO reported that "NRC reassigned the existing resident inspectors and assigned two inspectors. According to NRC, the new resident inspectors had little operational experience and a large workload." Ditto for Davis-Besse. The agency doesnt learn from its mistakes - perhaps because it be making so many that theres no time to catch its breath and learn a bit.
- 16) On page 34, GAo reported "inconsistent enforcement actions to address known violations of the regulatory requirements also contributed to the NRCs untimely recognition and correction of long-standing performance problems at the plant." Amen. By the way, how is the NRC Office of Investigations doing on its casual inquiry into what happened at Davis-Besse?
- 17) On page 35, GAo reported the NRC "did not consistently pursue enforcement actions against the licensee because it had developed a practice of providing the licensee with additional latitude to address known problem areas. This practice occurred because NRC mistakenly considered the licensee to be a good performer." Apparently, this NRC consideration was based on the observations by the understaffed rookie resident inspector staff. At Davis-Besse, NRC once again was tripped up by this disHonor Code.
- 18) On page 36, GAo reported "NRC did not identify the underlying safety problems that contributed to the event at the South Texas plant - another stated purpose of the inspection program - until after the plants shutdown." Ditto at Davis-Besse. Apparently, the NRCs rear-view mirror is so large that the agency cannot see out the front window.
The NRC did a formal lessons learned effort following the South Texas debacle. Its also done a formal lessons learned effort following the Davis-Besse debacle. Why should anyone believe that the agency will reform now given that the South Texas lessons were written down but not fixed?
There are some differences between South Texas and Davis-Besse. For example, Sam Collins was NOT the Director of the Office of Nuclear Reactor Regulation during the South Texas debacle. Nope, he was a senior manager in NRC Region IV, which overlooks South Texas.
Dave Lochbaum Nuclear Safety Engineer Union of Concerned Scientists 1707 H Street NW Suite 600 Washington, DC 20006-3962 (202) 223-6133 x113 (202) 223-6162 fax CC:
<JIZ@nrc.gov>
Mail Envelope Properties (3EF6F42B.DF7 : 8 : 19959)
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Mon, Jun 23, 2003 8:38 AM From:
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John Grobe To:
Dave Lochbaum; OPA3 OPA - Region III Date:
Tue, Dec 9, 2003 2:21 PM
Subject:
Re: Request for document
- Dave, I think that this document is not in electronic form, but in the older microfiche. Well make sure that you get a copy. Please send to OPA3 your fax number. Thanks.
Jack
>>> "Dave Lochbaum" <dlochbaum@ucsusa.org> 12/09/03 12:59PM >>>
Good Day:
Attached is a document I just downloaded from ADAMS. Its an e-mail exchange between NRC staffer Phil Qualls and a former NRC staffer Dennis Kubicki. Mr. Qualls wrote:
"A Region III inspeciton recently found a SER dated May 31, 1991 which approves some pretty outrageous stuff."
Prior to this sentence, Mr. Qualls indicates that the plant in question is Davis-Besse.
Being somewhat of a collector of NRC documents containing "pretty outrageous stuff," I was eager to add this referenced document to my collection. But Im unable to find it in ADAMS and the good folks at the Public Document Room cannot locate it.
Could you send me a copy of the referenced Safety Evaluation Report dated May 31, 1991, or explain why its not available?
- Thanks, Dave Lochbaum Nuclear Safety Engineer Union of Concerned Scientists 1707 H Street NW Suite 600 Washington, DC 20006-3962 (202) 223-6133 x113 (202) 223-6162 fax
Make your voice heard on important environmental and security issues. Join the Union of Concerned Scientists Action Network at www.ucsaction.org. Its quick, easy, and FREE.
CC:
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OPA3 (OPA3 OPA - Region III)
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From:
"Tom Gurdziel" <tgurdzie@dreamscape.com>
To:
"Christine Lipa" <cal@nrc.gov>
Date:
Tue, Jul 22, 2003 10:21 PM
Subject:
Davis-Besse Valve Position Good morning Christine, Today I was doing a little more thinking about manual valve position determined by apparently still current Davis-Besse procedure. As I believe I have read this week, proper position is determined by moving the handwheel one revolution in the opposite direction, (and then back, I guess). So, if the valve is supposed to be closed, if you can turn the handwheel one revolution in the open position, it was closed.
The trouble here is that, as long as the valve is more than one handwheel revolution from either full open or full closed, the valve can be shown to be either full open or full closed in full satisfaction of the procedure. Isnt this troubling?
Specifically, if the System Health Inspections done at Davis-Besse included valve line ups where position of manual valves without local or remote position indication was done by the procedure mentioned above, doesnt it seem proper to have them done again?
And, wouldnt it be interesting to see if other plants in the First Energy fleet use the same method to determine manual valve position?
Please note that all these comments accept zero play or slop in the valve train. In other words, movement of the valve handwheel immediately means movement of the valve gate.
Thank you, Tom Gurdziel CC:
"Richard W. Lamoreaux" <moreauxrs@yahoo.com>, "Rep. Marcy Kaptur"
<REP.KAPTUR@mail.house.gov>, "J. Mangels" <jmangels@plaind.com>, "J. Funk"
<jfunk@plaind.com>, "David Lochbaum" <dlochbaum@ucsusa.org>, "Ed Stronski"
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Date:
Fri, Oct 24, 2003 8:26 AM
Subject:
Davis-Besse LER 2003-009 Good morning Christine, Am I reading on page 4 of 6 that an inadequate thickness gasket was knowingly installed during the current outage on CCW Heat Exchanger 3? Why werent "the irregularities that existed in the gasket sealing surfaces" machined before maintenance was complete? Is this still the way maintenance work is done there?
Did the QA organization find this?
Did any site or corporate review organizations express any concern?
Thank you, Tom Gurdziel CC:
"Richard W. Lamoreaux" <moreauxrs@yahoo.com>, "Rep. Marcy Kaptur"
<REP.KAPTUR@mail.house.gov>, "Jim Mackinnon" <jmackinnon@thebeaconjournal.com>, "J.
Mangels" <jmangels@plaind.com>, "J. Funk" <jfunk@plaind.com>, "Ed Stronski"
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<opa@nrc.gov>
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"Tom Gurdziel" <tgurdzie@dreamscape.com>
To:
"Christine Lipa" <cal@nrc.gov>
Date:
Tue, Oct 21, 2003 11:10 PM
Subject:
10/21/03 Davis-Besse HPI Pump meeting slides Good morning Christine, I was unable to listen to the meeting but I appreciate being able to look at the 68 meeting slides tonight. Here are my comments:
Slide 26 When you hard face all critical wear surfaces, wont you wear out the pump as fast as you would have only worn out the wear rings?
Slide 33 tells me that pieces were tested. I thought that they were testing (entire) pumps. In other words, the cumulative effects of all the changes in a newly reconditioned pump have NOT been observed. Is this acceptable? (I dont think it would be.)
Slide 36 takes forever to display if you use dial-up, as I do.
Slide 57 says "preliminary analysis." How long will it be until there are final results?
Slide 59 took so long to display that my screen saver came on and, you guessed it, when I moved the mouse to clear the screen saver, the slide graphic started all over again. Naturally, I did not wait.
Slide 60, same story except that I timed the graphic. After 10 minutes I went to slide 61.
Slide 61 The acceptance line just doesnt make any sense to me.
Slide 62 says the French hard faced close clearances but does not say this includes wear (or should I say non-wear) rings.
Slide 64 tells of in plant testing of (a) worn pump. Same as before, I would want to see full testing of the complete, modified pump with non-worn clearances. (This was not a useful test, in my opinion.)
Slide 66 doesnt state anything is final BUT pump modifications are in progress anyway.
Wasnt there a lesson to be learned when you spend 3.8 million dollars (on a risk release basis) on a modified sump to filter water for a pump BEFORE you know to what size you have to screen or filter? Here is the lesson: if the modified screening or filtering was adequate, there would be no need to fix the HPI pumps. And the modified sump might have been adequate if
the complete design criteria had been obtained BEFORE starting the modification. (I guess you do have to say that they are consistent in their engineering design practices.)
Thank you, Tom Gurdziel CC:
"Richard W. Lamoreaux" <moreauxrs@yahoo.com>, "Rep. Marcy Kaptur"
<REP.KAPTUR@mail.house.gov>, "Jim Mackinnon" <jmackinnon@thebeaconjournal.com>, "J.
Mangels" <jmangels@plaind.com>, "J. Funk" <jfunk@plaind.com>, "Ed Stronski"
<ESTRONSKI@aol.com>, "David Lochbaum" <dlochbaum@ucsusa.org>
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10/21/03 Davis-Besse HPI Pump meeting slides Creation Date:
Tue, Oct 21, 2003 11:09 PM From:
"Tom Gurdziel" <tgurdzie@dreamscape.com>
Created By:
tgurdzie@dreamscape.com Recipients nrc.gov ch_po.CH_DO CAL (Christine Lipa) ucsusa.org dlochbaum CC (David Lochbaum) aol.com ESTRONSKI CC (Ed Stronski) plaind.com jfunk CC (J. Funk) jmangels CC (J. Mangels) thebeaconjournal.com jmackinnon CC (Jim Mackinnon) mail.house.gov REP.KAPTUR CC (Rep. Marcy Kaptur) yahoo.com moreauxrs CC (Richard W. Lamoreaux)
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"Christine Lipa" <cal@nrc.gov>
Date:
Tue, Aug 5, 2003 10:12 PM
Subject:
Bottom Head Inspection, First Energy Serial Number 2973, dated July 30, 2003.
Good morning Christine, "Following plant cooldown, a crawler video inspection of each IMI nozzle penetration will be conducted." Since I dont care how much radiation dose the crawler gets, I wonder why the inspection is not done while the reactor is pressurized and not cooled down. (Would there even be a difference in dose?) What will the crawler be doing during these 7 days anyway? (Page 10 of 14; or Attachment 1, page 7 of 10) Note what is being done here: instead of directly looking for leaks as they may occur, we ignore this opportunity to find leaks and, instead, try to determine leaks from secondary evidence. I dont like this method.
Also, why are we assuming that the bottom head cant leak, so we dont have to look at anything but the lower head nozzles? (Page 14 of 14)
Thank you, Tom Gurdziel
CC:
"Richard W. Lamoreaux" <moreauxrs@yahoo.com>, "Jim Mackinnon"
<jmackinnon@thebeaconjournal.com>, "J. Mangels" <jmangels@plaind.com>, "J. Funk"
<jfunk@plaind.com>, "Ed Stronski" <ESTRONSKI@aol.com>, "David Lochbaum"
<dlochbaum@ucsusa.org>
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Bottom Head Inspection, First Energy Serial Number 2973, dated July 30, 2003.
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To:
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Date:
Sun, Dec 21, 2003 10:33 PM
Subject:
NRC Special Inspection of Reactor Coolant System Leak Test Good morning Christine, (I am not going to say anything more here about how nothing at Davis-Besse ever seems to be considered a primary coolant pressure boundary leak when fixing it would cost time or money.)
I am reading page 4 and 5 of Report No. 05000346/2003023 and find it quite interesting to read that "this valve had been replaced during the current outage; therefore the leak was caused by a manufacturing defect."
Could we just think about this a minute? We have a manufacturing defect. It must be in either the valve body or the bonnet since these are the parts that are manufactured. As a defense in depth measure, the joint is also seal welded. Here, not only have we been told that one (or more), of the manufactured items is defective, we can easily conclude that the seal welding was faulty, too. What does this mean to me?
No (or inadequate), Quality Control, no credible Quality Assurance, no good purchasing requirements, workers unable to find defects in new parts, bad (or no), supervision, an inability to seal weld, and no weld inspection.
Also, no Maintenance Rule effectiveness and no effective peer-industry-group oversight. Also, poor workmanship (on the welding, at least.)
Please note that there are multiple failures here. Did anybody do a root cause? You know, it is possible that poor workmanship also damaged (good) new parts: perhaps nobody noticed that the bonnet was cross-threaded, because, if made up properly, the joint should not have leaked, even without seal welding. (In fact, wouldnt it have been more honest to do the pressure test first, then seal weld all joints that did NOT leak (only.) (Fix the others, then pressure test again.)
What I am trying to say is that the repair is not worthy of a United States nuclear plant. If the defect is a poorly manufactured item, I want that item replaced. Unfortunately, they dont.
On page 5
If the licensee accepts 11 findings in 5 days, how long do they plan to run their reactor and how many findings would they expect to have at their first planned shutdown? (Because it looks to me like they dont have a problem with an additional 2 a day.)
On page 9 "For each of the examination methods used during the outage, was the examination:
Performed in accordance with demonstrated procedures?"
Answer "No" Why not? Would that have either cost money or time?
On page 11 Wouldnt you feel better if the FirstEnergy organization had identified the "wrong call", not just fixed the problem after you (the NRC), identified it for them?
On page 12 Do you feel that the use of compressed air should be considered "pre-conditioning"?
On page 14 I dont like the thinking process here. It seems that as long as there is a "confirmed CCW leak",
we can excuse problems. Wouldnt an organization with the proper questioning attitude ask, Why not fix the leak, then look?
Thank you, Tom Gurdziel CC:
"Richard W. Lamoreaux" <lamoreauxrw@yahoo.com>, "Rep. Marcy Kaptur"
<REP.KAPTUR@mail.house.gov>, "Jim Mackinnon" <jmackinnon@thebeaconjournal.com>,
"James M. Trapp" <jmt1@nrc.gov>, "J. Mangels" <jmangels@plaind.com>, "J. Funk"
<jfunk@plaind.com>, "Glen Meyer" <gwm@nrc.gov>, "Gordon K. Hunegs" <GKH@nrc.gov>,
"Ed Stronski" <ESTRONSKI@aol.com>, "David Lochbaum" <dlochbaum@ucsusa.org>,
<.opa@nrc.gov>, <opa3@nrc.gov>
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NRC Special Inspection of Reactor Coolant System Leak Test Creation Date:
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"Tom Gurdziel" <tgurdzie@dreamscape.com>
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tgurdzie@dreamscape.com Recipients nrc.gov ch_po.CH_DO OPA3 CC (OPA3 OPA - Region III)
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Date:
Wed, Dec 24, 2003 7:09 PM
Subject:
The Journal News 12-24-03 article by Roger Witherspoon Good morning, I am disturbed to see that misleading information was provided to the public. Was misleading information provided to you? (If so, I believe such action should result in sanctions such as monetary fines, however, you couldnt tell from the NRC Region III performance at Davis-Besse.)
Also, what kind of latitude does the NRC allow for the actuation of a plant emergency facility?
Is there a specific number like one hour? Is compliance optional?
In the case of the Indian Point 3 generator which had an uncorrected problem from April 20003, (4 months), how long does NRC Region I allow before such problems are proven corrected?
In the case of the Indian Point 2 generator which had an uncorrected problem from February 2000, (3 years, 2 months), does Headquarters NRC provide any oversight of what is happening (actually, what is NOT happening) in the regions?
Additionally, I would like to know if any emergency generator for this site, (including the gas turbines they used to have), did NOT meet the degraded voltage requirement of, I believe, 75%
for the first load started, or did NOT meet the degraded frequency requirement. (Davis-Besse has been making excuses that such requirements dont need to be met by them, if I understand their situation correctly.)
And, while I think of it, were they (Entergy), able to remotely control their emergency generation power sources from the control room(s), or did they have to send an operator in a vehicle one mile (in person), as has happened before with a gas turbine?
Considering that I just read that one of the South Texas units just reported that they threw a connecting rod through the engine block of one of their emergency generator power sources,
does Headquarters NRC see a possible widespread problem with design, operation, and maintenance of emergency power sources?
Usually I dont request an answer to my e-mails, however, on this one, I do.
Thank you, Tom Gurdziel CC:
"Richard W. Lamoreaux" <lamoreauxrw@yahoo.com>, "Rep. Marcy Kaptur"
<REP.KAPTUR@mail.house.gov>, "Jim Mackinnon" <jmackinnon@thebeaconjournal.com>,
"James M. Trapp" <jmt1@nrc.gov>, "J. Mangels" <jmangels@plaind.com>, "J. Funk"
<jfunk@plaind.com>, "Gordon K. Hunegs" <GKH@nrc.gov>, "Glen Meyer" <gwm@nrc.gov>,
"Ed Stronski" <ESTRONSKI@aol.com>, "David Lochbaum" <dlochbaum@ucsusa.org>,
"Christine Lipa" <cal@nrc.gov>, <opa3@nrc.gov>
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Date:
Tue, Nov 25, 2003 8:20 AM
Subject:
LER 03-010-00, Davis Besse
Good morning Jan, I dont know what was done, but waiting from 8:12 to 8:15 to see this LER is probably now two or even three minutes longer than such a display used to take. This is not an improvement.
(I am talking about your News and Correspondence page.
Thank you, Tom Gurdziel Also, I couldnt find that reference where somebody higher than the 0350 panel approved the reactor pressure test WITHOUT using the lithium test.
CC:
"Christine Lipa" <cal@nrc.gov>, <opa@nrc.gov>
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LER 03-010-00, Davis Besse Creation Date:
Tue, Nov 25, 2003 8:19 AM From:
"Tom Gurdziel" <tgurdzie@dreamscape.com>
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From:
"Richard E. Wilmot" <richwilmot@worldnet.att.net>
To:
<jag@nrc.gov>
Date:
Fri, Sep 26, 2003 5:29 PM
Subject:
For you post panel 1 October 2003 consideration John A. Grobe Chairman, Davis-Besse Special Panel U.S. Nuclear Regulatory Commission Perhaps you can take time to read this on the airplane:
I have followed the D-B culture change efforts; the employee surveys; the personnel changes; and the plans to observe some managers inter-facing on issues as if that might be the protocol on a subsequent day to day basis. [In most General Motors plants, the safety railings were freshly painted yellow prior to executive visits]; and above all, the little confidence in management survey revelations.
A word about who is writing you. I am a senior. A retired GM group executive[32 years in human resources, corporate communications, organizational development and employee research {twenty years of trust of managementresearch}]. While at GM, and subsequently counseling senior executives in culture change hands-on process, I had the opportunity work with organizations like Texas Instruments, Hughes Aircraft, General Dynamics, American Medical International, TRW, plus several GM plants, divisions, and groups on a call back basiss.
In every situation, the root cause of varying issues, and always safety, was the site senior management. Research nationally for the past ten years has shown that the most important factor for employees sharing their talents and energies, and working safely...is how they are treated by their supervisors...ie.supervisors at all levels. Repeatedly, I have been asked by HR directors to train our managers, only to be asked right out of the box by the managers, This looks good, but are our bosses up the line committing to better communication, more openness, too? Over time, I stopped accepting engagements when the senior executives refused to accept my counsel and become personally involved. They would not be measured or held accountable for their personal roles in culture change. Without that, nothing important or lasting really happens. Trust me.
Regardless of who is in D-B, completing their consulting work with respect to safety culture change, when they are finished, I urge you to let me work with the site apex executives. Unless they model the general [not just safety] culture shift; talk about it and live it; the gains will be short-lived, I can assure you. There is no reflection on their choice of consultants. I believe your senior executives [at all your Region 3 sites] would benefit from working one-on-one with me, with 47 years experience.
My time with each senior executive [top person and immediate staff] requires less than eight hours with each individual [two split days]. The work is very introspective, geared specifically to daily tasks of each person and his/her specific mission, including relationship-building with all other organizational segments. Even the most stubborn participants finally realize we are working together on their own bottom lines; the safety of their employees; and collectively, contributing to the success of the entire facility. Another survey in eighteen months [by me or others] measures my own and organizational success.
Inasmuch as I now live west of Cleveland, conceivably we might have a conversation, or brief meeting, on your apparent visit to Davis-Besse in the near term. Frankly, I am preparing to retire in two years, but equally frankly, I am concerned about the safety of all such nuclear facilities in your region and elsewhere. I have much intellectual property to share with each executive you have chosen to manage them. If the participants buy-in, I can help them with a process that will be effective, measured, and for which they will be accountable in terms of rewards, career paths. They can call me for 12-months with questions.
And, if the next level executives become involved [because they or you so elect], a farm team of site executives will be developed, all of whom know how to earn the trust and respect of employees as they assume more responsibility at nuclear sites throughout the U.S. For the managers on the front lines, nothing could do more to make them reach out to other segments of the organization. And, when their employees see the culture change is actually a new way of doing business, they will respond in kind. A general change in culture also enhances quality of workmanship, reduced cost, and worker retention. Very clearly, safety first will be embraced by employees who are allowed to feel they are important to facility success.
Mr.Grobe, I hope you will step back from the fray to consider whether you are getting all the help you need. Several months ago, I asked to be considered after the survey was completed. I received no reply of any kind. I would appreciate your own reaction to my research-by-me and lessons-learned proposal to you. Obviously, if you would feel more comfortable speaking to some of my past clients, I will be most happy to locate them for you.
Richard E. Wilmot President, People Strategies Westlake, OH richwilmot@worldnet.att.net 440 250-0535 Mail Envelope Properties (3F74AFAE.7D1 : 21 : 22481)
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For you post panel 1 October 2003 consideration Creation Date:
Fri, Sep 26, 2003 11:28 AM From:
"Richard E. Wilmot" <richwilmot@worldnet.att.net>
Created By:
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Date:
Thu, Oct 16, 2003 5:37 PM
Subject:
Fw: Please keep in mind....
Original Message -----
From: "Richard E. Wilmot" <richwilmot@worldnet.att.net>
To: <lwmyers@firstenergycorp.com>
Sent: Thursday, October 16, 2003 5:36 PM
Subject:
Please keep in mind....
As you press forward to get Davis-Besse back on line, I offer you two thoughts for now, or later:
- If the hardware changes are approved by NRC, but there are lingering questions about the degree to which the site culture changed in recent months, I have a suggestion for you. As the basis for a lasting working environment of safety, I can provide on the spot training in real culture change for all of your senior site executives. It is there for you if further start-up delays hinge on institutionalizing a safety culture. [You need to take a hard look personally, at the content of questions in your announced next survey. If they should happen to be sissy questions, the results may have to be looked at under a bright light. Just a lesson learned over forty-seven years in the organizational change business].
- Notwithstanding the next events at Davis-Besse, if you have responsibility for other nuclear sites in Mr.Grobes NRC Region Three, I propose to you, as I have to him, that working with the senior nuclear site executives on a preventive basis, ie. training them to ensure that the culture lends itself to a safely environment, I would like to accomplish that for you as well..
The safety adage "If it can happen, it will", is less threatening if the employees are ready to buy-in to it...because they work in a site culture of values, shared information, and trust of all levels of management.
You have these availabilities from my office in a western Cleveland suburb. I urge you to have a phone visit with me as you move your team into the end zone.
Respectfully, Richard E. Wilmot President, People Strategies richwilmot@worldnet.att.net 440 250-0535 Mail Envelope Properties (3F8F0F75.0B4 : 22 : 28852)
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Fw: Please keep in mind....
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From:
"Donna Lueke" <dlueke@adelphia.net>
To:
"viktoria mitlyng" <vtm@nrc.gov>
Date:
Tue, Mar 4, 2003 8:39 AM
Subject:
re: davis-besse
- Viktoria, Would you please forward this letter to Mr. Grobe. It is a copy of a letter I sent to the editor of local papers and to local officials.
- Thanks, Donna Lueke
Dear Mr. Grobe:
On one hand, there are many conscientious, hard-working, safety-conscious people employed at Davis-Besse. On the other hand, mistakes and oversights over many years by many people at Davis-Besse and with the NRC resulted in the damage to the head and the shutdown.
On one hand, there are impressive safety-enhancing changes being made at Davis-Besse, and lessons learned at Davis-Besse have resulted in industry-wide directives that will help nuclear plants operate more safely. On the other hand, serious problems are still being revealed a year later. In the past few weeks it was revealed that a serious mishap could have occurred by now if the plant had kept running the way it was; that an employee may have been dismissed because he tried to warn about safety problems; and that it is still unknown what FirstEnergy or the NRC knew when.
On one hand, our local economy benefits from the jobs and tax monies and electricity generated by Davis-Besse. On the other hand, our local economy can also be negatively influenced and potential businesses and ecotourism discouraged by higher-than-average electric rates and by Davis-Besses incidents in 1985 and 2002. Frustration over potential economic and job loses should be directed to those at FirstEnergy and the NRC who put us at risk.
Since Davis-Besse came on-line, we have entrusted our safety and that of our environment to the utility and to the NRC. Twice they have nearly failed us. We should support FirstEnergy and the NRC in their remedial efforts. We should also support and welcome scrutiny from congressional investigations, public officials at all levels, industry watchdogs, citizens groups, and investigative journalists. An accident at Davis-Besse would impact not only our local safety, economy, and environment, but also the whole state of Ohio and the entire Great Lakes area.
- Regards, Donna Lueke 909 Elliott Street Marblehead, OH 43440
419-798-8062 dlueke@adelphia.net Mail Envelope Properties (3E64AC7F.CDE : 10 : 40158)
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Wed, Jul 2, 2003 12:11 PM
Subject:
Davis-Besse nuclear reactor restarting To: James E. Dyer, Regional Administrator, U.S. NRC I am emailing regarding the restarting of the Davis-Besse nuclear reactor. After so many years of inadequate maintenance, ignored repairs, and near-miss accidents, I am sincerely concerned for the safety of my family and friends should this reactor be started again. It is just not safe, based upon what I have seen, read and heard from friends who have worked at the plant.
Trying to correct years worth of problems is just too dangerous with so many public lives at stake. Please close it for good.
We live in Cleveland with family and friends living across Ohios Erie coast. We are acutely aware of our areas dependency upon Lake Erie for good, safe water and air. I have lived through the burning river, the foaming lake water, the red air in Cleveland. We have come so far, as a region, and I chose to move back to this area to raise children. An accident at Davis-Besse would set this entire region back for generations: people and businesses would leave again; educational institutions would struggle. Tourists actually want to come to visit Cleveland now for the first time in my life. This is an area to be proud of. ANY accident, catastrophic or not, will damage our economy. You have the power to avoid this situation by closing this old, deteriorating plant for good.
Please close the Davis-Besse nuclear reactor. Tear it down completely. Rebuild a new plant, if we really need the power at some point, but get rid of this old facility. I would appreciate a response/update from your office on your decision regarding the re-starting of the Davis-Besse nuclear reactor. Thank you for your time.
Sincerely, Mrs. Janice Ferrazzoli 9449 Highland Drive Brecksville, OH 44141 ferrazzoli@hotmail.com Mail Envelope Properties (3F030440.68C : 8 : 1676)
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Jonathan Wert <jwert@mdi-wert.com>
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Thu, Oct 2, 2003 10:44 AM
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Fwd: Lingering safety issues are snag at Davis-Besse Hi Jack, The news releases on the DB safety culture meeting tells me several things:
- 1. Some of the executives or senior managers at FE/DB and the contractors that they selected to help are/were not qualified to do the job...assess, advise and fix. Maybe the leadership isnt listening to its experts. Its relatively easy to identify safety culture problems, but there is not that many experienced people out there that know how to fix them in the shortest amount of time.
- 2. The safety culture program hasnt been packaged appropriately and effectively.
- 3. There are some major flaws, gaps, and lack of important detail in the wording of their material.
- 4. The leaders arent saying the right things and/or saying them the right way.
- 5. Their words arent backed up by actions...not walking the talk.
- 6. They apparently want NRC to tell it what do or as a minimum provide some guidance and direction on what safety culture does and doesnt include. They dont understand that NRC wants to see evidence of culture change. There is little, if any, evidence of behavior change.
- 7. The leaders appear to be trying to get by with a minimum of change or work on their safety culture; make minimum commitment to it.
- 8. It is obvious that the things that they say they want to be instilled in behaviors of people hasnt stuck, and certainly not in the leadership where it all must begin.
- 9. There is not enough evidence by "heads on poles" that those who were on watch and should have been held accountable for things at the time of the problem(s) are gone, and it appears that there needs to be two to four heads on the poles, e.g. they need a new plant manager, engineering manager, plant operations manager. QA manager...probably a new VP-Nuclear.
When most of what I have in this Attachment on NUCLEAR SAFETY CULTURE CODE OF CONDUCT shows up in the program material, expectations, values, policy, performance indicators, training, and accountability, DB will be ready for start up.
What is a high priority need for FE/DB at this time? In my view, as a minimum before start up, they need some good one on one mentoring and/or coaching of the executives and managers down to first line supervision and the worker bees.
Sincerely, Jonathan Wert Leadership Mentor on nuclear safety culture transformation Lingering safety issues are snag at Davis-Besse 10/02/03 John Funk and John Mangels Plain Dealer Reporters Lisle, Ill. - Workers and managers at the Davis-Besse nuclear plant have made major improvements in the facilitys ailing "safety culture," FirstEnergy Corp. executives assured federal regulators yesterday.
But NRC officials listening to more than four hours of testimony at the agencys Midwest headquarters in suburban Chicago said they were troubled by operators errors during a pressurization test of the idled reactor over the last week and by the way the company is evaluating the plants safety culture.
The agency has made safety culture - the values shared by managers and workers alike that put safety above all else - a major hurdle FirstEnergy must cross before it can win permission to restart the repaired reactor.
At the conclusion of the companys presentation, the chairman of the special panel overseeing Davis-Besse would not commit to a timetable to restart the reactor.
The agency has not scheduled a final meeting for the company to present its restart plan, said Chairman Jack Grobe, and it is not even contemplating such a meeting at this point. Routine monthly meetings with FirstEnergy are scheduled into December, he said.
FirstEnergys top officials have repeatedly told worried financial analysts during several recent conferences that they expect to have Davis-Besse ready to restart before the end of fall. The reactor is in its 20th month out of service after workers found a corrosion hole in its lid. The lid was eaten away by leaking coolant that was ignored for years.
In the months since the plants close call, FirstEnergy has replaced most of Davis-Besses management team; strengthened corporate policy about safety culture; trained personnel on identifying and reporting safety issues; revised the system that ranks the severity of potential
problems and tracks their resolution; hired outside consultants to create a safety culture assessment plan; and created programs for workers to report safety concerns.
The safety culture overhaul has been under way as hundreds of millions of dollars in repairs and improvements are made to the reactor and the plants mechanical systems.
>Most of the mechanical work has been completed, and workers during the past week used the reactors four huge coolant circulation pumps to heat up and pressurize the reactor to normal operating pressures to check for leaks.
While the reactor and its hundreds of valves and piping proved to be nearly leak-free, the operators were not error-free.
Twice over the seven-day test, operators made mistakes that created problems that interrupted the test for hours.
Operators last week opened valves in an improper sequence, causing an electrically operated valve in the emergency cooling system to open, dumping about 1,000 gallons of water into a drain. And this week, another crew depressurizing the reactor apparently lost track of the pressure levels, causing computer-operated equipment to switch into an emergency mode.
While Grebe said the errors posed "minimal safety risk, nonetheless I would not have expected the type of operator problems that were observed.
"This goes right back to a questioning attitude and a rigorous approach," the hallmarks of a healthy safety culture, he said. Most plants dont have two problems of that sort in a year, much less two in a week, Grobe said.
"Its troubling."
"It doesnt give us confidence," added James Caldwell, the NRCs Midwest regional administrator.
Reactor operators will get extra training, said Garry Leidich, president and chief nuclear officer of FirstEnergys nuclear operating company. "You dont make cultural changes overnight," he said. "We have a ways to go."
The NRC representatives also questioned how FirstEnergy could give itself overall good marks for safety culture when its own safety culture assessment has raised concerns about some individual plant programs.
The company has assigned red flags to plant managements "commitment to continuous improvement." Corporate executives willingness to assess themselves also earned red flags, yet FirstEnergy determined that the broader safety culture categories were acceptable.
Lew Myers, chief operating officer of FirstEnergys nuclear operating company, said the red-flag issues were in areas that wouldnt directly affect the plants readiness to be restarted. But NRC deputy regional administrator Geoffrey Grant questioned the message that would send to employees.
"What does that communicate to staff when you say safety culture is important, but your model has a red area and youre going to continue forward?" Grant asked.
"We would communicate why," Myers answered.
The NRC still has a team at the plant evaluating the ongoing efforts to improve safety culture.
Agency officials said they will want to meet again with FirstEnergy to get more information about the safety culture work the company is doing.
To reach these Plain Dealer reporters:
jfunk@plaind.com, 216-999-4138 jmangels@plaind.com, 216-999-4842
© 2003 The Plain Dealer. Used with permission.
Copyright 2003 cleveland.com. All Rights Reserved.
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Thu, Oct 2, 2003 10:46 AM From:
Jonathan Wert <jwert@mdi-wert.com>
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Jonathan Wert <jwert@mdi-wert.com>
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Mon, Oct 20, 2003 10:52 AM
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Comment/Question Hi Jack, What say you on this?
NRC has the hammer it needs for Davis-Besse. Its the D-B root cause analysis report! Not the Haber report, the actual root cause analysis it did as part of their corrective action process that spawned the Haber report. NRC, if it wanted to, could perform a corrective action effectiveness inspection strictly related to the safety culture root causes identified by Davis-Besse and determine if the corrective actions satisfactorily address the root causes identifiedNRC could ask Ohio PUC to send one or two of their staffers to serve on the inspection team. That would really give FENOC a wake-up call!
Jonathan This e-mail has been verified Virus-Free and Spam-Free using:
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Samuel Collins To:
Richard E. Wilmot Date:
Sat, Oct 11, 2003 3:51 PM
Subject:
Re: lasting culture change vs. safety enviornment change Richard, thanks for your recent E-Mail and thoughtful comments, I have forwarded to Jack Grobe.
Sam
>>> "Richard E. Wilmot" <richwilmot@worldnet.att.net> 10/09/03 01:25PM >>>
Samuel J. Collins Deputy Executive Director NRC By way of background, I am forwarding two e-mails sent to John Grobe, NRC Chair, Davis-Besse investigation, on 26 Sept. and 7 October respectively. I hope you will read them.
If you take the time, you will see an observation based on 47 years of experience in organizational change. While the media continues to characterize remedial actions at Davis-Besse as culture change, they really are the creation of an environment for safety, coupled with task training specific to the operation and maintenance for safe operation of equipment.
[I have not received a response from Mr. Grobe, and in fairness, I have no assurances that he received them. I did ask his office for such an acknowledgment, but received none].
Culture change is what needs to take place within the minds of employees, modeled by the senior executives as a new way of doing business, at a nuclear site, the same as with any other formidable business unit.
That sort of culture shift has to be put in place as a foundation for the safety and task procedure improvements underway. If there is no accompanying noticeable and lasting change in the way management treats employees - at all levels by the way, the expensive and back-against-the-wall environmental changes now being put in place eventually will be compromised. It always works that way, as researched by me, and as a matter of human nature.
Lessons learned show that it does not matter how many key positions FE changes; how many professional training people are appointed...all recent employee research indicates that the most important factor in the facility is how they are treated day-to-day by their supervisors
[whether old or new]. Please accept the fact...this all starts at the top of the organization.
You are aware, and I certainly am not from media stories, of the degree to which realtime culture change is being addessed in FE. Workers can get very solid training regarding work procedures and safety issues, but until they see, feel, and begin to believe there is real culture change, they will not share the best of their talents and energies. Productivity, cost savings, and other factors unique to a nuclear facility obviously are also involved.
The safety adage "If it can happen, it will" gets the attention of employees, not from slogan boards, but from belief in culture, and trust of management [at all levels]. The point, as explained in the referenced e-mails, is that by working one-on-one with FEs nuclear senior executives, I can work introspectively with each individual regarding his/her daily work challenges, and teach them how to change the culture in their own areas of responsibility. I have the intellectual property in hand and experience in doing so over a very long period of time.
From the standpoint of value added, their new templates for building improved relationships, face-to-face communication, and mutual trust will be measured, and they will be held accountable for the employee upgrades they have designed with me. I can help put all this in place with the senior site executives. Most senior HR executives see that as a real plus for their appraisal systems. The CEO has to take responsibility for this culture change becoming institutionalized. A simple trade-off really.
From the standpoint of organizational development, all of this personal involvement by the apex of a nuclear site has another major plus. It builds a farm team of younger executives who can take the knowledge and experience into positions of greater responsibility throughout the nuclear site regions. That is a consideration which for you along with the energy companies.
With respect to the cost, if one considers the true expense of Davis-Besse repairs to date in changing the safety environment, my involvement in culture change would be a pond ripple.
It would be helpful to have someone in your organizations let me know that you have considered my non-specific proposal. As I work alone, I certainly qualify as a small business. If I should ever need to use sub-contractors [not appropriate here], they would be top-grade, recently-retired organizational development executives from General Motors.
I desire to speak with any of the three of you gentlemen who accept the differences in safety environment and culture change.
Respectfully,
Richard E. Wilmot President, People Strategies richwilmot@worldnet.att.net 440 250-0535 CC:
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Re: lasting culture change vs. safety enviornment change Creation Date:
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Response from "Contact the Web Site Staff" Below is the result of your feedback form. It was submitted by
Fenoc (Blakesmim@sbcglobal.net) on Friday, October 17, 2003 at 11:51:08 Web Site Category: Comment comments: Attention Mr. James Caldwell. Dear Sir. I am a Nuclear Security Officer at the Davis Besse NuclearPower Plant. I have been a officer here at the station since its inception way back in the construction stages in the mid 70s to the present time. I have seen alot of changes during this time some good some not so good however, I always felt the plant was safe and adequatley run by the operators and management staff. Sure, there were times in the past where certain problems were encountered, however, we never had a release or a near meltdown. Theres always that cliche that news reports mention a near meltdown or this or that problem could have and I emphazise could but in reality nothing happened which caused a meltdown or a release.We can scurtinize any establishment and find alot of skeletons in closets, I personally think that our leadership here didnot think we had a Boric accid problem as bad as we did. I believe they realized there was boric accid on top of the head but not to the extreme it was. This is my personal opionon and I surely believe that our management would never had kept operating the plant KNOWINGLY that the reactor head was in the condtion it was in. My gosh, if for a minute I thought that the company running the plant in a unsafe manner I would be the first person to contact you or someone and address my concerns. I have a wife, two children, four grand children and many friends that I care for and love and this faciity or any other not on the up and up that could effect our lively hood would be reported.
The Davis Besse plant had its problems in the early years. I am not a engineer and I dont know a whole lot about nuclear power but I do know that I always felt safe here at the plant. We always were preached and to this day reminded that safety is first and foremost. This is why it puzzles me to think that the news media is making this reactor head issue one that makes our company look like we had or have no regard for safety. This is truely a false impression although these kinds of assumptions sell newspapers which opens another can of worms for journalists to write and talk about and speculate in regards to what COULD have happened but didnt. We can speculate on different things everyday, just look at the news stories we see and read about day in and day out. Hind sight is always 20/20 but from now until when the cows come home there will always be speculation. The what if questions will always be apart of our lifes and to those for future generations to come. Mistakes will be made, but, the question remains did we learn from that particular mistake ? In our case here at Davis Besse yes, we made a mistake, however, it was not a deliberate mistake but a mistake which we may have taken for granted or how things were done in the past. But to operate our plant in a unsafe manner knowing full well that the plant had a problem as severe as a corrided reactor head truly would be hog wash. In closing, I thank you for your time as I address my feelings. In a couple of years, I will be retiring from here. I will have close to 30 years of service as a security officer.
I will no longer need Davis Besse to provide a living for me, its been a great place to work with excellent pay and benefits for my family and myself. Without it, I would not have all the many things I have today. Yes, I could say the hell with it, its not my problem, I am retiring soon let someone else worry about its outcome however, I have made many many friends there at the plant, and alot of young people joining our guard to replace us older ones. I hope they too will have a job like I have had to provide for thier family and needs. Thanks again for your consideration in order to get our plant someday back on the line.
- Sincerly,
Jim Bilgen Ext. 7556 organization:
address1: 2208 Karl Ann Drive address2:
city: Sandusky state: OH zip: 44870 country: usa phone:
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Thu, Feb 27, 2003 3:23 PM
Subject:
Is DB Culture Adequate for DB Restart? What is the Question to Ask?
- Jan, Please forward the below message on safety culture to the DB/NRC Safety Culture Oversight Group: Jim Dyer, Jack Grobe, Christine Lipa, Bill Dean and Tony Mendiola.
Thank you, Dave From: "collidm <collidm@y...>" <collidm@y...>
Date: Thu Feb 27, 2003 12:22 pm
Subject:
Is DB Culture Adequate for DB Restart? What is the Question to Ask?
When a professional is hired by a company to provide some kind of testimony so that company is let off the hook regarding some violation, regulation or lawsuit, the process usually begins with the professional identifying the needed answer and then going out and developing a body of supporting evidence. If this is not what is happening right now with safety culture at Davis Besse, I would be a bit surprised, although if no one admits to this, I would not be surprised.
I believe a question the NRC will soon be askoing is whether DB has established a safety culture that is adequate for restart and continued safe opertions. I suspect this question will asked of Dr. Haber at some point and will be something like this: "In your professional judgement, is the DB culture acceptable for restart?
Using what I witnessed at Millstone as a guide, I suspect the answer from Dr. Haber will be something like: "The culture could use a little more work, but in my professional judgement I would say it is acceptable for restart".
So what is the problem with this answer?
The problem is that it goes against the NRC's recent philosophy, which is a correct one. The NRC's recent philosophyhas been to reject subjective indicators in favor of objective, performance based, risk based ones. The NRC's main tool for assessing safety, the Reactor Oversight Process, was established upon this assessment philosophy.
So what question should the NRC really ask of Dr. Haber?
The NRC should not be satisfied with anything less than a substantially
supported answer to this question: Dr. Haber, what is the objective evidence that the DB safety culture going forward will represent an acceptably low risk of a future SOE. What is your objective evidence that the risk of a SOE like those experienced at DB in 1985 and 2002 is as low as reasonably acheivable."
If this question were asked, Dr. Haber might respond: "there is no objective way to demonstrate the risk is acceptably low now or going forward. However, in my professional judgement it is very low today."
But there is. There is an objective way to assess the risk introduced by the safety culture. It involves studying the culture of the many events with similar cause that have occured over and over again in the almost 25 years since TMI.
It also involves establishing a communications pipeline around plant management and directly to the NRC, so when employees like Andrew Siemaszko and others hit management roadblocks on safety significant issues, the NRC is flagged before the event, not after. If the NRC gets enough of these reports, the underlying attitudes are bounced off those attitudes that were found to be responsible for the 14 SOEs identified in INPO 02-005 where an inadequate focus on safety was identified as the primary cause.
This can be accomplished, but not with any of the methods currently applied by psychologists like Dr. Haber. This can not be accomplished if, as former ACRS Chairman Apostolakis claims, the Commission continues to block funding for the ACRS to do full and proper studies of safety culture. This can not be accomplished if the merits of state of the art methods for assessing and managing safety culture, such as the ones I have been proposing for some time now, are not fully and properly evaluated by the concerned members of the NRC.
Dave David M. Collins Engineering Analyst Millstone Power Station Dominion Nuclear Connecticut Phone 1-800-269-9994 x3710 Fax 860-444-4315 CC:
<DXP@nrc.gov>, <pmblanch@attbi.com>
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"Richard E. Wilmot" <richwilmot@worldnet.att.net>
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Subject:
Followup Mr. John A. Grobe Chairman, Davis-Besse Special Panel If my e-mail of 26 September 2003 did not cross your desk, I would greatly appreciate you associate so advising me. I would like you to see it and consider its contents.
If it did reach you, I would add these points. Based on lessons-learned in situations where the focus is suddenly on safety, and on proper job procedures, with much at stake from so many standpoints, I hope you will consider this:
Sometimes we tend to confuse the foregoing needs in terms of the word culture. Employees do not like that word, agreeing among themselves that culture is for the front office people, or what they hear consultants talk about in meetings.
SAFETY [to the thousands I have surveyed] is about job ENVIRONMENT; the area or areas in which they work on a daily basis; the safety training they receive; managements apparent concern for volume vs. insisting that employees well being is foremost, until there is a variance to suit a particular output need.
MANAGEMENT INTEREST in employees has everything to do with their task/job training and SAFETY TRAINING and what is likely to happen to an employee who is hurt or has a near lost time accident. i.e..W ill there be speedy care, or some level of discipline in the case of a near miss which will be argued in a grievance, which improves nothing safety-wise, and destroys managements credibility in terms of safety?
CULTURE CHANGE is a term they dont really understand, but if it is a better way of being treated, with some modicum of appreciation shown by management...fine. As I noted before, culture change has to start at the very top of the organization, often in response to employee surveys and focus groups. If the senior executives do not explain or model culture change, the consultant stuff...even with or without all the big words like seamlesss and intervention will mean nothing to First Energys people. Culture change must precede lasting safety changes. It has to come first to be of value. How many time does First Energy have to go through this to get it right?
I imagine they dont consult you with respect to competency of consultants. FE may not understand the foregoing facts. They obviously are in a big hurry to get back on line...with a new safety culture. What they need is an understood by all culture shift the deployment of which will be graded for credibility by employees at all levels. Greatly upgraded safety will follow.
Finally, the point: If they are so bent on creating a safety culture in response to your insistence and oversight, and still ignore the three proven underlying values needed to make it credible, they will have improved safety for a while, but like the equipment, it will leak and rust, and become just another program paid for....but not institutionalized as a FE way of doing business.
But, this will be the reality.
In my view, either First Energy senior officials know all of this cold, or they just do not respond to people like me. Just a few years ago, the then CEO invited me in for a one-on-one visit about real culture change. It was just as the first mergers were beginning to unfold. He said he wanted things to proceed for a few months, and then he would want me back in to see him and his HR vice president. I was still living in San Diego, and it seems that he retired early, or lost out in the seating arrangements, but he saw the needs I have explained to you. There has been no response, ever, from First Energy in recent months. All really good consultants expect courtesy responses. Essentially, that accounts for my e-mailing you based on all the changes you define as necessary to the media. As noted before, I believe that on a preventive basis, I could make an important contribution by working briefly with all the senior managements of your District 3 nuclear facilities. I emphasize preventive, and hope you will contact me with your thoughts.
Respectfully, Richard E.Wilmot President, People Strategies Westlake, OH
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"Jim Riccio" <jim.riccio@wdc.greenpeace.org>
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Date:
Thu, Jul 31, 2003 11:26 AM
Subject:
Davis Besse Question
Dear Mr. Grobe,
Thank you for returning my phone call so promptly and taking the time to answer my questions concerning the Davis Besse restart check list. Im encouraged by your answer.
It was unclear to me from Mr. Collins proposed denial of Congressman Kucinichs 2.206 petition whether the NRC would allow Davis Besse to restart prior to addressing the design
basis issues that were supposed to have been resolved back in the 1990s. As I mentioned in our telephone conversation, the nuclear industrys lack of fidelity to the design and licensing basis has been of particular concern to me. I believe it undermines NRCs attempts to move to risk based regulation and has the potential to blind the industry and the agency to issues that contribute greatly to core damage probability. Since Davis Besse, has over its history, been unable or unwilling to ensure the adequacy of its design and licensing basis, I believe it is appropriate that the NRC not allow the reactor to restart unless and until the design basis deficiencies identified in the 1990s are resolved. I eagerly await the inspection report that closes out these long standing design basis problems and finally addresses design basis issues that evolved as a result of the Millstone debacle.
The other question that I was unable to properly characterize in our conversation arises out of the NRCs Special Inspections of the Adequacy of Safety Significant Programs dated July 7, 2003.
In the second report, NRC assesses the plant modification program at Davis Besse because, the lack of adequate safety evaluations associated with the modification program, specifically installed modifications, had the potential to effect the facility design basis. NRC inspectors concluded that the program adequately identified deficiencies and that corrective actions were established. However, the inspectors stated that they were unable to assess the latent impact of newly identified deficiencies relative to past modifications that were installed. The licensee and inspectors agreed that the corrective action program would address these deficiencies and closed out the modification control item on the restart checklist.
My concern is that if the NRC and the licensee rely upon the corrective action program, latent deficiencies in the 50.59 modifications will only be addressed when they become glaringly evident in the form of an incident or an accident. Given the industrys past history with 50.59 and Davis Besses track record of near misses, waiting until these latent deficiencies become self evident may not be the most prudent approach to reactor safety. I hope you can address this concern.
Thank you for your time and your kind words regarding my testimony before the Commission.
Unfortunately, the Commissioners did not view my release of the unedited version of the Davis Besse Lessons Learned Task Force report in the same light. In fact, they attempted to shoot the messenger. If the NRC had released the versions I read, the agency would be viewed as a much stronger regulator. At least it helped me realize that there are still good people working at the NRC who actually want to regulate the nuclear industry, if only the Commission and Senior management would let them.
Thank you again for your time and consideration of my concerns.
Jim Jim Riccio Greenpeace 702 H Street NW #300 Washington, DC 20001
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Davis Besse Question Creation Date:
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Jon Hopkins To:
Lipa, Christine; Mendiola, Anthony; Stang, John Date:
Fri, Nov 21, 2003 9:19 AM
Subject:
telephone call Place:
DBCommunication I was contacted on Thurs. 11/20/03 2:50 pm by Vicki Bier of the University of Wisconsin. She stated that she has previously performed contract work for the NRC and Paul Lewis of NRC RES told her to call me with her question. Her question was; Is the NRC going to respond to the recent UCS document? (The "Disaster at Davis-Besse: What Might have Been" document)
Background info. provided by her was that she (and others) may write a response to document if NRC does not. I told her that I did not know if NRC was preparing a response to document.
I then took her phone no. 608-262-2064, and told her that I would turn over her question to Comm. team and someone would get back to her.
Jon CC:
Burnell, Scott; DBCommunication; Kotzalas, Margie; Muniz-Gonzalez, Adrian Mail Envelope Properties (3FBE1EE7.92D : 6 : 20443)
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telephone call Creation Date:
Fri, Nov 21, 2003 9:19 AM From:
Jon Hopkins Created By:
JBH1@nrc.gov Recipients nrc.gov ch_po.CH_DO CAL (Christine Lipa) nrc.gov owf1_po.OWFN_DO SRB3 CC (Scott Burnell) nrc.gov owf2_po.OWFN_DO AJM (Anthony Mendiola)
DBCommunication CC (DBCommunication)
MXK5 CC (Margie Kotzalas) nrc.gov owf4_po.OWFN_DO AXM8 CC (Adrian Muniz-Gonzalez)
JFS2 (John Stang)
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Ben Wisner <bwisner@igc.org>
To:
<allegation@nrc.gov>
Date:
Thu, Dec 4, 2003 1:04 PM
Subject:
Davis Besse facility
Dear NRC,
I am an expert in social and human aspects of risk, a field in which I have been active for nearly 40 years. The second, expanded edition of my text book, At Risk, was just published in London by Routledge (B. Wisner et al, At Risk, 2nd Edition, London: Routledge, 2003, 471 pp.).
I am also a citizen of Ohio who lives approximately 40 miles from the Davis Besse nuclear facility.
I want to register my considered opinion that this plant should not be restarted. First Energy Corporation has proven itself definitively and irreparably incapable of understanding, much less implementing, a so-called "culture of prevention". They claim to have "learned" a great deal from the execrable and irresponsible lack of maintenance and oversight that led to the shut down 20 months ago. However, none of that "learning" was evident in precisely the same kind lapses (lack of maintenance, poorly trained staff) that recently led to a electricity blackout that affected 50 million people. As a corporation they clearly have learned nothing.
My own specialty area is precisely concerned with what the United Nations Decade for Natural Disaster Reduction termed the "culture of prevention". This is an easy term for a corporation to bandy about. What actually does First Energy Corporation mean when they use the term?
They recently announced that their own survey of Davis Besse employees showed 99% of them think that the plant is safe to restart. Who in their right mind could take such a "survey" seriously? Is there no awareness of the built-in bias when an employer "surveys" employees?
Can First Energy seriously have meant this "survey" to have any weight or to provide any data of relevance to the re-start application? Surely a survey of the crew of the Titanic or the workers at Three Mile Island or Chernobyl on the eve of their respective disasters would have revealed high levels of confidence. If this is what First Energy Corporation takes to be evidence of a culture of prevention, I despair.
I believe among other simple, robust indications that the entire workforce at Davis Besse has safety first and foremost in mind and understands that in complex, tightly coupled systems even small, "routine" problems can escalate and produce system failure, is the following. How many reports have there been by Davis Besse employees of any kind of irregularity in the plant over
the past, say, 48 months? Graph these. Is there a trend? If training and re-training has been successful, and if there has been put in place a system that rewards (and does not punish) such reports, then the number should be growing, especially in the last, say, 10 months.
I would be very grateful if you would provide the public with such a graph. It would do a great deal to clarify the safety situation in the mind of the public. Failing this, I remain convinced on the basis of what I know of First Energy Corporation that I must throw all my professional and private influence into the campaign to shut Davis Besse down for good.
Yours sincerely, BEN Dr. Ben Wisner Affiliated Researcher, Environmental Studies Program, Oberlin College & Research Fellow, Benfield Hazard Research Centre, University College London CC:
<bwisner@igc.org>
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Davis Besse facility Creation Date:
Thu, Dec 4, 2003 3:59 PM From:
Ben Wisner <bwisner@igc.org>
Created By:
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Standard From:
"Jim Greer" <jpg@cros.net>
To:
"Jack Grobe" <JAG@nrc.gov>
Date:
Wed, Nov 26, 2003 5:00 PM
Subject:
Island Evacuations Mr. Grobe, As you are aware, evacuation planning for the Lake Erie Islands has been a topic of conversation at a few of our public meetings. After each of those meetings, I have invited members of the Ohio Citizen Action group to visit the Ottawa County EMA office / EOC to discuss the issue. To date, no one has taken me up on my offer.
Below is a copy of a letter I sent to Put-In-Bay Township trustees, the mayor of P-I-B, the islands police, fire and EMS and school superintendent when Amy Ryder first made her accusations. No additional meetings were requested by island officials as a result of the letter.
Now, "the residents" of Kellys Island (Erie County) are raising similar concerns. I have used maps produced by 4 different agencies and find that Kellys is 18.3 - 18.5 miles from DBNPS. It is difficult to foresee any scenario that would require evacuating the approximately 400 permanent residents of Kellys. It is even more difficult to postulate a scenario that would require a fast evacuation. However, if events ever did require such a move, Im certain that it would be handled similar to our plan for Put-In-Bay Township.
Jim Greer To: Put-In-Bay Officials From: Jim Greer Date: July 11, 2003
Subject:
Lake Erie Islands Evacuation Plans Amy Ryder of Ohio Citizens Action (OCA) stated in a Nuclear Regulatory Commission (NRC) public meeting Wednesday that plans do not exist for evacuation of the Lake Erie Islands. She then claimed to have spoken to me and had been told, "There are no plans for the Islands. The island residents are the most resilient people around and have no need for a plan."
After the meeting, I introduced myself to Amy and she admitted that we had never talked. She said, however, that she read the notes taken by another OCA member who had called me.
When I tried to clarify that plans do exist, she alleged that Island officials were unaware of any plans.
Ottawa County Emergency Management personnel have participated in a number of planning meetings with Put-in-Bay police, fire and EMS chiefs and mayors. Based on these discussions, we envision an evacuation proceeding as follows.
Visitors would be advised to leave utilizing the same mode of transportation that brought them i.e. aircraft, private watercraft or ferry. Enclosed is a current mainland transportation resource list.
Evacuees would be ferried to four locations to alleviate congestion. This also facilitates faster unloading thus allowing the boats to return more quickly to shuttle additional evacuees.
When the ferries are not running, there are obviously fewer people to transport. A State of Emergency would be declared by the Ottawa County Commissioners and by the Governor.
National Guard aircraft could then be utilized. We would also request helicopter assistance from the US Coast Guard and from air ambulance services.
If weather conditions preclude water and air transport, residents would have to shelter in place until conditions improve. The Ottawa County District Office of the American Red Cross can provide training on shelter management and on a host of other topics.
We would be happy to meet with you at your convenience to discuss this or any other concerns. Please contact the EMA office if you are interested in meeting.
cc: Board of Commissioners County Administrator Red Cross JPG/cah CC:
"Jere Witt" <jwitt@co.ottawa.oh.us>, "John Papcun"
<jpapcun@co.ottawa.oh.us>, "Carl Koebel" <ckoebel@co.ottawa.oh.us>, "Steve Arndt"
<sarndt@co.ottawa.oh.us>
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Island Evacuations Creation Date:
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jpg@cros.net Recipients nrc.gov ch_po.CH_DO JAG (John Grobe) co.ottawa.oh.us sarndt CC (Steve Arndt) ckoebel CC (Carl Koebel) jpapcun CC (John Papcun) jwitt CC (Jere Witt)
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Standard From:
Jonathan Wert <jwert@mdi-wert.com>
To:
<JAG@nrc.gov>
Date:
Sat, Dec 20, 2003 2:06 PM
Subject:
A question for you
- Jack, Do you (or the NRC) concur that this document represents what a good nuclear safety culture is????
Jonathan
NUCLEAR SAFETY CULTURE CODE OF CONDUCT Jonathan Wert, Ph.D., President Management Diagnostics, Inc.
P.O. Box 240 Port Royal, PA 17082-0240 717-527-4399 E-Mail: <mailto:Jwert@mdi-wert.com>Jwert@mdi-wert.com URL: <http://www.mdi-wert.com/>www.mdi-wert.com 2003 Developing and maintaining an effective nuclear safety culture requires leadership by the chief nuclear officer (CNO) and spreading the culture throughout all levels of the organization.
Because of the importance to accident prevention, the Board, Chief Executive Officer (CEO),
and regulators must, to the extent that they are able to do so, guide, support, and encourage the chief nuclear officer (CNO) as he or she manages the organizations nuclear safety culture to obtain the desired results.
Giving the CNO a free hand and total empowerment regarding nuclear safety culture is not enough. The nuclear safety culture upgrade and maintenance process requires the non-nuclear top leadership in the organization to continually monitor, evaluate, and actually require that the CNO develop and maintain a healthy nuclear safety culture. While it is up to the CNO to reward, recognize, and reinforce the appropriate behaviors throughout the nuclear facility, the senior nuclear manager must have a continuing and crystal clear understanding that continuous nuclear safety culture improvement is both expected and fully supported by the top corporate hierarchy.
The individual employee has a parallel and complimentary obligation: to identify issues and conditions adverse to safety and quality, to use available avenues to inform responsible management of those issues and conditions, to perform daily tasks and assignments in accordance with established polices and procedures, and to comply with the organizations Standards of Conduct.
All senior managers should keep in mind that no nuclear organization has ever suffered from a nuclear safety culture that was too good. Nevertheless, almost every organization involved with nuclear power has suffered from a lack of understanding of nuclear safety culture and what constitutes a good nuclear safety culture. With this in mind, it is useful to try to improve everyones understanding by stating a Nuclear Safety Culture Code of Conduct.
Nuclear Safety Culture Goals - An effective nuclear safety culture (NSC) is a work environment where a safety ethic permeates the organization and peoples behavior focuses on accident prevention through critical self-assessment, pro-active identification of management and technical problems, and appropriate, timely, and effective resolution of problems, ensuring that no problem ever becomes a crisis. This includes assuring that adequate resources are available to identify and correct safety and quality issues in a timely manner and to assure that a philosophy of continuous improvement can be sustained over the long-term. The goal of an
effective nuclear safety culture is to assure that defense-in-depth is maintained for all aspects of the nuclear facility. This best assures that safe, reliable production is maintained throughout the operating lifetime of the facility.
This goal is not a fixed endpoint; rather it requires continued commitment to maintain it over the long-term. Many organizations cannot sustain such a commitment for all emergent situations.
It is expected that the existence of a Nuclear Safety Culture Code of Conduct, properly stated and applied and backed with the proper resources, is a necessary first step in developing such a commitment to assure that safe, reliable production can be maintained over the long-term despite changes in senior nuclear managers and other key staff positions.
Intent: To promote lawful and ethical behavior by all employees and to ensure that a healthy safety culture is continuously maintained according to the values of the Company and all applicable rules, regulations, and laws.
Applies to: This policy applies to all employees involved with any aspects of nuclear plant activities.
Guidelines: The Company is committed to conducting its business ethically and with integrity.
Moreover, the Company has an extraordinary mandate to provide proper stewardship of its nuclear plant, ensuring employee safety as well as public safety.
The ethical conduct of the Company depends on the collective conduct of its employees and officers. The Company has adopted the following principles to guide employee behavior in order to maintain a healthy nuclear safety culture:
- 1. The nuclear safety culture program shall be championed by Company leaders who are expected to lead by example in the pursuit of continuous improvement of the organizations nuclear safety culture.
- 2. Each employee in their day-to-day activities must be vigilant in considering (a mindset) the potential nuclear safety implications of their actions in order to assure that the foremost priority of nuclear reactor safety is achieved.
- 3. All employees are expected to be ethical and truthful, boldly doing the right thing at the right time for the right reasons.
- 4. All employees are expected to ensure open and truthful communications, whether the news is good or bad, without fear of reprisal, being rewarded rather than condemned for raising potential problems or issues.
- 5. All managers, supervisors and team leaders are expected to pay attention to people concerns, showing care for and trust of their fellow workers, and ensuring that, to the extent feasible, all workers are proud of what they do within a no-fault management environment.
- 6. Actions by managers must be such that they encourage excellence in job performance and demonstrate a continued, high level of appreciation for each workers knowledge and experience, which are maintained through rigorous training.
- 7. All employees are committed to maintaining and enhancing defense-in-depth, preserving safety margins relative to any unknown conditions that may exist.
- 8. All workers are expected to do the job right the first time and, when that doesnt happen, take prompt and appropriate corrective actions that will fix it right the first time.
- 9. All employees are expected to pay attention to detail in all their activities and not proceed without a suitable risk assessment being conducted.
- 10. All employees are expected to promote a questioning attitude within themselves and within their fellow employees, cultivating an environment where no one is afraid to raise issues or ask questions, and everyone rigorously challenges assumptions.
- 11. Leaders are not only expected to practice management by walking around (MBWA) to see what is really going on in the plant, they are expected to understand what they are looking at and to be able to contribute to direct supervision and oversight of activities.
- 12. All managers are expected to maintain true open communications, ensuring that an open door policy is practiced and recognized as an option for communicating issues and concerns by all workers.
- 13. Managers are expected to recognize and reward workers and supervisors for their sustained nuclear safety related improvements and achievements. Personal performance will be judged, in part, on the individuals achievement of safety, and accountability for substandard performance is understood.
- 14. All employees are expected to learn from experience, internal as well as external, heeding first the lessons of the industry as well as events and near misses experienced within the organization.
- 15. Employees are expected to recognize that regulatory compliance is the ground level they are to be standing on, not a wall to be climbed over.
- 16. Work-arounds and operating with known degraded equipment are the exception and are discouraged, tightly monitored, controlled, and corrected in a timely manner.
- 17. Managers will ensure that appropriate financial, human and other required resources are provided to employees in addressing day-to-day tasks related to safety. This also includes assuring that adequate resources are brought to bear when unexpected problems are identified.
- 18. All nuclear plant personnel are expected to know the plant design and its current configuration as it directly applies to their duties. Further, each staff member is encouraged to learn more about these items so that they can be even more effective in performing their assigned duties.
- 19. Managers and supervisors will address conflicts and employee concerns promptly and fairly, ensuring a work environment in which workers feel free to raise concerns.
- 20. All employees are charged with encouraging fellow employees to raise safety concerns and ensuring an environment free of negative management and peer pressures as well as an environment free of retaliation for those who raise safety concerns, regulatory issues, questions concerning the adequacy of work, or procedural issues.
Comply with laws, regulations, rules and policies: Employees are expected to be familiar and comply with all of the policies of the Company that apply to their employment. In addition, a commitment to ethical conduct requires that employees comply with the spirit of the law as well as the letter of the law. It is each employees duty to know, understand and comply with any job-related laws, regulations, and rules. This also includes truthful communication with regulators. Violating the law will in the least seriously damage the Companys and the employees reputation and can also lead to financial liability beyond available resources.
Moreover, all such requirements are ultimately intended to provide for the safe and efficient operation of the nuclear plant, so full compliance with all requirements and the associated intentions of the requirements is expected.
Practice good conduct: Each employee has a responsibility not only to do the right thing but also to avoid behavior that could be perceived as failing to do the right thing. Employees should always act in the best interest of the Company and avoid even the appearance of a conflict of interest. (See Company Conflict of InterestPolicy).
No harassment: Harassment of any kind seriously undermines the integrity of the employment relationship and respect for human dignity. The Company is committed to providing a work environment free from harassment, intimidation, and coercion based on or related to race, sex, religion, national origin, age, disability, or any other classification protected by law. Each employee has a responsibility to uphold the Companys commitment to provide a workplace free from harassment of any kind.
Commitment to safety: Each employee should perform his/her job safely at all times, protecting the public, customers, other employees and themselves from injury. It is each employees responsibility to look out for and resolve unsafe situations. An employee should immediately report to management any unsafe situation he/she is unable to resolve.
Keep accurate records: It is important that the Company maintain accurate and reliable records that meet applicable legal, financial, regulatory and management requirements. Each employee has a responsibility to ensure all Company records, such as accounts, reports, bills, invoices, work and time keeping records, and correspondence are accurate.
Treat confidential information properly: Confidential information is any non-public information that -- if disclosed -- would be damaging to the best interests of the Company. Each employee has a responsibility to hold all such information in confidence except in the event an employee believes that a safety issue has not been properly addressed and that the only avenue for resolution is referral to an outside regulatory authority, as prescribed specifically for nuclear reactor licensing. Except in that case, Company information should not be shared with the media, competitors or any other third parties. If there is any doubt about whether such information has already been publicly released, the employee should contact Corporate Communications, the Legal Department, or Investor Relations for guidance.
Report violations: If an employee knows about or suspects misconduct, illegal activities, fraud, misuse of Company assets or violations of Company policies, the employee has a duty to report
concerns. The employee is encouraged to report any such concerns to his/her supervisor or Legal Department. Calls and e-mails can be anonymous. There will be no retribution against any employee making such a report in good faith. Violations should be reported as soon as they are discovered or suspected.
No retaliation: It is a violation of this policy for any Company officer or employee to retaliate or discriminate, directly or indirectly, or encourage others to do so, against an individual who reports a suspected violation or provides information relevant to an investigation of any conduct which the individual reasonably believes to be a violation of applicable laws, regulations, or Company policies.
Accountability: Disciplinary action for deliberate or willful non-compliance may include termination, referral for criminal prosecution, and/or reimbursement to the Company for any losses or damages resulting from violations of the Safety Culture Code of Conduct. Examples of violations include:
Authorizing or participating in actions which violate applicable laws, regulations, or Company policies.
- Failing to report a violation or willfully withholding relevant and material information concerning a violation.
- Retaliating against individuals who report or assist in investigations of suspected violations of applicable laws, regulations, or Company policies.
Audit: To ensure that the safety culture program meets its intended purpose and is continuous or ongoing, an independent, third party entity will monitor and evaluate the program, and a status report with improvement recommendations will be submitted to the Board on an annual basis. The audit process may include a combination of interviews, review of documentation, surveys, tests, and work observation. The Board and leadership will respond to each recommendation and report conditions, results and needs to all employees. The executive management or leadership must validate the accuracy and integrity of their safety culture program and its financial management. Specifically, the Chief Executive Officer (CEO),
President, Chief Nuclear Officer (CNO), and the Plant Manager must sign off on safety culture program and related financial expenditures. The requirement for sign offmay also be required at lower management and supervisory levels in the organization. The processes and documentation required for nuclear safety culture program compliance are rigorous; the nuclear plant owner must have established procedures for measuring, monitoring and reporting obligations, with suitable certification by Company officers that reports are complete and accurate.
Compliance Officers: The Companys General Counsel serves as the Companys Chief Compliance Officer. As such, he has appointed several high level officers to serve as Compliance Officers. Each Compliance Officer has a responsibility to ensure that the Companys Safety Culture Program functions effectively within his or her area of responsibility and to ensure that the Safety Culture Code of Conduct is effectively communicated to employees and implemented on an ongoing basis.
END
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Subject:
A question for you Creation Date:
Fri, Dec 19, 2003 10:46 PM From:
Jonathan Wert <jwert@mdi-wert.com>
Created By:
jwert@mdi-wert.com Recipients nrc.gov ch_po.CH_DO JAG (John Grobe)
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Standard From:
Paul Gunter <pgunter@nirs.org>
To:
<cal@nrc.gov>
Date:
Wed, Dec 31, 2003 3:10 PM
Subject:
Ltr re: OMA@Davis-Besse Hello Christine,
Here is the letter that was emailed to Jack Grobe re: questions pertaining to operator manual actions for fire protection and the 1998 Confirmatory Order for the restoration of fire barrier systems affecting by Thermo-Lag 330-1 per 10 CFR 50 Appendix R III.G.2.
Paul Gunter, Director Reactor Watchdog Project Nuclear Information and Resource Service 1424 16th Street NW Suite 404 Washington, DC 20036 Tel. 202 328 0002 www.nirs.org Mail Envelope Properties (3FF32D22.605 : 10 : 62981)
Subject:
Ltr re: OMA@Davis-Besse Creation Date:
Wed, Dec 31, 2003 3:10 PM From:
Paul Gunter <pgunter@nirs.org>
Created By:
pgunter@nirs.org Recipients nrc.gov ch_po.CH_DO CAL (Christine Lipa)
Post Office Route ch_po.CH_DO nrc.gov Files Size Date & Time MESSAGE 453 Wednesday, December 31, 2003 3:10 PM NRCltr-12292003-DB0350-fireprotection[1].doc 21504 Mime.822 31255 Options Expiration Date:
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