ML040230201
| ML040230201 | |
| Person / Time | |
|---|---|
| Site: | Davis Besse  |
| Issue date: | 12/19/2003 |
| From: | NRC/RGN-III |
| To: | |
| References | |
| MC 0350 | |
| Download: ML040230201 (103) | |
Text
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2 PUBLIC MEETING BETWEEN U.S. NUCLEAR REGULATORY COMMISSION O350 PANEL 3 AND FIRST ENERGY NUCLEAR OPERATING COMPANY OAK HARBOR, OHIO 4
5 Restate Readiness Assessment Team and 6 Management & Human Performance Phase 3 Inspection Results Meeting held on Friday, December 19, 2003, at 9:00 a.m. at 7 the Administration Building of the Davis-Besse Nuclear Power Plant, Oak Harbor, Ohio, taken by me, Marie B.
8 Fresch, Registered Merit Reporter, and Notary Public in and for the State of Ohio.
9 10 PANEL MEMBERS PRESENT:
11 U. S. NUCLEAR REGULATORY COMMISSION 12 John "Jack" Grobe, 13 Senior Manager, Region III Office
& Chairman, MC 0350 Panel 14 William Ruland, Senior Manager NRR
& Vice Chairman, MC 0350 Panel 15 Christine Lipa, Projects Branch Chief Christopher Scott Thomas, 16 Senior Resident Inspector U.S. NRC Office - Davis-Besse 17 FIRST ENERGY NUCLEAR OPERATING COMPANY 18 Lew Myers, FENOC Chief Operating Officer 19 James J. Powers, III Director - Nuclear Engineering 20 Mark Bezilla, Vice President/Plant Manager Mike Roder, Manager - Plant Operations 21 Barry Allen - Director of Operations 22 ---
23 24 25 MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
2 1 INSPECTION TEAM MEMBERS - RESTART READINESS ASSESSMENT 2 Rick Skokowski, Team Leader SRI - Byron Facility 3 Dave Passehl, NRC Region III Project Engineer 4 Tim Hoeg, Senior Resident Inspector Granville Nuclear Station 5 Jerry Blake, Senior Project Manager &
Senior Metallurgic Engineer 6 Division of Reactor Safety, Region II George Wilson, Senior Resident Inspector 7 Duane Arnold Energy Center John Zeller, Senior Resident Inspector 8 NRC Region II Office - Vogtle Jack Rutkowski, NRC Resident Inspector 9 Davis-Besse Nuclear Power Plant 10 INSPECTION TEAM MEMBERS - MANAGEMENT & HUMAN PERFORMANCE 11 Geoffrey Wright, Region III, Team Leader 12 Clare Goodman, NRR Julius "Jay" Persensky, RES 13 Lisamarie Jarriel, NRR John Beck, Consultant 14 Michael Brothers, Consultant 15 ---
16 17 18 19 20 21 22 23 24 25 MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
3 1 MS. LIPA: Good morning.
2 Welcome to the NRCs public meeting here today to discuss 3 recent inspection findings from two of our inspection 4 teams.
5 And, I just wanted to make sure everybody knows we 6 have people on the phone lines that have called in today, 7 and so everybody will need to speak clearly into their 8 microphones. Can everybody hear me in the back all right?
9 Okay, Ill try to speak up a little bit.
10 My name is Christine Lipa. Im with the Nuclear 11 Regulatory Commission. Im a Branch Chief out of Region 12 III. What Im going to do today is introduce the folks up 13 here at the table, go through some opening 14 administrative-type comments for the meeting, and then Ill 15 turn it over to the first inspection team, for them to 16 introduce their members and give their findings; and then 17 weve have the second inspection team.
18 Well be taking a break about every hour to an hour 19 and a half. So, thats kind of the order of activities for 20 today. And then, we will be having time before the 21 meeting is adjourned today, after the business portion is 22 adjourned, well be having time after that for public 23 comments and questions; both from people here in the room 24 and from people on the bridge lines. So, thats kind of 25 the overview of what were having this morning.
MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
4 1 Okay, so, up here for the NRC folks that are at the 2 table, we have Jay Persensky, who is a member of Geoff 3 Wrights team and Geoff will introduce his team more fully 4 later. Geoff Wright is the Team Leader out of Region III 5 for the Management and Human Performance Phase III 6 Inspection.
7 And then to my right, I have Scott Thomas. Hes the 8 Senior Resident Inspector here at Davis-Besse.
9 To my left, I have Bill Ruland. Hes a Project 10 Director out of NRR. Hes the Vice Chairman of the panel.
11 To Bills left, we have Jack Grobe. Jack Grobe is 12 the Chairman of the 0350 Panel.
13 Then, we have the inspection team, Rick Skokowski is 14 the Team Leader for the Restart Assessment Team. And Rick 15 will introduce, and have his team members introduce 16 themselves in a few minutes.
17 I also wanted to acknowledge Jan Strasma is here, 18 hes the Public Affairs Officer of Region III, in the 19 back.
20 There were a couple of handouts when you came in 21 this morning. One of them is a feedback form that you can 22 use to provide feedback on how this meeting is working 23 today, and what you got out of it and any comments you have 24 for us.
25 We also will have at one of the breaks, you can get MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
5 1 up, there is a handout for Geoff Wrights team, which will 2 be second. So, you dont need to run for your handouts 3 now, youll have time at the break to get those.
4 The first inspection team results, we do not have a 5 handout for that, so youll have to just listen carefully.
6 This is what we consider a Category One Meeting from 7 the NRCs classification of meetings. That means it is a 8 business meeting with FirstEnergy and there will be time 9 for public comment and question before the meeting is 10 adjourned.
11 We have a transcriber today. And this meeting will 12 be transcribed. The transcription will be available within 13 about 2 to 3 weeks on our web page. Because we have a 14 transcriber, because of the people on the bridge lines, I 15 want to emphasize how important it is to speak into the 16 microphones today.
17 And thats really all I had for now. Ill go ahead 18 and turn it over to Rick to introduce his team.
19 MR. SKOKOWSKI: Thank you, 20 Christine.
21 Good morning. As Christine said, my name is Rick 22 Skokowski. I was the Team Leader for the Restart Readiness 23 Assessment Team Inspection. Im currently the Senior 24 Resident Inspector at the Byron facility run by Excelon; 25 prior to that Ive been the Resident at the Fitzpatrick MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
6 1 Plant run by Entergy most recently, before that New York 2 Power Authority; and prior to that I was Resident at Niagra 3 Mohawk, Nine Mile Point 1 and 2.
4 Ill go to Dave Passehl.
5 MR. PASSEHL: Hi, Im Dave Passehl.
6 Im currently the Project Engineer at NRC Region III.
7 Prior to that, I was a Senior Resident Inspector at 8 Callaway Plant in Missouri, run by the former Union 9 Electric Company. Prior to that, I was a Resident 10 Inspector at Palisades run by Consumers Power. I was also 11 prior to that the Resident Inspector at D.C. Cook run by 12 American Electric Power.
13 My primary assignment for this current inspection 14 was to assess QAs involvement in Restart Readiness.
15 MR. HOEG: Good morning. My name 16 is Tim Hoeg. Im currently the Senior Resident Inspector 17 at the Granville Nuclear Station in Port Gibson, 18 Mississippi. Thats a Region IV Plant. Prior to my 19 assignment at Granville, I was a Resident Inspector at 20 Calvert Cliffs Station in Maryland owned and operated by at 21 the time by Gulf Core Gas and Electric.
22 My primary responsibility for the Restart Readiness 23 Inspection was Engineering.
24 MR. BLAKE: My name is Jerry 25 Blake. Im a Senior Project Manager and Senior Metallurgic Metallurgical MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
7 1 Engineer from the Division of Reactor Safety in Region II.
2 Ive been with the Division of Reactor Safety for 28 years 3 and during that time Ive been a supervisor, Ive been a 4 Team Leader on a number of Restart, Accident Investigation, 5 Maintenance, and Engineering Evaluation Team Inspections.
6 My part of this inspection was observing 7 Maintenances support of Operations.
8 MR. RUTKOWSKI: My name is Jack 9 Rutkowski. Im a Resident Inspector here at Davis-Besse 10 since June of last year. Prior to joining the NRC, from 11 the period of 1986 to the period of 1996, I was Assistant 12 Plant Manager at the Donald C. Cook Nuclear Power Plant.
13 After that, I was a Senior Internal Consultant working out 14 of Organizational Development Organization in American 15 Electric Powers corporate office in Columbus, Ohio.
16 My primary responsibility for this inspection was 17 Configuration Control.
18 MR. ZELLER Zieler: Good morning, my 19 name is John Zeller Zieler. Im the current Senior Resident 20 Inspector out at NRC Region II Office down at Vogtle, which 21 is owned and operated by Southern Nuclear Company. Prior 22 to that I was a Resident Inspector at H. P. Robinson, who 23 is operated by Progress Energy. Prior to that, I was a 24 Resident Inspector at the Catawba Station, which is owned 25 and operated by Duke Energy down in South Carolina.
MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
8 1 My primary responsibility during this inspection was 2 to look at Surveillance Testing.
3 MR. WILSON: Im George Wilson.
4 Im presently the Senior Resident Inspector at the Duane 5 Arnold Energy Center, operated by the Nuclear Management 6 Company. Prior to that, I was a Resident Inspector at the 7 LaSalle Nuclear Plant operated by Excelon. Prior to that, 8 I was an Operator Licensing Examiner in Region III. And 9 prior to that, I was a Senior Reactor Operator and I&C 10 Supervisor for TVA.
11 My primary responsibility during this inspection was 12 to look at the assessment of Operations.
13 MR. SKOKOWSKI: Lew, do you want 14 to introduce the main players of your team?
15 MR. MYERS: Let me take a 16 moment now.
17 First to my right is Mike Roder. Mike Roder is our 18 Operations Manager. Mark Bezilla, to my left. Mark is the 19 Site VP. Barry Allen, the Director of Operations, is 20 beside him. And then, Jim Powers is at the end of the 21 table. Hes our Director of Engineering.
22 We also have some people in our audience today.
23 Fred von Ahm Ahn, VP of Oversight, is with us; the Senior VP of 24 Engineering and Services, Joe Hagan is here with us. Gary 25 Leidich, the President of FENOC, is also with us.
MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
9 1 MR. SKOKOWSKI: Thank you.
2 As I said, this is the Exit Meeting for the 3 Davis-Besse Restart Readiness Assessment Team Inspection.
4 The findings will be documented in Inspection Report 2003 5 Number 11.
6 MR. GROBE: Rick, excuse me.
7 Lew, did you have any opening remarks you wanted to 8 make?
9 MR. MYERS: Well, I had 10 thought about, some thoughts before the meeting. As you 11 know, the purpose of this meeting is to discuss our recent 12 plant operations and our Operations group, if you will, 13 and then finally the Management/Human Performance Building 14 Blocks.
15 We had a debrief over the past few days of findings 16 that this team has had. And, you know, one of the comments 17 I would make, this is a very strong team that you brought 18 in, one that I have been able to understand very clearly.
19 So, you know, from a standpoint of their issues, they dont 20 have any issues that Ive heard that we dont understand 21 and we dont agree with. So, going into the meeting, let 22 me say that.
23 Our operators, in general, what we see is our 24 operators are not having events. Let me be clear of that 25 at the very beginning of the meeting. And consistently, MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
10 1 when faced with abnormal equipment operating issues, have 2 shown a consistency to provide safe and comprehensive and 3 conservative operations. They stop, put the plant where 4 they need to, equipment where they need to, and 5 troubleshoot in places they need to, you know.
6 In general though, what I think this team is seeing, 7 what were seeing as a management team also in both our 8 management observations and our industry observers, is that 9 we have not consistently performed our routine operations 10 in a manner that, thats consistent. We need to continue 11 to improve there before we start the plant up.
12 For example, let me use some examples of what were 13 seeing, is that, were not consistently seeing the 14 requirements of our Conduct of Operation nor our Prejob 15 Briefs consistently being implemented. The management 16 tools that we use to ensure that activities go off as 17 planned, are not consistently being implemented in our 18 Operations group.
19 As you know, were planning a meeting on December 20 the 29th to discuss the results of the Safety Conscious 21 Work Environment that well discuss later. And at that 22 time, I think we will be ready, its our intention to be 23 ready, to not only discuss the Safety Conscious Work 24 Environment survey that we recently took, but the actions 25 were taking and going to continue to take in Operations to MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
11 1 ensure that we have consistency in our day-to-day 2 operations.
3 And, in closing, once again, we were debriefed by 4 this team, for what, four hours last night. And this is a 5 very fine team. Were seeing the same things you are. We 6 wont heat the plant up until were ready. We wont start 7 the plant up until were ready. I dont think we have any 8 disagreements from FirstEnergy today on the issues that 9 you, that weve heard from you. Okay?
10 MR. SKOKOWSKI: Understand. Thank 11 you, Lew.
12 I do wish if there is any questions regarding the 13 inspection findings and observations, that you hold them 14 until I finish going through the results.
15 The purpose of this inspection was to evaluate the 16 readiness of the Davis-Besse Plants hardware, plant staff, 17 the management program to support restart.
18 Based on our review, the plants failure, the 19 failure of your staff to consistently implement 20 expectations and standards do not give us reasonable 21 assurance that you would be able to adequately operate the 22 plant at power without additional observations on our 23 part.
24 These consistencies were noted in several areas.
25 First -- and Ill go through a list of the different areas MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
12 1 and then provide some details regarding why these areas 2 showed inconsistencies.
3 Several examples of deficient Prejob Briefs 4 indicating a lack of preparation for plant activities.
5 Several examples were noted where operators lack awareness 6 of plant equipment and plant status. Several examples were 7 noted where the operators were not following managements 8 expectations and written standards.
9 On occasions, Work Control appeared to be 10 disorganized and there appear to be a lack of project 11 oversight to ensure proper rigor in the Work Control 12 Process. There were several schedule changes that 13 occurred. They may have contributed to some of the 14 problems that we observed during this inspection.
15 We noted that several system engineers for 16 safety-related systems were not qualified for their 17 assignments. We had concerns regarding traceability of 18 test equipment. We saw examples where procedure quality 19 and procedure adherence was inadequate. And we had some 20 examples where Corrective Actions resulting from the 21 operational performances issues in September were either 22 not tracked or were ineffective.
23 Regarding Prejob Briefs, we did observe the Prejob 24 Brief for a positive safe pump start. During that brief, 25 we noted that the operators did not adequately address all MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
13 1 the special precautions and limitations described in the 2 subject procedure, nor did they address any of the limits 3 associated with tripping the pump. These issues were only 4 addressed after the inspectors brought it to the test 5 controllers -- or to the, to the operators attention.
6 We observed the Prejob Brief control of a bubble in 7 the pressurizer. This brief did not cover all the 8 applicable propulsions and limitations, nor did it address 9 the fact that there was out of service equipment, including 10 a pressurizer instrument needed to be used by the 11 procedure, and that there were a number of issues tied to 12 the pressurizer heaters that would have made them out of 13 service.
14 We observed the Prejob Brief for the Full Float Flow Test 15 in the Train One of the Aux. Feedwater System. We noted 16 that the test controller failed to recognize that 17 additional test equipment was needed to be installed to 18 monitor one of the Aux. Feedwater Flow instruments. The 19 reason this test equipment was needed was to determine the 20 cause of a past problem.
21 Once the inspectors brought this issue to the test 22 controllers attention, the Licensee stopped and placed the 23 test on hold to evaluate the need to install this test 24 equipment. They brought in the System Engineer, discussed 25 it, and made the determination that it was not needed to MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
14 1 use the test equipment.
2 The test went on; and during the test, again, some 3 insignificant flow oscillations were identified on the 4 associated Feedwater Flow instrument indicating that the 5 problem was still there.
6 We also observed the Prejob Brief for the Train Two 7 Aux. Feedwater Flow Test. Again, we noticed that the 8 Prejob Brief failed to address specific, one particular 9 specific propulsion problem associated with the test that had to do 10 with opening the steam emission valves slowly to ensure --
11 or to prevent a water valve hammer condition.
12 Additionally, during the preparation for the 13 assigned Prejob Brief, the test controller failed to 14 adequately review the past test associated with this 15 system. The results in, this resulted in the need to abort 16 the test, because during the test you were unable to meet 17 the specified minimum recirculation flow for the pump.
18 Had the test controller reviewed past tests, they 19 would have identified that during the last two test 20 performs, performed on that system, that you werent able 21 to obtain the minimum recirculation flow, and they would 22 have had the opportunity to assess the condition and change 23 the procedure prior to running the test.
24 These several examples associated with Prejob Briefs 25 are important; and Prejob Briefs in general are important MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
15 1 because they allow the operator to understand the upcoming 2 evolution and it also ensures timely completion of the 3 evolution, which during online maintenance would minimize 4 the unavailability time of the equipment.
5 Furthermore, these Prejob Brief concerns were 6 similar to concerns that were identified with your 7 operational problems back in September. And you were 8 taking corrective actions to attempt to correct these 9 issues, and it appears as if they were not totally 10 effected effective. These issues associated with Prejob Briefs are 11 being considered potential violations of your Tech Spec 12 regarding Procedure Adherence.
13 Indications where the operators lacked awareness of 14 plant equipment and plant status --
15 MR. MYERS: Can I ask you a 16 question, for clarification? Did you see, you saw some 17 places where the Prejob Briefs were not as effective as 18 they could be, but did you see any good Prejob Briefs?
19 MR. SKOKOWSKI: Yes, we did see 20 some examples of good Prejob Briefs and there was some 21 improvement over the course of the inspection, but again, 22 for the consistency wasnt there, and expectations should 23 be followed out a hundred percent of the time.
24 Well try to keep the questions until the end, if we 25 could.
MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
16 1 MR. MYERS: Okay.
2 MR. SKOKOWSKI: Thank you.
3 Again, back to indications where operators lack 4 awareness of the plant status and what the status of their 5 equipment was. We witnessed the evolution of drawing a 6 bubble in the pressurizer. The operators did not realize 7 there was an interlock associated with the heaters and 8 Safety Actuation System.
9 And in the configuration the plant was in, during 10 the evolution, there was one channel of the Safety Features 11 Actuation System out of service, and this would result in 12 some of the heaters not being capable of operating.
13 Therefore, when the operators went to turn the heaters on 14 in accordance with the procedure, the heaters did not 15 energize.
16 Furthermore, the operating crew did not know that 17 there was no power available to the variable control 18 heaters because the associated motor control center breaker 19 was tied tagged out. The motor control center would provide power 20 to all these heaters.
21 There was no indication on the, in the control room, 22 one controller, there was no power to the, these heaters, 23 and when the operators attempted to operate the heaters via 24 the controller, there was no response.
25 Another item was, during a morning turnover meeting MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
17 1 on Sunday, the 14th of December, the shift manager did not 2 have a proper understanding of the plant conditions; 3 particularly two pieces of important safety equipment. The 4 status of those equipment was unknown or incorrect by the 5 shift manager, and that was the Number One Train of Decay 6 Heat Removal and the Number One Train of the Emergency 7 Diesel Generator. They were both inoperable, and the shift 8 manager thought they were operable.
9 In addition, the shift manager reported the risk to 10 be at a baseline risk or green risk, when actually it was 11 slightly elevated, what would be considered a yellow risk 12 by the plant.
13 Later that morning, senior management did have the 14 shift manager removed from the watchstanding duties for 15 further evaluation, which was the appropriate actions.
16 Another example was, during the time test of a 17 service water valve, the operators did not understand that 18 the associated interlock requiring the service water valve 19 to be open as long as a fan was running. This was 20 evidenced in that the operators did not anticipate that the 21 valve would automatically reopen when it was stroked during 22 the testing evolution, because the fan was running when 23 they did the test.
24 Again, these issues are similar to issues that were 25 identified with the operational problems you had back in MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
18 1 September; and again, you were supposed to have taken some 2 actions to attempt to correct these issues, and again, they 3 did not seem to be totally effective.
4 These issues associated with plant awareness are 5 also being considered potential violation of your Tech Spec 6 regarding Procedure Adherence.
7 Regarding operators not following management 8 expectations and written standards, we had a number of 9 observations regarding alarm responses. Items like shift 10 managers acknowledging and silencing alarms instead of 11 maintaining their role as command and oversight.
12 An operator assigned to silence a recurring nuisance 13 alarm took it upon himself to lean against the alarm panel 14 such that he was keeping the alarm silenced and also any 15 other alarms that could have come in would not have been 16 audibly recognized.
17 Other items would have been not knowing whether an 18 alarm that was received was expected or not; and then if it 19 was not known to be expected, not following through to look 20 at the alarm response procedures.
21 Moreover, these issues have been identified by other 22 outside organizations as an area that should have been 23 improved.
24 We did see items associated with Procedural 25 Adherence. Items like not routinely completing the end of MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
19 1 shift critiques. Also, other operators were unaware of the 2 cognitive operator procedure requirement to mark on the 3 chart orders whenever a bump pump was started associated with 4 that system.
5 We also noted a supervisor that went through a door 6 that was posted "Contact security prior to going through 7 this door." The individual did not do that; and when 8 challenged, tried to justify his possession in that, saying 9 that he only needed to call security if he did not get the 10 proper indications. After being challenged again, 11 acknowledged that what he had done was wrong.
12 In general, the need to implement management 13 expectations and standards are an important tool to ensure 14 that the activities completed are done properly. And this 15 is another example where there was issues similar to this 16 back in September during your operational events that you 17 had taken some corrective actions, but again, were not as 18 effective as they should have been.
19 These issues are also being considered potential 20 violations of your Technical Specifications for Procedure 21 Adherence.
22 On occasions, we did note that Work Control appeared 23 to be disorganized and there appeared to be a lack of 24 management rigor in the project oversight to ensure the 25 proper rigor in the Work Control Process.
MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
20 1 We also did see this show up with respect to moving 2 things up into the schedule and change the schedule around, 3 which may have impacted some of the other activities going 4 on in the plant and added to the problems that we have 5 noted before.
6 And this was supported by numerous observations 7 during Work Planning Meetings, Prejob Briefs, Shift 8 Turnover Meetings, and Plant Evolutions where members of 9 the staff seemed unorganized and uncertain of the status of 10 the activities.
11 We also noted that valve line-up verifications that 12 needed to be complete werent shown in the schedule, which 13 makes it difficult to understand where all your resources 14 are.
15 During the turnover of the night on September 13th, 16 the Operations Department failed to ensure that all 17 expected watchstanders knew to show up on site, knew they 18 had duty that night. That meant that there was two 19 operators their reliefs didnt show up. Although, the 20 technical specification requirements for manning were 21 always met. This was an unexpected situation. Additional 22 operators were either called in or brought in from other 23 activities on site at the time. But, but this impacted the 24 number of expected resources to complete tasks that night.
25 So, again, from a Work Control Process, made things more MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
21 1 confusing than they should have been.
2 Again, the significance of adequate Work Control 3 allows for equipment being taken out of service to be, work 4 efficiently such that you would minimize the unavailability 5 problem of any safety-related equipment.
6 There are no violations associated with this area 7 with respect to Work Control.
8 Another area we looked at was System Engineering and 9 particularly the system engineers or system, safety-related 10 systems not being qualified for their assignments. And 11 this was evidenced by the fact that the primary and back-up 12 system engineers for some safety significant systems, such 13 as Aux Feedwater, High Pressure Injection and Low Pressure 14 Injection were not qualified by your training program for 15 those positions.
16 Furthermore, there was no system engineer on site 17 trained or qualified in accordance with your training 18 program for the motor driven or startup feedwater pumps.
19 Although these individuals filling the positions 20 were competent, the failure to qualify these individuals by 21 your program could impact their ability to understand your 22 systems and processes and is being considered a potential 23 violation of your Tech Specs regarding Plant Staff 24 Qualifications.
25 Additionally, during our review of the System MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
22 1 Readiness Affirmations, we noted that several of the 2 safety-related systems were system affirmations for having 3 the systems ready for Modes 1, 2, 3 and 4 were completed by 4 nonqualified system engineers with no reviewers or no peer 5 checks. We do note that subsequent that these affirmations 6 were reviewed by qualified engineers.
7 Our next concern was associated with the 8 traceability of test equipment. We noted that out of 34 9 pieces of test equipment used in some surveillance tests 10 that we reviewed, we identified eight that you did not have 11 traceability tying the test equipment back to the completed 12 test.
13 Additionally, procedures controlling test equipment 14 require a travel form to be issued with the test equipment 15 to record each of its uses if more than one use is 16 expected. However, the practice was that the issuance of a 17 traveler was optional, was only used if the, was requested 18 by the user or if the user did not know which parameters 19 the equipment would be used on.
20 The impact of this concern is that this equipment 21 post-calibration reports that would come back out of cal, 22 you would then need to go back to determine what tests were 23 impacted by using out of cal equipment on it. It was 24 without having good traceability, it would be next to 25 impossible to determine which surveillance tests were MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
23 1 impacted.
2 We did note some additional concerns associated with 3 your Test Equipment Program. They were a lack of a formal 4 process to control or prevent the use of the same piece of 5 test equipment on false training tests. And a concern here 6 is, if you had a piece of equipment that used on train one, 7 use the same equipment on train two, and you did the 8 post-testing calibration, that you would have both of those 9 train and it came back unSat, you could have both trains in 10 an inoperable condition.
11 We also noted that your program does not define 12 critical use applications for test equipment where 13 immediate post calibrations were required. This was only 14 utilized on certain ASME Code applications. And we also 15 identified that your Test Equipment Program Procedure had 16 been misqualified as a quality procedure versus a 17 safety-related procedure. And that would be addressed by 18 your staff.
19 Again, the importance of these concerns, of the 20 post-calibration reports, if they came back saying that a 21 piece of equipment would be out of calibration, it would be 22 very difficult to go back and determine which equipment 23 that surveillance, or which equipment would be affected by 24 those out of cal test equipment.
25 These issues are being considered potential MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
24 1 violations of your Tech Spec on Procedure Adherence.
2 We also noted a number of examples associated with 3 Procedure Quality and Procedure Adherence. During the Full 4 Flow Test of train one of the Feedwater System, the test 5 was supposed to check the reverse flow function of some 6 selected check valves. The valve lineup for this test was 7 incorrectly established to ensure this evolution was 8 completed properly; and, therefore, the check valve was not 9 tested; and one particular check valve was not tested as 10 designed by the procedure. Since this mispositioned valve 11 was a locked valve, it also indicated some concerns 12 associated with the Lock Valve Program.
13 During the Valve Stroke Test, the Service Water 14 Valve 1366, there was other issues with that procedure, 15 particularly this procedure was written to allow partial 16 use of completion; and it was inadequate for that process 17 as evidenced by the test that was performed.
18 When the test was performed, the associated fan was 19 running, and when the operator performed the test, the 20 associated service water valve, what closed as according to 21 the test, but then unexpectedly reopened. This was due to 22 the fact that the procedure, which required that the fan be 23 off in the first section of the procedure, did not 24 similarly reference the need in the second section of the 25 procedure to ensure the fan was off. The second section of MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
25 1 the procedure is the one that was done to test the valve, 2 Service Water Valve 1366. If the procedure would have been 3 written properly, this problem would not have occurred.
4 We also noted during just in time frame training, that one of 5 your operators had identified that the heatup had a 6 deficiency in that it specified Reactor Coolant System 7 pressure and temperature limits that could have allowed you 8 to possibly operate without the required positive suction 9 head for reactor coolant pumps.
10 We do know that you identified this in preparations 11 for training, and the scenarios over in the simulator; 12 however, it was not identified during your Procedure Change 13 Process.
14 We also identified that there were periods of time 15 where train two protected equipment, particularly all the 16 aspects of the division train two emergency diesel 17 generator, and again, the particulars were the air receiver 18 tank room, the door for that, the door for that room was 19 not protected in accordance with the expectations in your 20 program and it ended up being due to the fact that one item 21 was not explicitly called out in the associated procedure.
22 Another item we noted with respect to Procedure 23 Adherence was during the post-mod testing with the hot 24 checks of the breaker for the service water two strainer, 25 strainer motor leads were lifted, but they were not MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
26 1 controlled in accordance with the lifted lead sheet as 2 required by your procedure.
3 These issues regarding Procedure Adherence and 4 Compliance are considered potential violation to the Tech 5 Specs on Procedure.
6 We also noted areas where the Corrective Actions 7 operate resulting from your operational performance issues 8 back in September of 2003, were either not tracked or they 9 were ineffective. There were several cases as Ive already 10 described regarding prejob briefs, awareness of plant 11 status and activity, and follow through management 12 expectations, all came into play with your events back in 13 September. Its obvious that the Corrective Actions were 14 ineffective and more needs to be done in that area.
15 We also noted that there were several 16 recommendations from your Licensees assessment of the 17 heatup to NOP/NOT back in September that were documented in 18 your Assessment Reports. These actions were either not 19 tracked or not completed; and, we understand there may be 20 some more information to follow regarding that area and we 21 will be looking at that.
22 Currently, both of these areas indicate potential 23 violations of 10 CFR Appendix B Criterion 16 associated 24 with Corrective Actions.
25 They were the major areas we had indications of MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
27 1 concerns. We did have some other more isolated items I 2 would like to talk about. One, having to do with problem 3 identification and particularly deficiencies on the, some 4 of your Emergency Core Cooling Systems were identified by 5 our inspectors that werent picked up by your staff, even 6 though they had already done their System Readiness Review 7 Walkdowns for the systems.
8 The first item was, we had identified that a spring 9 can on the discharge piping of the operating gate train of decay heat removal 10 pump was under compression and reading off scale indicating 11 that the spring may not be capable of performing its 12 function.
13 The inspectors brought this to the attention of the 14 system engineer, and only after several attempts by the 15 inspector did the system engineer bring the issue to the 16 attention of the control room.
17 Because of the potential of this concern, this 18 concern had on the operability of the operating equipment, 19 this issue should have been immediately brought to the 20 attention of the shift manager for assessment.
21 After subsequent review, it was determined that the 22 concern with the can ended up not being an operational or 23 operability concern, although it was not what we expected.
24 Additionally, the inspectors identified two issues 25 associated with an inoperable train of high pressure MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
28 1 injection, particularly that a unistrut was missing bolts 2 from where it connected to the floor and that the DC lube 3 oil pump junction box was broken, peeled back such that you 4 could see some of the wires inside the junction box.
5 These failures to identify concerns are potential 6 violations of 10 CFR Appendix B Criterion 16 Corrective 7 Actions.
8 We also noted some issues with a particular work 9 order. There was a work order that was revised and ended 10 up indicating work to be done on the wrong train of high 11 pressure injection. Your staff had initiated a CR after 12 identifying this, particularly that the work instruction 13 issue for work on November 2nd, with the High Pressure 14 Injection Pump A should have been issued to work on -- let 15 me start that over.
16 That it was issued for work on the Number Two High 17 Pressure Injection Pump, but it should have been written 18 that it was issued for work on the Number One High Pressure 19 Injection Pump.
20 During the evolution, work was performed on the 21 correct pump, but the questions that came up were, "Why did 22 so many people review this work order and approve it when 23 it was indicating work to be done on the wrong piece of 24 equipment?"
25 This is a potential violation, again, of 10 CFR 50 MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
29 1 Appendix B Criterion 16 Corrective Actions.
2 The last item had to do with our review of some 3 completed work orders involving the installation of cable 4 splices. We noted that not all installations were being 5 reviewed by your QA -- or QC Organization. Follow-up 6 review of this issue indicated that there were some QC 7 inspections that were, and associated decisions with these 8 inspections that were not well documented.
9 We did have one other area, that was the area of 10 ladders. We did see a number of places where ladders were 11 not tied off in accordance with your procedures. We 12 brought this to your attention and they were corrected in 13 every case.
14 There were some areas that looked acceptable; 15 particularly control room operators use of communications.
16 They consistently used three-way communications. They used 17 the phonetic alphabet consistently. Peer check were used 18 consistently. There was good use of self-checking of your 19 Star Process. And they did a very good job controlling 20 control room access.
21 We did note that the support from Engineering to 22 Operations, Engineering had installed a process to ensure 23 they provide timely response to Operations concerns. We 24 did see this in work. And based on the discussions with 25 your Operations staff, they believe it also was working.
MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
30 1 We thought the performance of your nonlicensed 2 operators was very good. And the general overall plant 3 material condition was good.
4 In conclusion, the failure to consistently implement 5 expectations and standards did not give us reasonable 6 assurance that the Davis-Besse plant was ready to 7 adequately operate at full power.
8 In addition, based on our observations, we had 9 questions regarding the effectiveness of the Corrective 10 Actions require operational concerns, which will require 11 further assessment by your staff and should include an 12 understanding of why past Corrective Actions were 13 ineffective and why the new Corrective Actions will be more 14 effective.
15 This effort will be needed to, to determine whether 16 the readiness of the station to make the transition back to 17 full operations.
18 As always, with these Exits, that the classification 19 of the findings is still up to my managements discretion.
20 Thank you for your attention. And are there any questions?
21 MR. GROBE: Before we go to 22 questions, Rick, thanks. Let me make a couple of comments 23 and observations.
24 First, I want to recognize the fine work that this 25 team did, and also express appreciation for their MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
31 1 management around the country for making them available to 2 us.
3 Christine and Rick pulled together an outstanding 4 team with experience, as I was listening, upwards of a 5 dozen different nuclear plants, assessing operational 6 performance, of about a dozen nuclear plants around the 7 country. Hundreds of years of experience of operational 8 assessments sits up at this table. They did an outstanding 9 job performing this inspection; worked continuously for the 10 last twelve days, including day shift, night shift, 11 round-the-clock activities, observing Davis-Besses 12 performance.
13 As Rick indicated, these are preliminary inspection 14 findings. We wanted to provide this information to you on 15 a timely basis. The inspection actually was continuing 16 through this morning, and additional information was 17 gained.
18 Consequently, it is possible that these findings 19 will be further refined and could change. If they do, we 20 will inform you of that, before the report is issued.
21 Similar to the findings of our inspections of your 22 Normal Operating Pressure Test in September/October, this 23 inspection revealed that there were no safety issues. That 24 your operators performed sufficiently, that the plant was 25 not a safety risk. However, there were areas of violation MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
32 1 of NRC requirements and your operating organization did not 2 perform consistent with your standards and expectations.
3 The team was concerned, as Rick expressed, about 4 these inconsistencies in your performance. The team 5 briefed the panel on the results of their inspection, and 6 we spent quite a bit of time considering these results.
7 The panels conclusion was that we need additional 8 information, prior to the panel being able to assess 9 whether it would have reasonable assurance that the plant 10 could be operated safely and in compliance with the NRC 11 regulations and your license.
12 Previously, the meeting on December 29th, was 13 anticipated to be the Restart Meeting. And that was always 14 contingent upon ongoing inspections and evaluations. Now 15 understand and appreciate that, that you expect to be able 16 to prepare information for us, that we need to understand 17 your assessment of the causes of these violations and 18 inconsistent performance; your evaluation of the reason 19 that the prior Corrective Actions taken after the Normal 20 Operating Pressure Test activities were not fully 21 effective; what further actions you believe are necessary 22 to improve compliance and consistency in performance; why 23 you believe those actions will be more effective after the 24 Normal Operating Pressure Test; how you will assess the 25 effectiveness of those actions prior to requesting MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
33 1 rescheduling of the Restart Meeting.
2 So, those are the activities we expect you to be 3 ready on the 29th to discuss with us, and we look forward 4 to that meeting. I believe that meeting is scheduled at 5 Oak Harbor High School at 6:00 in the evening.
6 Is that right, Christine?
7 MS. LIPA: Thats correct.
8 MR. GROBE: Very good.
9 At this point, I would like to turn it over to you, 10 Lew, for any questions or comments your staff has.
11 MR. MYERS: I think that once 12 again, there is nothing here, were seeing the same 13 indications. There is nothing here that I saw yet that we 14 disagreed with.
15 I would say that, you know, if you look at the, you 16 mentioned that the safety significance here, you said no 17 safety significance; is that right?
18 MR. GROBE: Yes.
19 MR. MYERS: And our operators 20 are continuing to, when presented with problems, to behave 21 very well.
22 These management tools that we have in place are 23 designed to ensure that we understand what should happen 24 when we start this equipment.
25 The other thing I would say, I appreciate the kind MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
34 1 remarks on our nonlicensed operators, but a lot of these 2 issues that you did bring up are not in my mind the 3 nonlicensed operations found. The ladders in the field, 4 theyre responsible for the facility, for a strut being 5 broke or the, or there was another one too, but I expect 6 these guys to find these things, you know. Theyre the 7 facility manager for their facility, what they have to do.
8 So, the performance weve seen there does not meet 9 our expectations, and were going to work hard to increase 10 that, that adherence to our standards. You know, were 11 going to work very hard on that the next few weeks. We 12 think we can, in a timely manner, make the adjustments we 13 need to so its consistent, with Mark in charge and stuff 14 with our other plants.
15 Were going to get this stuff consistent. Were 16 going to take hard actions. Were going to hold people 17 accountable, but were going to make sure that were ready 18 to restart the plant, and that we can do that shortly. And 19 we will not come to you and ask permission to restart the 20 plant unless were comfortable that were ready to restart 21 this plant. And this team needs to understand that. So, 22 thats all.
23 Do you have anything, Mark?
24 MR. BEZILLA: Nothing to 25 add, just reiterate what Lew said, is that we wont heat MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
35 1 the plant up and we wont restart the plant until were 2 ready and make sure our people are ready.
3 I would like to thank the team. I think they did a 4 real good job. Sometimes its not always easy to relish 5 the feedback, but you guys did a real good job and you will 6 help us be better, my teammates and myself. So, we 7 appreciate that.
8 And, Jack, well find out why we werent as 9 effective as we could have or should have been, and well 10 get this squared away.
11 MR. MYERS: The only comment I 12 would make, we thought before this team got here, that we 13 would have all the equipment issues, we had about seven 14 days and some of our equipment issues went longer than 15 expected, but thats no excuse. So, we didnt have the 16 seven days or week or so to prepare that we should have, 17 but thats no excuse, because we should be prepared all the 18 time. So, were just not satisfied with this performance.
19 Well take the actions that we need to.
20 MR. GROBE: Okay. Thank you 21 very much.
22 MR. MYERS: Let me add this 23 too. You know, sincerely, you know, you have these 24 comments all the time, you know, we thank you for being 25 here and you dont mean them, but we really mean it. This MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
36 1 was an outstanding team. We think their comments are good, 2 and we enjoyed having you guys here. We think you did a 3 really good, good job.
4 MR. GROBE: Rick, any other 5 comments?
6 MR. SKOKOWSKI: No.
7 MR. GROBE: Any other comments 8 from the panel?
9 I think what we would like to do is take a very 10 brief break. That doesnt mean get up and go out in the 11 hallway, that means just give us a few minutes to change 12 our teams up here, and then well proceed with the second 13 exit. Thanks.
14 MS. LIPA: But we would like 15 to give everybody a chance to get handouts in the hallway, 16 so well probably need about ten minutes.
17 MR. GROBE: Okay, thank you, 18 Christine.
19 (Off the record.)
20 MS. LIPA: Okay. I want to 21 make sure we have the bridge lines back on.
22 Okay, bridge lines are ready. And, what Im going 23 to do now is turn it over to Geoff Wright to introduce his 24 team and his inspection results.
25 MR. WRIGHT: Thank you, MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
37 1 Christine.
2 Good morning. My name is Geoff Wright. I am the 3 Team Leader of the Management and Human Performance 4 Inspection Team.
5 I am going to hold just for a minute introducing the 6 rest of my team with the exception of Jay Persensky, who is 7 on my right. Ill have a little bit additional, but I 8 wanted to give Lew a chance if there are any different 9 players that you would like to introduce.
10 MR. MYERS: I dont think so.
11 I think were okay.
12 MR. WRIGHT: Okay. What I 13 would like to do is describe first what the scope of our 14 inspection activities were to give you some sort of a 15 framework when I introduce the different team members, so 16 you can see the relevance and the experience that this team 17 brought to this effort and youll have an ability to look 18 at it in that perspective.
19 The purpose of this particular meeting is to provide 20 you with the results of the third phase of our Management 21 and Human Performance Inspection. For those of you who may 22 not be familiar with this inspection, I would like to 23 briefly review the inspection plan with you.
24 To facilitate the entire scope of the work that we 25 envisioned for the Management and Human Performance Area, MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
38 1 we divided the inspection into three phrases.
2 Phase One: Assess the techniques and results of the 3 original Root Cause Analyses into the Human Performance 4 Contributions to the degraded reactor vessel head.
5 Based on our review of the root causes for 6 Management and Human Performance at that time, we concluded 7 that the completed reviews had been appropriately conducted 8 and provided meaningful insights; that planned Corrective 9 Actions, if properly implemented, were sufficient at that 10 time.
11 The team identified that additional assessments in 12 the area of Engineering, Operations, Nuclear and Corporate 13 Oversight Activities were necessary. The team also 14 identified the Collective Significance Review of the 15 individual area assessments had not been performed.
16 At the time we exited on Phase One, we could not 17 conclude whether the Corrective Actions identified to-date 18 were sufficient until additional, the additional 19 assessments I just mentioned were completed, and the 20 Collective Significance Review had been accomplished.
21 We came back after those assessments had been 22 completed, and identified that indeed they had been 23 appropriately completed and that the Corrective Actions 24 that were associated, if as I said were implemented 25 properly and monitored, should prevent recurrence of the MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
39 1 problem.
2 The Phase One results are documented in Inspection 3 Report 2002-15.
4 Phase Two of our assessment looked at the 5 appropriateness of the Corrective Actions against your 6 causes and implementation of those Corrective Actions 7 through the original evaluations.
8 Our inspection concluded that, again, if properly 9 implemented and monitored the Corrective Actions would 10 appropriately address the issues identified in the 11 assessments, and that the scheduling and implementation of 12 the Corrective Actions had been appropriate.
13 Phase Two inspection results are documented in 14 Inspection Report 2002-18.
15 Phase Three of the inspection effort was designed to 16 assess the Safety Culture Assessment and Monitoring Tools, 17 the current status of the Employee Concerns Program, the 18 Safety Conscious Work Environment and Safety Conscious Work 19 Environment Review Team, and the tools planned to be used 20 to monitor Safety Culture in the future.
21 Phase Three was specifically developed to provide 22 the NRCs 0350 Panel with information necessary to 23 effectively integrate information from all inspections to 24 reach an overall conclusion regarding the Safety Culture at 25 Davis-Besse.
MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
40 1 More about that later, but first some administrative 2 activities, if I might. The Phase Three Inspection has run 3 from March 20th of this year through yesterday. And the 4 Report Number is 2003-12.
5 Given the history and where we are as far as what 6 the purpose of the Phase Three was, we put together a team 7 that was composed of both NRC individuals, as well as 8 consultants from industry.
9 The team members included Claire Goodman, who is a 10 Senior Human Factor Specialist in the office, in the NRCs 11 Office of Nuclear Regulation. Claire is an expert with 12 over 30 years of experience in the areas of Human 13 Performance, Organizational Effectiveness and 14 Communications and Safety Culture at nuclear power plants.
15 As I indicated earlier, Jay Persensky, on my right, 16 was a member of the team. He is a Senior Technical Advisor 17 for Human Factors in the NRCs Office of Research. Jay 18 holds a Ph.D. in applied psychology and has over 30 years 19 of nuclear experience in the areas of Human Factors and 20 Behavioral Science Technologies in the work environment.
21 Lisa Marie Jarriel of the NRCs Office of 22 Enforcement was also a member of the team. She has over 21 23 years of experience in Nuclear Safety, Safety Conscious 24 Work Environment, and Employees Concerns Program 25 implementation.
MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
41 1 Rick Pelton joined us for a short period of time.
2 Hes a training and assessment specialist in the NRCs 3 Office of Nuclear Regulation with over 35 years of 4 experience in evaluating Human Performance Training and 5 Root Cause Evaluations.
6 The two consultants that we had with us were John 7 Beck, who is the Chief Executive Officer of a consulting 8 firm specializing in Safety Culture and Safety Conscious 9 Work Environment at nuclear facilities. John has over 36 10 years of nuclear management experience, serving as a Chief 11 Operating Officer, Executive Vice President, Vice President 12 and Director of Engineering for three different successful 13 nuclear utilities. John also played a key role in the 14 recovery of the Safety Conscious Work Environment at the 15 Millstone Facility in the mid 1990s.
16 The other consultant that we had with us was Mike 17 Brothers. Mike is the head of his own engineering and 18 consulting firm. He is an expert in nuclear safety 19 facility operations, including Safety Conscious Work 20 Environment and Employee Concerns Programs. Mike has held 21 a number of positions at nuclear utilities, including Vice 22 President Nuclear Operations at Millstone. In this 23 position, he was responsible for overseeing the recovery of 24 the Safety Conscious Work Environment and safe operation of 25 that facility.
MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
42 1 I would like to take some time to go over, since the 2 inspection that we did here, looking at Safety Culture, 3 Safety Conscious Work Environment, Safety Conscious Work 4 Environment Review Team and the Employees Concern Program, 5 is significantly different than we have done at other 6 facilities.
7 There was no inspection module that you can look up 8 in our inspection manual that will identify to you exactly 9 what we did. So, we developed our own inspection process 10 that was reviewed and approved by the 0350 Panel. And so, 11 you have an idea of the depth and breadth of the inspection 12 activities, I would like to go through exactly what we were 13 talking about as far as items here.
14 The inspection deliverables, as I indicated earlier, 15 the special inspection was designed to provide the NRCs 16 0350 Panel with an evaluation of the processes used to 17 assess the sites Safety Culture, the monitoring activities 18 involved with improving Safety Conscious Work Environment, 19 and the status of the Employees Concern Program, and an 20 assessment of survey results.
21 Let me just take a minute and make sure that Im 22 coordinated with the slides behind me here.
23 The input from this inspection when combined with 24 other inputs, for example, System Health Inspections, 25 Program Review Inspections, Containment Health Inspections MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
43 1 and the Corrective Action Team Inspection, along with the 2 RATI results that youve heard just previously, will allow 3 the panel to make an informed decision on the effectiveness 4 of the overall Management and Human Performance Corrective 5 Actions. To that end, the following deliverables were 6 expected from this team.
7 On the Internal Assessment -- let me back up. There 8 were a number of areas that we looked at. Your Internal 9 Assessment, the External Assessment, the integration of 10 those two into a long term plan, the Safety Conscious Work 11 Environment, Safety Conscious Work Environment Review Team, 12 and the Employee Concerns Program.
13 In the area of the Internal Assessment, we were to 14 provide an assessment of the input parameters, evaluation 15 techniques, and methods to develop conclusions used in the 16 Internal Assessment.
17 For the External Assessment, we were to look at the 18 input parameters, evaluation techniques, and, again, 19 methods to develop conclusions from the individual imputs.
20 From the integration of Internal and External 21 Assessments, we looked at whether or not and how the 22 benchmarking of your Internal Review against the External 23 Review to see if there were any holes in the program.
24 For Safety Conscious Work Environment and the Review 25 Team, the assessment, we looked at current and future MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
44 1 activities promote the open identification of deficient 2 conditions, those programs defined to prevent retaliatory 3 actions, and to monitor -- and your actions to monitor the 4 effectiveness of those programs.
5 For the Employees Concern Program, we looked at the 6 assessments that had been brought to the Employees Concern 7 Program to-date, the methods used to review those issues, 8 and resolve the issues. The team also, to the extent 9 practical, provided assessment of the reason individuals 10 are using the Employees Concerns Program.
11 There was one additional item that you will see, 12 which dealt with measurements to monitor the effectiveness 13 of all of the above. There will not be a separate section 14 in the inspection dealing with that. It was integrated 15 into each one of the previous areas discussed.
16 When we looked at the Internal Safety Culture 17 Assessment, we basically looked at the appropriateness for 18 evaluating the Safety Culture, the appropriateness of the 19 monitored items, and we looked for any weaknesses that 20 would limit the practices effectiveness as a tool for long 21 term evaluation of the Safety Culture at the facility.
22 In evaluating the External Safety Culture 23 Assessment, we looked at the suitability of it for 24 monitoring Safety Culture, including the questions that 25 were asked, interview questions, actions observed by that MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
45 1 team. We also reviewed documents and looked at the 2 sampling plan that your external experts had used in 3 picking people to interview.
4 We looked at the implementation of that plan. We 5 looked at the methodology used to take the results from the 6 interviews, observations, and surveys, and how those were 7 factored into conclusions. And we also looked at the 8 results of the Safety Culture monitoring tools and the data 9 collected to determine whether or not they were 10 consistent.
11 We also looked in the area of what was called 12 convergent validity. That being if I looked at what the 13 interviews have told me, I looked at what surveys may have 14 told me, what the documents tell me and say; are they all 15 pointing in the same direction.
16 When we looked at the Internal and External 17 Assessments, what we wanted to do is see, were the Internal 18 and External in sync with the information that was being 19 found, and how you took that information and transformed it 20 then into a long-term process for monitoring the Safety 21 Culture at this facility.
22 In the areas of Safety Conscious Work Environment, 23 and the Safety Conscious Work Environment Review Team, we 24 looked at the matrix that you were using to monitor the 25 programs effectiveness. We looked at the performance in MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
46 1 the, your use of your policy on Safety Conscious Work 2 Environment. We looked at the effectiveness of the 3 training programs for your employees, contractors, and 4 management. And we were looking for the effectiveness of 5 the internal communications at the facility in those 6 areas.
7 Then, finally, for Employees Concerns Program, we 8 evaluated the matrix you were using to monitor the program, 9 the quality of the investigations, and the confidentiality 10 provisions of the program.
11 We used varying techniques in doing our 12 evaluations. Those included as normal, independent review 13 of documents, development and implementation of interview, 14 a special interview questionnaire which we used to query 15 about ten percent of the staff here on sight.
16 We did a comparison of the results of the questions 17 that we had asked to the information that you were 18 gathering in the Safety Conscious Work Environment arena.
19 We looked at the implementation of the External Assessment 20 Program through the interviews with selected people who had 21 participated in that.
22 We also interviewed selected managers and senior 23 managers. We observed both interdepartmental meetings, 24 SCWERT, thats Safety Conscious Work Environment Review 25 Team meetings, the Restart Readiness Review Panel meetings, MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
47 1 we observed two of those and one follow-up to there. For 2 ECP, we actually looked at the case files up through the 3 summer, late summer of 2003 in detail.
4 I talked a minute about the Restart Readiness Review 5 Process. We reviewed Revisions 2 through 9 of that 6 document in detail each time we received a new one. And 7 then we looked at what were the, the various Safety Culture 8 surveys doing and telling us as it came out, particularly 9 those in March and November of this year.
10 Thats the inspection process, and the approach that 11 we took. I would like to now transition over to the 12 observations. I will follow the same outline as far as the 13 areas that weve looked at.
14 In the Internal Safety Culture Assessment Tool, the 15 overall conclusion in this particular area was that the 16 Internal Safety Culture Assessment Tool, tools in this 17 case, are adequate and provide appropriate information to 18 monitor the Safety Culture at this facility.
19 In this regard, we were including the Restart 20 Readiness Review Business Practice, along with the Nuclear 21 Oversight Survey, and the Employees Concern Program Survey; 22 since none of them by themselves really encompass the whole 23 of what you should have been, what you should be looking 24 at. In connection, when you put all three together, it 25 would cover the areas appropriately.
MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
48 1 In reviewing these areas, we noted that the business 2 practice developed, was an excellent initiative by the 3 facility. Some of the areas that were of particular note 4 were the areas; and these are specific definitions for the 5 Restart Readiness Review Practice; the areas criterion 6 attributes, those being the management staff and corporate 7 entities. The criteria used to look at those areas and the 8 individual items that were assessed, we found were 9 generally in alignment with internationally recognized 10 guidelines.
11 One of the positive attributes that came out of this 12 was, and that I have not seen in very many facilities is, 13 the meeting itself gathered all 21 organizations 14 represented at the site, the managers of those 15 organizations, put them in one room to be able to discuss 16 what was the health of the organization overall.
17 The first meeting we observed took two full days, on 18 just the Safety Culture portion of it. The second one took 19 three, virtually three full days to accomplish. The 20 dialogue between the managers and the challenges that you 21 would find from organizations that you would think were 22 disparate from what was being discussed, we concluded was 23 very healthy and got a lot of good information out of it.
24 The weaknesses that we observed, some of the 25 weaknesses that we observed in the process was Performance MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
49 1 Evaluation Criteria, while generally appropriate at what 2 you call the white and green level, we found were often not 3 appropriate at the yellow or red, particularly red/yellow 4 level, without additional information being provided to 5 understand the exact reason for that.
6 The originally designed green evaluations area were 7 occasionally inconsistent with quality operations.
8 Overall, we would have to say that the first Mode 4 9 assessment, we could not use without actually going back to 10 the individual ratings for each organization in each area 11 to understand what was going on.
12 And, that on occasion, one example, that the 13 operating experience, which was one of the key items from 14 the original Root Cause Analysis aspect of being a learning 15 organization, hadnt been well represented in the original 16 business practice when we had reviewed it.
17 The current status, looking at these positives and 18 the weaknesses, is that you had taken a number of steps to 19 improve the individual attribute rating standards. You 20 implemented a management review for each area where you had 21 yellows or reds. That, that worked well in accounting for 22 the differences in organizations, both size and importance 23 for that particular item, and then provided a report that 24 assessed or looked at how do you reach the final 25 conclusions. And where appropriate, you implemented, you MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
50 1 wrote Condition Reports and developed Corrective Actions.
2 For the External Safety Culture Assessment Tool, our 3 determination was that it was an appropriate tool to 4 provide valuable insights into the Safety Culture at the 5 facility.
6 The tools, interviews, surveys, observations used 7 for that to assess the Safety Culture were appropriate.
8 The tools have a strong technical basis, since they were 9 developed through extensive research. They have been 10 widely used internationally and in numerous industries.
11 The areas selected for review and evaluation were derived 12 from internationally recognized and used guidance on Safety 13 Culture monitoring.
14 The process was implemented as planned. All 15 individuals that the inspection team interviewed felt that 16 their answers would be kept confidential and the questions 17 were understandable.
18 An opportunity was missed to enhance independence in 19 this area when the individuals to reinterview were 20 basically selected by the Utility as opposed to the 21 Assessment Team at that time.
22 The results derived from the interviews, surveys, 23 and observations that were reported to you were consistent 24 with the collection, collected data. Independent 25 assessments by my team were consistent with the external MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
51 1 surveys results.
2 The concept of identifying whether a number of 3 diverse monitoring tools all point in the same direction 4 was appropriately implemented, that is as I talked before, 5 the convergent validity concept was appropriately used.
6 Any outlayers that were identify were not included in the 7 combined data.
8 The final report provided information to you that 9 could be used to focus efforts to improve the Safety 10 Culture at the facility.
11 In the area of Safety Conscious Work Environment, 12 your efforts to improve the Safety Conscious Work 13 Environment at the staff level, we find to have been 14 effective. Very few individuals provided negative feedback 15 regarding their personal understanding of their 16 responsibilities and obligations to report safety issues.
17 Further, most individuals felt free to raise 18 concerns. Individuals were also aware of the various 19 avenues available to them to raise issues, that being their 20 immediate supervisor or manager, the Corrective Action 21 Program, the Employees Concern Program, or the NRC.
22 However, we have not seen the same level of positive 23 feed, staff feedback related to the management commitment 24 in this area. Our observations, interviews, along with 25 your survey data indicate, in general, managers have not MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
52 1 understood or internalized the basic Safety Conscious Work 2 Environment concepts.
3 Some of the things I would like to point out as 4 observations in this area. The matrixes that you are 5 implied -- or implementing are appropriate. All of the 6 managers and operators, Operations Department, I believe, 7 have received specific training in Safety Conscious Work 8 Environment. Our review of the training documents 9 indicated that they were very good and that training was 10 appropriate.
11 We did note that the training of the staff is not, 12 has not been as vigorously pursued as we would have hoped; 13 however, the training is scheduled for 2004.
14 While appropriately training, like I said, while 15 appropriate training was provided to all managers, 16 interviews with managers indicated that many had not 17 appropriately internalized the message, as I had mentioned 18 before. Specifically, the areas of what constitutes an 19 adverse action, and what constitutes protected activities, 20 didnt seem to be well understood.
21 Surveys; the recent survey information was more 22 negative on independence and confidentiality of the 23 Employees Concern Program than we had seen in the past.
24 And the survey was more negative on managers dealing with 25 concerns brought to them. I think the survey data also MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
53 1 indicated, as I had indicated, noted earlier, that most 2 individuals at this site, understand their responsibility 3 and obligations, and indicated that indeed they would write 4 safety concerns.
5 Its interesting that a higher percentage said they 6 would raise safety concerns and a slightly lower percentage 7 indicated that they could do so without fear of 8 retaliation. So, there is a group in the middle that say, 9 "Ill tell you even though Im not sure what youre going 10 to do to me."
11 In the Safety Conscious Work Environment Review 12 Team, commonly called SCWERT, if I slip up along here 13 somewhere. The bottom line on a conclusion there is we can 14 not say that the Safety Conscious Work Environment Review 15 Team can protect the environment at Davis-Besse. That is 16 not to say that they cant, we cant make the positive 17 statement that they can.
18 That is based on, that the effectiveness of the 19 program is self-limiting; and, therefore, the potential 20 exists that it will miss issues that could have a negative 21 impact on the sites Safety Conscious Work Environment.
22 Why do I say that? There are basically two items that 23 limit the effectiveness, potential effectiveness of this 24 program; one being that it does not include contractors, 25 review of actions for contract personnel prior to the MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
54 1 action being taken; and as weve mentioned before, the 2 managers do not have a broad understanding of what adverse 3 action is.
4 In the area of the Employees Concerns Program, we 5 found that it functioned well between January and November 6 of this year when it was in place. The investigations were 7 thorough and survey results indicated general acceptance of 8 the program by the staff.
9 One concern we have at this time is the programs 10 ability to imagine issues in a timely manner in the future 11 because of the organization size. We do understand that 12 provisions are being put in place to bring in contractors 13 where necessary to support that organization.
14 General observations, that there were improvements 15 seen over the Ombudsman Program that had been in place.
16 The investigations were generally acceptable and timely.
17 There was a concern raised on the use of individuals in the 18 ECP program as consultants for managers. The concern there 19 is, if the manager asks an ECP person, is this an 20 appropriate action or what should I do, the action is 21 taken, that individual really has no independent place now 22 to raise the case. The ECP program that would have been an 23 appropriate place to go has been compromised because of 24 consultations up front.
25 The matrixes used to monitor the area are MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
55 1 appropriate. I should say were appropriate.
2 In the area of the Long Term Safety Culture 3 Monitoring, that program, unfortunately because of some of 4 the material associated with it not being finalized at this 5 point, we cannot make an overall assessment at this time.
6 It is not something that would limit the restart of 7 the facility. We will be back to review it. We did note 8 that it really encompasses about five different items; that 9 being a monthly performance monitoring, the surveys done by 10 the Nuclear Oversight Organization, the Employees Concerns 11 Program Surveys, the Restart Readiness Review Process, and 12 we also noted that you have planned for late in 2005 to 13 bring in an external organization to do an independent 14 assessment.
15 MR. MYERS: Right.
16 MR. WRIGHT: Overall 17 conclusions. The assessment tools and programs to address 18 Safety Culture and Safety Conscious Work Environment, well 19 beyond, were well beyond any sort of regulatory 20 requirement.
21 Overall, we found that the tools being used to 22 assess the Safety Culture at Davis-Besse were adequate and 23 appropriately implemented. Further, based on the 24 independent inspection activities that I have previously 25 described, we have concluded that the output from these MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
56 1 tools provided valuable and appropriate insights into the 2 Safety Culture at the site.
3 Based on the input from these tools, we have 4 determined that a significant improvement in Safety Culture 5 and Safety Conscious Work Environment has occurred on a 6 site-wide basis; however, a recent survey taken in November 7 of this year, calls into question the effectiveness of some 8 of the Corrective Actions that were required by 10 CRF 9 Appendix B Criterion 16, which stemmed from the Management 10 and Human Performance Root Cause Assessment made -- calls 11 into question how effective those Corrective Actions have 12 been.
13 We are specifically concerned with the declines 14 between March and November of this year in Operations, 15 Engineering and QA and significant areas related to safety, 16 safety and schedule and cost, as well as Safety Conscious 17 Work Environment.
18 One of the items you just sat through, the Restart 19 Readiness Assessment Team, we believe that a number of the 20 performance deficiencies -- this is based on a preliminary 21 review -- that a number of those performance deficiencies 22 can be attributed or considered as symptomatic of the 23 underlying problems shown in the survey.
24 The team has concluded that absent an understanding 25 of the conditions that caused the declines, we do not have MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
57 1 reasonable assurance in the quality and consistency of 2 future performance; and, therefore, we are unable to make a 3 positive recommendation to the 0350 Panel regarding restart 4 of the Davis-Besse facility.
5 To that end, and weve already talked, weve already 6 heard this a little bit, we are requesting that you provide 7 a detailed assessment of those areas that exhibited a 8 notable decline. The assessment should be of sufficient 9 detail to allow an understanding of why the different 10 organizations responded to the, in the declining areas.
11 And the assessment should include Corrective Actions where 12 appropriate and measures to monitor their effectiveness.
13 Following receipt of that and evaluation of your 14 assessment, we plan to conduct additional inspections in 15 this area to gain the confidence that we need to make a 16 recommendation to the 0350 Panel.
17 Before I conclude this, I would like to ask if there 18 are any comments that members of my team, who were either 19 on the phone or Jay, if there is anything additional you 20 would like to add?
21 MR. PERSENSKY: No.
22 MR. WRIGHT: I think Lisa may 23 be on, I dont know if she can get through.
24 Lisa? Lisa, can you hear me?
25 I guess we have some technical difficulties.
MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
58 1 MS. JARRIEL: Geoff, can you 2 hear me now?
3 MR. WRIGHT: Yes. I can.
4 Thank you, Lisa. It worked. Is there anything that you 5 would like to add specifically? As I indicated, Lisa was 6 our expert specifically in Safety Conscious Work 7 Environment and ECP programs.
8 MS. JARRIEL: No, I dont have 9 anything to add, thank you.
10 MR. WRIGHT: Thank you, Lisa.
11 Before absolutely concluding this portion of the 12 meeting, I would like to thank all three of my teams of 13 which there were actually three separate groups that looked 14 into these three areas, and the many FirstEnergy and FENOC 15 personnel that supported us.
16 The first phase of the inspection started about, you 17 know, in the second quarter of last year. So, weve been 18 at this for almost 18 months, which means for some of the 19 resumes that I gave you, I would actually have to add 20 probably a years worth of experience at this point.
21 We have received outstanding performance, or 22 outstanding support, I should say, from this organization 23 in all aspects of that inspection activity.
24 This concludes my presentation regarding the 25 observations and conclusions from Phase 3 Management and MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
59 1 Human Performance Inspection.
2 Jack, would you?
3 MR. GROBE: Yeah, thanks, 4 Geoff. I just have a couple of comments and observations.
5 As Geoff indicated, there are no NRC inspection 6 procedures for this area. This is not an area that the NRC 7 normally looks at. We have regulations that require 8 utilities to operate nuclear power plants in a quality 9 fashion. Those regulations are contained in 10 CRF CFR 50 10 Appendix B.
11 Geoff highlighted one of those regulations, which is 12 Criterion 16, and that requires that Corrective Actions for 13 conditions adverse to quality be taken and be effective.
14 The regulatory foundation for this inspection was 15 that requirement. And we were out here to understand what 16 actions FirstEnergy was going to take to correct one of the 17 significant root causes that they identified and 18 communicated to us in August of 2002, that resulted in the 19 degradation of the reactor head, and that was specifically 20 an inappropriate focus on productivity at the expense of 21 safety margins.
22 I think I simplified that with just a few words, 23 much more simply than you articulated to the audience.
24 The NRC does have regulations, as I mentioned, in 25 Appendix B regarding quality. Also at 10 CRF CFR 50.7 MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
60 1 regarding the prohibition of retaliating against 2 individuals for raising safety concerns. In addition, the 3 commission has expressed the policy statements, our 4 expectations in the area of Safety Conscious Work 5 Environment and Safety Culture are also addressed in those 6 policy statements.
7 The regulatory approach and focus of our inspection 8 programs is what we call Performance Based Inspection or 9 Outcome Based Inspection, where we look at the performance 10 of the organization and then through Appendix B go back and 11 look at what the root causes might be of performance 12 problems.
13 As Geoff indicated, by and large, the programs and 14 processes that you put in place to assess the Safety 15 Culture and Safety Conscious Work Environment at your 16 facility are well structured and founded. As he indicated, 17 I think one of those processes went through ten revisions 18 over the past many months, so its been refined many times; 19 and the outcome of that refined process is an effective 20 tool to assess the organizational effectiveness in the 21 organization.
22 Geoff made a number of comments regarding those 23 tools and ways in which they could be enhanced. Those are 24 not regulatory requirements and theyre simply provided by 25 a team of highly capable and competent people in these MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
61 1 areas as observations and comments for you to consider.
2 There is one issue though that is necessary to 3 address. One of the handouts that Geoff provided was a 4 brief summary of some of the data from a survey that you 5 conducted of your staff in November. And there is only a 6 little bit of the data. The overall set of data from that 7 survey is very comprehensive, but this is just a brief 8 summary of some of the areas where we saw declines in 9 performance. I want to emphasize that these numbers are 10 your numbers, theyre not ours.
11 MR. MYERS: Thats right.
12 MR. GROBE: They are 13 percentages of negative responses to the various questions, 14 and the questions have to be read carefully to understand 15 what the data is saying.
16 There are no requirements to have these types of 17 surveys or to have any level of performance per se in each 18 of these areas. Our concern is not the specific values of 19 the data; our concern is that there has been a notable 20 decline in several departments in several areas between 21 March and November.
22 Some of these departments had significantly better 23 performance or indications of performance in the survey in 24 March. Some of these departments actually improved in a 25 number of areas. There are many other departments and many MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
62 1 other areas of the survey where performance was strong; 2 however, we dont understand what has caused the declines 3 in these areas and these departments.
4 The particular departments highlighted on these 5 surveys, this table, are the Operations Department, Plant 6 Engineering, the Maintenance Department, and Quality 7 Assessment Department. There were other, as I said, there 8 is other departments with data that is also declining, 9 however, these were the ones that were most notable by our 10 team.
11 As I mentioned, we dont understand what has caused 12 these declines; and until we understand that, it is 13 difficult to express a view. The panel has found it 14 difficult to express a view on the future success of the 15 organization in resolving one of the root causes to the 16 head degradation.
17 I understand, Lew, that youve also, you also 18 anticipated on the 29th, you will be able to provide us 19 some additional information regarding this data and what it 20 means; and particularly, I would hope that you would 21 address your appreciation of what caused the performance 22 decline in these areas, the indicated performance decline, 23 if in fact it is a performance decline; what actions that 24 youve taken in the past were not effective; what 25 activities you may have taken that contributed to this MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
63 1 decline; what actions youre going to take in the future 2 that will address the issues that you identify, and why you 3 believe in the future those to be effective.
4 The 29th is only ten days from now, and between the 5 inspection that you presented earlier, the Restart 6 Readiness Inspection Team Inspection and this inspection, 7 there is a number of issues that need studied and 8 additional information from the organization.
9 We certainly will not have an opportunity to review 10 any of the information that youre going to present on the 11 29th before the meeting.
12 MR. MYERS: Right.
13 MR. GROBE: So, that meeting 14 though will be our first step in continuing dialogue and 15 assessment in these areas with you. I anticipate that 16 well have a number of staff available for that meeting, 17 and that they will be either available in person or on the 18 phone. I anticipate that well have a lot of questions for 19 you, and there will likely be additional work that you will 20 need to do and could likely be additional work that you 21 would need to do following that meeting, before progress 22 could be assessed and a decision could be made as to when 23 it would be appropriate to schedule additional 24 inspections and schedule a restart meeting.
25 Christine? Others? Bill, do you have any other MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
64 1 comments? Christine?
2 MS. LIPA: No.
3 MR. GROBE: Lew, at this 4 point, why dont I turn it over to you; do you have any 5 comments?
6 MR. MYERS: Yes, I do. I 7 thought about this, this area last night, and the journey 8 that weve been on in the past couple years, year and a 9 half or so, you know, concern identifying a safety problem, 10 starting at my level and all down through the nuclear 11 organization. I believe when you take a job in this field 12 as a nuclear worker, you accept a responsibility. That 13 responsibility is that you identify any safety problem, 14 that personal responsibility we accept as nuclear workers, 15 if we have one.
16 From a management standpoint, what we have to do is 17 provide multiple methods of identifying those problems and 18 allowing our employees to raise those concerns through our 19 normal management process, through the Corrective Action 20 Process, Employees Concerns Process, if necessary to the 21 NRC. I would have been much happier today if somebody said 22 something about the reactor vessel head to the NRC, than 23 not brought up at all; much better, you know.
24 That being said, this is a journey, you know. Its 25 our responsibility. Safety Culture is a term. You know, I MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
65 1 started in this industry a long time ago, back in 67.
2 And, who would have thought at the end of my career I would 3 be talking about Safety Culture. Maybe the most important 4 thing Ive learned in my career.
5 If you would have asked several of us sitting this 6 room today, the difference between Safety Conscious Work 7 Environment and Safety Culture a year and a half ago, we 8 would have given you the definition of Safety Conscious 9 Work Environment, you know, pretty confident of that.
10 Today we have gone a long way. We have a model of 11 Safety Culture. I was at our other plant the other day 12 watching us do our assessment and its a leading model in 13 industry that were using. Im extremely proud of what we 14 have done in that area. And, its another management tool 15 that we can help be more effective at in operating our 16 nuclear power plants and ensuring that we have the right 17 standards and environments present.
18 Safety Conscious Work Environment is an important 19 thing also. And everything that we do as management is 20 received differently by different individuals. We think, 21 you know, we went through a development, a discovery phase, 22 an implementation phase, and a design phase, and now were 23 into the implementation phase.
24 What that does is puts stress on a lot of key 25 departments, like Chemistry, Ops, HP, stuff like that, and MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
66 1 Maintenance, you know. Were seeing some of those 2 stresses, because weve taken action now every day to drive 3 getting the work done, you know, to get the NOPT Test 4 done. Restart the plant, thats our focus now; where a 5 year or so ago was walking down systems, you know.
6 What weve got to do is take this data, which weve 7 already started. Weve got a few hundred feedbacks already 8 from our employees and what data means. Were having 9 standdowns with each and every employee over the past day 10 or so, because before this meeting, one thing I learned at 11 Davis-Besse, if I havent learned anything else, I always 12 try to share stuff with the employees before it gets to the 13 public meetings. Thats one thing our employees feel very 14 strongly about.
15 So, we met with all of our employees in about four 16 different meetings through last night talking about some of 17 the results in the survey and also the results of the 18 Readiness Team before this meeting, and shared as honestly 19 as we could with them our perception of where were at.
20 Now, thats not to say were through. Were going 21 to continue over the next few days, were having some 22 outside help come in and help us look at the data, and 23 understanding of, well probably do some more interviews; 24 and then well figure out what we want to share with our 25 employees and you, and our Corrective Actions that we need MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
67 1 to take going forward. But we think thats healthy. We 2 think its healthy.
3 Overall, the survey, once again, if you look, I 4 would share that, that the overall results went up, but 5 there are some areas that we need to go look at. Thats 6 what managers do. Well do that. Well take it 7 seriously. Well bring in the best help we can. Well 8 give you the best information we can on the 29th, and we 9 look forward to that meeting.
10 And, you know, Ill tell you, this model that were 11 using for Safety Culture and the Safety Conscious Work 12 Environment stuff may wind up being the most important 13 thing Ive done in my career. So, I think the past two 14 years I look at, this has been a learning experience for 15 myself. So, I appreciate the effort, and look forward to 16 this effort going forward.
17 MR. GROBE: Okay. Thanks, 18 Lew.
19 Geoff, Jay, any other comments?
20 MR. WRIGHT: None.
21 MR. GROBE: Christine? Bill?
22 MS. LIPA: No.
23 MR. GROBE: At this point, 24 this would conclude the business portion of the meeting.
25 What I would like to do is take a few minute break, and MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
68 1 then go into the question and answer process. Well take 2 questions here in the room first, and then go to the phone 3 lines and circle back and forth to make sure that all 4 questions are answered.
5 So, lets take a ten minute break. Its five to 6 11. Well reconvene at 5 after 11.
7 (Off the record.)
8 MR. GROBE: Thank you very 9 much. This is Jack Grobe. Before we get started I want to 10 correct some misinformation that I provided. The meeting 11 on the 29th is at Oak Harbor High School at 6:00 in the 12 evening. We anticipate several hours of dialogue with 13 FirstEnergy, and it will be just like all of the meetings 14 weve conducted where there will be an opportunity for 15 public questions and comments.
16 We will have that meeting transcribed. The 17 transcription will be available shortly after the meeting; 18 however, we will not have telephone hookup for that 19 meeting. I dont believe we have that capability at Oak 20 Harbor. So, that was the information I wanted to correct.
21 At this time, what I would like to do is recognize 22 one individual in particular. The Nuclear Regulatory 23 Commission has maintained a very close relationship with 24 the Ottawa County officials, officials of the State of 25 Ohio, as well as federal elected officials who represent MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
69 1 the State of Ohio in the local districts here. And we have 2 a representative of the State of Ohio here today who has 3 been monitoring our performance of the Restart Readiness 4 Assessment Team Inspection, as has the state and 5 representatives here monitoring various other inspections 6 over the last two years.
7 Sonya Eischen is in the audience.
8 Why dont you stand up, Sonya.
9 She represents the State of Ohio and has been 10 observing our activities. We welcome their presence, and 11 its assisted us in keeping a very close communication 12 channel open for the State of Ohio. So, thank you for 13 being here today, Sonya.
14 Are there any other elected official or 15 representatives of elected officials that are here in the 16 room? I didnt see any.
17 Very good. Thank you.
18 We do have some 80 callers on the phonelines. Well 19 get to those in a minute. What I would like to do first is 20 take any questions or comments from the members of the 21 public that are here in the audience today.
22 If you could approach the microphone and speak very 23 clearly and loudly into the microphone. Also sign in, if 24 you would, so we have a record of who you are. Thank you.
25 DR. WIZNER: Good morning. My MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
70 1 name is Doctor Dan Wizner. Im a retired geography 2 professor. I live in Oberlin, Ohio, which is 60 odd miles 3 downwind. And Im here as a citizen, but also because over 4 the last 37 years Ive worked, in fact, in the area of 5 disaster management.
6 This year alone, 2003, I published three books, a 7 second edition of my textbook written for Rutledge in 8 London about risk; a book in furtherance of higher 9 education project, an instructors guide, called 10 Vulnerability Approach to Emergency Management; and a book 11 for the World Health Organization I co-edited called 12 Environment in Health and Emergency Disasters.
13 So, I want to make, I simply want to remind the 14 Commission of two truisms, and then reflect a little bit on 15 Safety Culture very briefly.
16 Safety Culture is in fact my prime professional 17 expertise. I participated with several UN agencies during 18 the International Decade for Natural Disaster Reduction, 19 1990 through 1999.
20 The two truisms are simply that, as Mr. Grobe said 21 earlier in summary, inappropriate focus on productivity as 22 opposed to safety; thats the phrase he used more or 23 less -- Im paraphrasing; I would assert is inevitable, is 24 inevitable.
25 Were living in a period of increasing MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
71 1 privatization, and if I may use the C word, were living in 2 a Capitalist society, and the pressures therefore on this 3 plant will be unrelenting. All right. Thats first 4 truism.
5 The second is, as most of you have engineering 6 backgrounds, you know quite well that tightly coupled 7 complex systems necessarily produce falls and anomalies; 8 and as Charles Perot at Yale University says in his book, 9 Normal Accidents, they almost inevitably fail in one form 10 or another. Thats the second truism.
11 Now, whats this got to do with Safety Culture?
12 Well, clearly, it just makes it extremely important, so I 13 agree entirely with Lew Myers, who said very well that in 14 his long career this may be the most important aspect of 15 the restart process for him and for everyone else.
16 Those two truisms mean that Safety Culture is what 17 stands between my grandchildren, my neighbors, and a plume 18 of radioactivity.
19 Now, I simply want to remind you of the language 20 used by the Nuclear Regulatory Commission in its February, 21 1997, ten-page publication on Safety Conscious Work 22 Environment. They, in fact, use very interesting language 23 to describe a Safety Culture. They talk about the 24 maintenance of a safety ethic at all levels, from page 3 of 25 the, February 1997 document.
MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
72 1 Quote, "Safety ethic at all levels that is 2 characterized by inherently questioning attitude, attention 3 to detail, prevention of complacency, the commitment to 4 excellence and personal accountability in safety matters."
5 That sounds pretty good to me. Although, this plant 6 is part of a large corporation called FirstEnergy 7 Corporation. And, I know that, that the Nuclear Regulatory 8 Commission has no jurisdiction over, for instance, the 9 electricity grid operations of FirstEnergy. However, 10 yesterday, when I was in the Public Relations Office in 11 this building, I saw a sweatshirt on the back of someones 12 chair. It said, "Blame Canada" "Blame Canada".
13 Now, you probably all know that that refers to a 14 dispute thats been going on, thats actually, I think its 15 successfully settled now by various commissions; whether or 16 not the energy outage in August that plunged 50 million 17 people in North America in darkness was the fault of 18 operators in Canada or the U. S., or in particular, the 19 fault of FirstEnergy Corporation operators.
20 And, I think that as a symbol of what this plant is 21 up against, as it, as it tries to show to public servants, 22 that is my servants, you on the commission, that its ready 23 to restart, the sweatshirt is really quite telling. Its 24 really quite a powerful symbol.
25 FirstEnergy Corporation did not train its operators MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
73 1 properly, the grid operators. Their computers 2 malfunctioned. All right?
3 Now, at the core yesterday, Mr. Bezilla told me, 4 that the core of safety system here rests essentially with 5 the analysis of faults. Now, its about a four-fold 6 process, as I see it. Youve got to be aware of the 7 potential problems in the first place. We heard for nearly 8 an hour this morning between 9 and 10 that that awareness 9 is not there yet. Maybe it will get there.
10 But then these things have to be reported. Of 11 course, thats where the second team comes in on the Safety 12 Conscious Work Environment, the Employee Concerns Program, 13 et cetera.
14 But then, this important step of analysis, because 15 you dont act with all ten thousand, approximately, ten 16 thousand reported anomalies each year, a number that is a 17 gross estimate, one that Mr. Bezilla shared with me 18 yesterday. Okay? You simply cant act on all of them.
19 So, what do you do? You have to analyze them.
20 Well, I asked Mr. Bezilla yesterday, I said, "Gee, 21 that must take a lot of computational power. How many 22 gigabytes of computational power do you have here on site?
23 And how old are these machines?"
24 Turns out, if Im not mistaken, he told me the 25 machines are in fact off site. They may or may not be MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
74 1 maintained by a subcontractor. I dont know whether the 2 Nuclear Regulatory Commissions brief has actually extended 3 to looking at those computers that will be used to do trend 4 analysis on these reported faults. The whole system will 5 fall apart unless you do that.
6 MR. GROBE: Sir, if you could, 7 we have a lot of people, Im sure are interested, if you 8 could wrap up your comments.
9 DR. WIZNER: Right, Ill wrap 10 up with one more, one more concern.
11 I talked about a sweatshirt. All right? And, the 12 point, the point here is that, FirstEnergy Corporation, 13 unless it has a Safety Culture from the top, from the Board 14 of Directors right the way through all of its operations, 15 right, its not, youre not going to successfully have a 16 Safety Culture here, you cannot, unless you stage a coup 17 and you set yourself up as an entirely different entity.
18 Thats the first point.
19 The second concerns a commitment banner. Like the 20 sweatshirt. This is a flyer I obtained yesterday that 21 invites people to a meeting that was supposed to take place 22 yesterday. And, many of them, I guess are here today. It 23 invites people to come along to the cafeteria and sign and 24 autograph the commitment banner; "Were ready. Were 25 ready. The plants ready, so are we."
MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
75 1 I submit -- this sounds anecdotal and perhaps silly, 2 but I submit as someone with 37 years of work 3 internationally in this area, that there is no worker in 4 this plant in their right minds who in this high school pep 5 rally environment, "Were ready, Were ready, Lets sign 6 the commitment banner", will stand up and say, "Well, wait 7 a minute, maybe were not ready."
8 I think this is the elephant thats actually in the 9 room that nobodys talked about. All right? You can have 10 all the fine details of employee, employee communication 11 systems and anonymous phonelines and all the rest of it, 12 but it has to do with the overall culture in the plant.
13 And I am very much concerned with this whole notion of a 14 commitment banner and getting everybody out to the 15 cafeteria to autograph it, so they can put it forward.
16 MR. GROBE: I really 17 appreciate your comments, sir, and I would like to make a 18 couple comments.
19 DR. WIZNER: Right. Thank you 20 very much.
21 MR. GROBE: A couple of 22 observations of things that you may not be familiar with in 23 our regulatory environment that is different than the areas 24 that youve worked, our regulations require action on every 25 deficiency identified that concerns safety. So, if there MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
76 1 is ten thousand, or five thousand, or one thousand, it 2 doesnt matter, every one needs to be fixed. And, thats 3 clearly in our regulations, and its something that we 4 focused on in our inspections.
5 Secondly, you made some very valid observations, and 6 largely, I agree with your observations, that any time you 7 have complex technical systems, its, the systems are 8 challenged to perform successfully because of their 9 complexity.
10 And for that reason, the regulatory structure, 11 Nuclear Regulatory Commission in ensuring safety to nuclear 12 power plants, ensures on diversity and redundancy in all 13 those systems; and ensures on duplicity -- duplicate 14 reviews and validations of all design information and 15 evaluation of those systems.
16 So, there is multiple layers of protection; and 17 within each of those layers, there is redundancy and 18 diversity in the equipment that is intended to protect the 19 public.
20 You indicated that there is commercial pressure 21 which is in direct conflict with a safety focus, and thats 22 absolutely true. Operating a business in a commercial 23 environment, a competitive environment, necessarily creates 24 conflict with Safety Culture. And, thats why there is 25 organizations within FirstEnergy; for example, the MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
77 1 quality -- Nuclear Quality Assessment at the corporate 2 office and at the site, as well as the independent Onsite 3 Review Committee that evaluates the performance of the 4 organization in an ongoing nature, as well as the Offsight 5 Review Committee, which is experts from other organizations 6 that continuously evaluates whats going on.
7 And, FirstEnergy went a step further and created a 8 group that they call the Restart Oversight Panel, which was 9 all independent experts, both from the Nuclear Regulatory 10 Commission, former employees of the Nuclear Regulatory 11 Commission, as well as outside experts from the industry, 12 both current employees of various utilities and former 13 employees of the industry, to ensure that there is a proper 14 balance.
15 Were in a situation right now, what I would 16 describe as a check and adjust situation. There has been 17 significant progress made over the last 22 months. There 18 is some inconsistencies in the outcome of the actions taken 19 by FirstEnergy. We need additional information regarding 20 whats causing those inconsistencies.
21 We certainly dont regulate by banners and 22 sweatshirts. I think what you saw today was two teams of 23 exceptionally capable individuals that were brought to bear 24 on this problem. And we will continue in a methodical 25 process of bringing the right experts with the right MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
78 1 capabilities to assess what FirstEnergy is doing.
2 Our focus has always been on safety and will 3 continue to be there. And I can assure you that this plant 4 wont restart until the Oversight Panel makes 5 recommendation to the NRC management that it can be safely 6 restarted and operated.
7 Just one more observation, and well go on to 8 another comment. The nuclear power industry in the United 9 States is the largest in any country in the world. We 10 currently have 103 reactors that have -- excuse me, 103 11 reactors with operating licenses, 102 of those are 12 operating today. The safety performance over the last two 13 decades of those nuclear power plants has continuously 14 improved, and is setting standards in the world regarding 15 safety.
16 Your observations regarding the inherent conflict 17 between competitive environments and safety focus are 18 absolutely on target, and thats why it requires the 19 continuous diligence that you so carefully quoted from our 20 publication. I like it when people quote back our 21 publications to us.
22 Those attributes of a safety focus are essential, 23 and are in place, and are resulting in extraordinary safety 24 performance in the nuclear power industry in the United 25 States, and well continue to evaluate those attributes MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
79 1 here at Davis-Besse prior to restart of this plant.
2 Is there somebody else here in the room that has a 3 question or comment?
4 MS. HIRSCH: My name is Judith 5 Hirsch, Im a 27 year employee of Davis-Besse, and I would 6 like to respond to one comment. The gentleman made a 7 comment that he does not believe there is any employee at 8 Davis-Besse that would have the courage to stand up and say 9 this plant is not ready.
10 I would like to disagree with that. I believe there 11 are a number of employees here who would do that. I would 12 do that, and if you read the Condition Reports that are 13 written every single day at this site, you will find a 14 large number of them where employees are raising concerns; 15 those concerns are being addressed; and those concerns are 16 being answered.
17 Thank you.
18 MR. GROBE: Thank you, Judy.
19 Other questions or comments from here in the room?
20 Okay. Very good. Well come back, if you have a 21 question or comment, think about it, well come back to the 22 folks here in the room in a few minutes.
23 What I would like to do now is go to the 24 phonelines. Operator, if you would let us know if there is 25 anybody on the phone that has a question or comment, we MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
80 1 would be glad to take that at this time.
2 OPERATOR: Thank you, our 3 first question comes from Jim Pulsen with Newberg News.
4 MR. PULSEN: Mr. Grobe, Ive 5 been listening. I was wondering if you could be a little 6 bit more specific. FirstEnergy has basically been held 7 against permission to restart by the end of the year.
8 Doesnt sound like it, but I wonder if you could offer a 9 little more insight on that.
10 MR. GROBE: Yes, I can provide 11 insight. The NRC will not be considering restart of the 12 Davis-Besse facility before the end of the year.
13 MR. PULSEN: But beyond that, 14 youre not sure.
15 MR. GROBE: Well, on the 29th, 16 you will be getting some additional information from 17 FirstEnergy. The issues that were identified this morning 18 are difficult issues that require careful study. And, 19 Mr. Myers from FirstEnergy has indicated that they will be 20 prepared to provide some information to us on the 29th, and 21 that will be our first step in receiving that information 22 and evaluating it and determining what further actions are 23 necessary on the part of the NRC to evaluate the 24 performance at Davis-Besse before restart.
25 MR. PULSEN: Is the procedure MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
81 1 for NRC approval the same as it has been, it goes from 2 inspection committees upstairs.
3 MR. GROBE: Yes. There is, 4 weve been following a methodical process thats outlined 5 in our internal procedures. Its called a Manual Chapter 6 0350 is the number. Weve been following that process for 7 about 21 months, I think now, and we will continue 8 following that same process.
9 MR. PULSEN: Thank you.
10 OPERATOR: Thank you. Our 11 next question comes from Paul Patterson with Glen Rock 12 Associates.
13 MR. PATTERSON: Good morning. How 14 are you?
15 MR. GROBE: Just fine.
16 MR. PATTERSON: What I wanted to 17 ask, I guess sort of a follow-up on that. I guess the next 18 time were going to see the ability of the company to 19 address some of the Safety Culture issues is on the 29th, 20 but it sounds from what I heard today that there is 21 probably going to be an additional meeting associated with 22 these Safety Culture issues. Is that a reasonable 23 assumption?
24 MR. GROBE: Well, there will 25 be as many meetings as are necessary for us to get the MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
82 1 information we need. We have routine public monthly 2 meetings, the 0350 Panel does, and we will continue those.
3 Our next one is scheduled for January 13th. And, I believe 4 the February one, the date is not finalized yet. But those 5 schedules are available on the NRC Web site, and so well 6 be meeting on a regular basis.
7 If we need specific meetings on specific topics, 8 those will be scheduled and conducted. We generally give 9 ten days advance notice of all of our meetings, so there is 10 plenty of opportunity for public access. And we have done 11 something unique on this project, and that is virtually all 12 of our meetings are transcribed. And if we conduct a 13 meeting outside of this immediate area, we try to provide a 14 phone link similar to this one.
15 We recognize that this meeting might be of 16 significant interest to folks, and its close to the 17 holidays, so we provided a phone link on this meeting also, 18 even though were here in the local area of Ottawa County.
19 MR. PATTERSON: I think its 20 great that you have this link, but just to get a better 21 idea of the 29th; it sounds like because the issues are so 22 complicated, et cetera, we should assume that the 29th 23 meeting wont resolve, wont probably resolve enough issues 24 in order for there not to be additional meetings before 25 restart.
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83 1 MR. GROBE: I can say that, I 2 dont know if there will be additional meetings before 3 restart. There will certainly be a restart meeting, but 4 there will certainly be additional evaluation by the NRC, 5 and I would anticipate additional inspection.
6 So, we generally discuss those inspection results 7 when theyre ready to be discussed publicly at our routine 8 monthly public meetings.
9 So, there will be additional meetings before restart 10 as a minimum, the meeting that was required in our 11 Confirmatory Action Letter, and call that the Restart 12 Meeting. If there is a need for additional meetings, they 13 will be scheduled and conducted.
14 MR. PATTERSON: Okay. And on 15 the 29th, just so I understand, will the company be going 16 to Mode 4 and Mode 3 at that point in time?
17 MR. GROBE: When the plant 18 goes to Mode 4 and 3 is up to FirstEnergy. The NRC doesnt 19 have any hold on that. And there has been nothing observed 20 during these inspections that would indicate that the plant 21 cannot go to Mode 4 and 3 -- excuse me. All of our 22 inspections to-date indicated that the plant can go to Mode 23 4 and 3 successfully, if they choose to do that. It was 24 done safely in September and October. There were a number 25 of performance problems that required action, but the MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
84 1 evolution was safely controlled.
2 So, if FirstEnergy chooses to go to Mode 4 and 3, 3 thats their choice. They can do that as they need to, to 4 accomplish work, and check out the various systems in the 5 plant. But --
6 MR. PATTERSON: But we shouldnt 7 see that as basically going to start?
8 MR. GROBE: No.
9 MR. PATTERSON: No, okay. The 10 start will take longer than that, will take obviously 11 sometime past the 29th to be figured out what happened.
12 MR. GROBE: Thats correct.
13 MR. PATTERSON: Thank you very 14 much.
15 OPERATOR: Thank you. Our 16 next question comes from Daniel Horner with McGraw-Hill.
17 MR. HORNER: Yeah. I just 18 wanted to ask, Jack, if you could clarify a statement that 19 was made at the beginning of the meeting after the RATI 20 presentation.
21 You said, the inspections are really no safety 22 issues, then a couple minutes later you said, this would 23 have assurance, I think, when you said the plant will be 24 able to restart safely, that there was a potential safety 25 question. So, I think I maybe got tripped up on the MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
85 1 terminology, so if you could explain those two statements 2 and how they fit with each other.
3 MR. GROBE: Thats an 4 excellent question, Dan. Thanks. Youre starting to talk 5 like a bureaucrat and use our acronyms.
6 The panel is challenged with a difficult decision; 7 and that is, when does the panel have sufficient 8 information to make a recommendation to NRC management that 9 it has reasonable assurance that this plant can be 10 restarted and operated in a manner thats consistent with 11 our regulations and the plant will be consistently safe in 12 the future.
13 The issues that were identified to-date during the 14 two Exit Meetings caused questions. There are no safety 15 issues that have been specifically identified. What I mean 16 by that, we categorize inspection findings in different 17 risk categories or safety categories. We use 18 simplistically colors; green, white, yellow, and red.
19 Well, there were no findings that were discussed today that 20 would be greater than green from a risk perspective or a 21 safety percent effective.
22 Not withstanding, these findings raised questions in 23 our mind that the panel needs to understand before it can 24 feel comfortable making the recommendation to NRC 25 management that this plant is ready to restart.
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86 1 MR. HORNER: Okay. Another 2 quick one. On the scheduling thing, your response to the 3 previous question; so, in other words, there has to be, 4 there certainly has to be a minimum of one more meeting, 5 which is the restart meeting, which was to have been, which 6 was planned on the 29th, but that has to take place in 7 addition to any of the monthly meetings, and there may or 8 may not be additional meetings according to what sort of 9 responses FENOC provides and what further inspection and 10 evaluations are required from the NRC. Is that basically 11 right?
12 MR. GROBE: I believe so.
13 Im a little concerned, and maybe I could talk about this 14 for just a moment. Im a little concerned with the focus 15 on meetings. The Confirmatory Action Letter requires that 16 FirstEnergy committed to conducting a meeting, which we 17 call a Restart Meeting. Thats going to be near the end of 18 this process prior to restart.
19 The focus of that meeting is kind of a wrap-up 20 meeting, where FirstEnergy will present in a holistic way 21 what caused the problems in the long term shutdown at 22 Davis-Besse, what actions were taken to resolve those 23 problems, why they believe those actions have been 24 effective, and why they believe theyre ready to restart 25 the plant.
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87 1 That will likely be the last meeting before the NRC 2 considers the question of restart. Its certainly a 3 prerequisite for us to make a decision on whether this 4 plant is ready to restart.
5 The meeting on the 29th is going to be the beginning 6 of the dialogue and further inspection in the two areas 7 that we focused on today. If FirstEnergy chooses to go to 8 Mode 4 and 3, we will certainly observe that. We can get 9 valuable insights and additional data on plant performance 10 if they choose to go through those evolutions; however, I 11 anticipate that there will be a need after we understand 12 the information that we will begin to discuss on the 29th; 13 after we have a thorough understanding of that, I 14 anticipate there will be an additional meeting for 15 inspection, both of the areas that we discussed this 16 morning. And the panel has not identified those inspection 17 plans yet.
18 Rick Skokowski and Christine will be working on what 19 further assessments need to be made in the area of conduct 20 of operations. And Geoff Wright and I will be working on 21 what further assessments need to be made in the area of 22 Safety Culture and Safety Conscious Work Environment.
23 Those inspections will occur after we have a clear 24 understanding of the specific aspects of information that 25 we ask FirstEnergy to be prepared to provide on the 29th.
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88 1 And just to refresh your memory, those specific issues are:
2 What caused these inconsistencies in performance?
3 Why were the prior corrective actions not effective, 4 not fully effective?
5 What additional actions if any are necessary to 6 improve performance?
7 And how they will assess the effectiveness of those 8 actions prior to a restart recommendation from the Utility 9 to the NRC.
10 So, were going to hear FirstEnergys information.
11 Im sure we will have some questions. We usually do. And 12 following our understanding of that information, we will 13 schedule some additional assessments on site and those will 14 all occur before the NRC would be prepared, along with the 15 restart meeting, before the NRC is prepared to make a 16 restart decision.
17 MR. HORNER: Okay. One more 18 quick question, if I could. I know that the going to Mode 19 4 and 3 does indicate imminent restart, but is there, does 20 FirstEnergy have a schedule at this point when they will go 21 to Mode 4 and 3? Its been changed a couple times. What 22 is the current schedule on that?
23 MR. GROBE: Dan, I think you 24 would have to ask FirstEnergy that and you can do that 25 separately.
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89 1 MR. HORNER: Okay. Thank you.
2 MR. GROBE: Yep.
3 OPERATOR: Thank you. Our 4 next question comes from Lou Dale Monte with the Correction 5 Group.
6 MR. MONTE: Good morning.
7 This morning youve outlined a number of violations, 8 as well as a bit of Davis-Besse personnel performance 9 following safe procedures. I was wondering whether or not 10 you could help me understand, and specifically looking 11 through some of these open items, if you could detail for 12 me maybe three or four of the more prevalent open items 13 that would be absolutely necessary before the NRC could 14 consider establishing another restart meeting.
15 MR. GROBE: I think I just 16 did that. Let me again say, that the specific issues are 17 not of unique safety significance. What is important to 18 the NRC is why they occurred and what actions FirstEnergy 19 will be taking to ensure that their people perform their 20 safety activities in a manner that is consistent with their 21 expectations and consistent with our regulations. So, that 22 is the focus.
23 Why has the Corrective Actions to-date -- why have 24 the Corrective Actions to-date not resulted in the kind of 25 consistent performance that FirstEnergy expects and why MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
90 1 hasnt it resulted in compliance, consistent compliance 2 with our regulations as both they and we expect.
3 MR. MONTE: All right. So, 4 that they know one, two, or three of these items are safety 5 significant.
6 MR. GROBE: None of these 7 items are uniquely safety significant. Theyre indicators 8 that there is something going on that we dont fully 9 understand yet and we need additional information to 10 understand whats going on.
11 MR. MONET: Thank you.
12 OPERATOR: Thank you. Our 13 next question comes from John Funk with the Plain Dealer.
14 MR. FUNK: Okay, my question 15 is, it was almost answered, but its a simple one. Will 16 the two teams, special inspection teams that reported 17 today, will they stay on site or depart until after you 18 decide -- well, until, or will they depart until after the 19 meeting the 29th?
20 MR. GROBE: These 21 inspections, both of them are complete, and these 22 inspectors will be writing a report of their findings. We 23 have not yet planned any further inspections. We need to 24 develop those inspection plans to focus on our particular 25 areas of concern.
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91 1 What will be very helpful to us in planning those 2 inspections will be receiving the information that 3 FirstEnergy will provide on the 29th and any further 4 dialogue that is necessary regarding that information. And 5 then those inspections will be conducted.
6 MR. FUNK: Thank you.
7 OPERATOR: Thank you. Our 8 next caller is Paul Patterson with Glen Rock Associates.
9 MR. GROBE: If you could 10 repeat your name, that would be helpful for the 11 transcriber.
12 OPERATOR: Mr. Patterson, 13 your line is open.
14 MR. PATTERSON: Its Paul 15 Patterson with Glen Rock Associates.
16 What I wanted to ask just briefly is, it sounds like 17 from the assessments and all the evaluations which yet have 18 to be made, that were probably talking at least 30 days or 19 so before a restart meeting, much less when you guys make 20 your final assessment at the earliest for the plant to 21 restart. Does that make sense just from a lay persons 22 perspective listening to this?
23 MR. GROBE: No. What I can 24 tell you is that the NRC will continue to evaluate 25 Davis-Besse performance in a methodical and well MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
92 1 articulated public fashion.
2 That was a complex sentence, wasnt it?
3 We do not focus on schedule. Schedule is not a 4 concern to us. I appreciate that its an important concern 5 to others, but whats important to us is the decision we 6 have to make as to whether or not there is reasonable 7 assurance that this plant will be consistently operated in 8 a manner which assures public health and safety.
9 Prior to authorization of restart, the Davis-Besse 10 Oversight Panel has to make a judgment in that area and 11 make a recommendation to Senior NRC Management, and they 12 will evaluate that recommendation. And Im sure they will 13 have questions for us, and the final decision will be made 14 by my boss, Jim Caldwell, who is the Regional Administrator 15 in Region III in Chicago, Illinois.
16 Part of that process will be a public meeting that 17 we call a Restart Meeting, and that will be a further 18 information gaining meeting. And well get to the point of 19 doing additional inspections when were satisfied that we 20 understand the information weve requested on the 29th.
21 And when those inspections are complete, we can make a 22 judgment as to whether or not were ready to take that next 23 step, which would be scheduling of the Restart Meeting.
24 So, its, were not focused on schedule, were 25 focused on safety. Were going to continue to perform our MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
93 1 responsibilities in a very methodical manner, and well 2 continue to provide plenty of opportunity for public 3 scrutiny and questions and answers.
4 MR. PATTERSON: Thats very 5 helpful. I understand that. I guess what Im just trying 6 to ask, if at all possible, if there is a minimum amount of 7 time that were talking about? I realize that you cant 8 and certainly now probably focusing, as you said, how long 9 its going to take, but just from a lay persons 10 perspective not being familiar with the process, I guess 11 what would be helpful to some of us would be just an idea 12 on a minimum of all these things that are probably going to 13 be taking place, what the end might be from just the 14 earliest it could theoretically be resolved.
15 MR. GROBE: I cant. What I 16 can tell you is there has been a significant amount of work 17 thats been done over the past 22 months, and the 18 activities that need to occur to address these, the final 19 issues, is a small fraction of that amount of work thats 20 been accomplished. I cant speculate on what amount of 21 time it might take to address these issues.
22 MR. PATTERSON: Thank you.
23 OPERATOR: Thank you. We 24 have no further questions at this time.
25 MR. GROBE: Excellent. Are MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
94 1 there any other questions here in the room? Yes?
2 MR. GORE: I do have.
3 MR. GROBE: Could you sign in 4 first and tell us your name.
5 MR. GORE: Judith Hirsch 6 came up, I guess shes been here 27 years. My name is 7 Kevin Gore, Ive been here 5 days. So, youll have to 8 excuse me if I dont know too many people.
9 MR. GROBE: There is two 10 bookends, right?
11 MR. GORE: Right.
12 Dr. Wizner came up and said basically he didnt know 13 if safety would override productivity. I can tell you that 14 I came from Salem Generating Station and Operations, and we 15 didnt do any fire protection at Salem Operations.
16 Apparently, here we do.
17 I guess, when you talk about a fire department, 18 they dont start fires. When you talk about an Operations 19 Department, they dont just operate the plant, both of 20 those departments protect stuff. They protect from fires, 21 they protect from nuclear accidents.
22 When you talk about a nuclear license, whether its 23 a Senior Reactor Operator License for a plant, Tech Specs, 24 any design specifications, its for the nuclear plant, 25 its not for sending electrons down a wire.
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95 1 So, as an example for Doctor Wizner, I can say, if 2 the reactor were on fire, would you put it out? Would you 3 trust that the operators would put it out? That makes 4 sense, they would absolutely do that. Same thing for a 5 nuclear accident. If the reactor was undergoing an 6 accident, would you stop that or would you worry about 7 electrons going down the road?
8 I have every confidence that our people would take 9 the corrective actions and stop the reactor from, putting 10 out, you know, from starting a fire. At least common sense 11 would dictate. And if we train our people for months and 12 years to do the right thing, I believe that we will do 13 that. I know certainly from my perspective, I would.
14 Thats all I have to say.
15 MR. GROBE: I appreciate your 16 comments; and I also have confidence at this point in time, 17 that if there were a fire and ongoing nuclear accident, 18 that the operators would respond to those things.
19 Whats more important to us is several orders of 20 magnitude below that, and that is the type of disciplined 21 operating behaviors, procedural -- adequacy of procedures, 22 and procedure adherence, safety focus, the questioning 23 attitude that are just absolutely essential to prevent 24 nuclear accidents.
25 There are safety systems, and operating procedures MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
96 1 that will mitigate an accident, but we also want to make 2 sure that there isnt an accident to be mitigated.
3 So, any other questions or comments here in the 4 room? Yes, maam?
5 MS. LUTMAN: My name is Dorothy 6 Lutman, and Ive been an employee here for almost 18 7 years. Im a representative to and for everybody at 8 Davis-Besse, in the last two years as the safety -- Plant 9 Safety Chair Person. And I think a real good commitment to 10 safety that we have shown, every one of the employees here, 11 is the nine million eighty thousand eight hundred eighteen 12 man hours on a lost time accident.
13 Im also in agreement with Judy. Im sure everybody 14 here would stand up here, if they werent nervous and my 15 heart was pounding, to get the nerve to come up here too, 16 and say that we would not be afraid to stand up and say if 17 we saw something, recognized something to prevent the 18 plant, as our CEO did at the beginning of this meeting.
19 And, he -- a very good display of honesty, that we, if 20 were not ready to restart, well admit that. Hence, the 21 delayed meeting.
22 As far as when I signed my name on the commitment 23 banner, it was not as part of a pep rally, it was because 24 of my personal promise and commitment to safety, to the 25 plant, to be loyal, to give what I have to give in my own MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
97 1 job, in my own department. And when I sign my name, thats 2 what that was.
3 Also on the comment about the sweatshirt. It wasnt 4 a sweatshirt. It didnt say "Blame Canada". It was a 5 little gift that now the Communications Group is going to 6 know how much I spent; $4 for a T-shirt that said, "I blame 7 Canada". And it would be a testimony that, as a nuclear 8 professional, I still have a sense of humor. And thats 9 all that that was, just a, just to show a sense of humor, 10 as a joke, not as a banner or a statement from the 11 Communications Group.
12 Thank you.
13 MR. GROBE: Thank you.
14 Any other questions or comments? Yes, sir.
15 MR. GORE: My name is Martin 16 Gore. No relation to Kevin.
17 Im with the Operations Training Group. Ive been 18 with them four years, equipment operator for approximately 19 ten years before that.
20 What I would like to say is that these past three, 21 four months, the Operations Training Group has undergone 22 evaluations from the NOP/NOT Test. Weve looked at 23 observations out of our database. Many of the same issues 24 that we are finding in Observations, was brought up in this 25 panel.
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98 1 We are continuing looking at the expectations that 2 are expressed, which are relatively new as far as being 3 written down. We are enforcing those within the 4 nonlicensed operators, as well as the licensed 5 individuals.
6 I will say that from the discussions with the, the 7 information put out by the two inspection teams, that Im 8 sure more focus areas of training may be changes to our 9 evaluation processes of the Operations Group from 10 nonlicensed operators to licensed operators; may be a way 11 to go to ensure that some of these expectations, standards, 12 procedural compliance issues are addressed.
13 I would also say that with the number of 14 modifications the plant has undergone, the number of 15 revisions for these procedures that continually come out, 16 its not uncommon to see two revisions distributed in the 17 same day.
18 So, its all the amount of work and the amount of 19 procedure revisions that are being in place. It is a very 20 difficult opportunity for the operators to be successful.
21 They are trying. Ive observed the controlling 22 activities. They demonstrate the proper behaviors. I 23 observed the nonlicensed operators who just successfully 24 completed all of their annual exams, performance 25 examinations very successfully.
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99 1 So, we are looking to improve and better our 2 processes. Thank you.
3 MR. GROBE: Thank you very 4 much for your comments. You bring up a good perspective.
5 And sometimes when we comment on Operations performance, 6 people immediately perceive that as a criticism of 7 individuals, and sometimes it is a criticism of 8 individuals, but in most cases, there is a number of 9 contributors to an activity not being successfully 10 accomplished.
11 In some cases there is procedural deficiencies, in 12 other cases there is work planning and scheduling 13 problems. There is other activities that put unique or 14 inappropriate stressors on the behaviors in accomplishing 15 an activity, theres training.
16 So, there is a whole spectrum of activities that 17 could be contributors. And, those are the types of things 18 that we expect to get additional insight on, on the 29th.
19 As to what it is thats caused this inconsistent 20 performance and what actions need to be taken to shore that 21 up.
22 Other questions or comments?
23 Yes, sir?
24 MR. ANDREWS: Yes, my name is 25 Doug Andrews. Ive been working here at Davis-Besse for 16 MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
100 1 years. The last two years or so, since this issue with the 2 reactor vessel head, Ive been working in Quality 3 Assurance and Quality Assessment Oversight. I also have 25 4 years in the United States Navy. And I have an 5 understanding and a desire for safety.
6 I just want to say two truisms and then one comment 7 for consideration. I think the first truism is that, Jack, 8 I think youve expressed since the beginning that 9 Davis-Besse will not start up until we have a Safety 10 Culture and Safety Conscious Work Environment thats 11 proper. I think youve been consistent in that stand. I 12 think that the management understands that, and I think 13 Davis-Besse employees understand that and appreciate that 14 truism, that we are not going to start up until thats the 15 case.
16 The other truism, I think, is that these 22 months 17 have been very difficult for the employees here at 18 Davis-Besse. Theyve been working very hard, putting in 19 many hours of overtime, time away from their families that 20 cannot be regained. Its been a hardship on us, and we 21 want to start up.
22 Those two truisms then, I guess, lead to one 23 comment. You mentioned that we have these surveys that the 24 NRC seemed to think that these are pretty good indicators 25 of our Safety Conscious Work Environment and Safety MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO
101 1 Culture, the way that we are trying to figure these things 2 out.
3 I guess the thought for consideration is that as 4 people are filling out these surveys, and they keep in mind 5 these two truisms, that we cant start up until we have a 6 good Safety Culture and Safety Conscious Work Environment.
7 And yet, being shut down is a hardship.
8 They have to answer these questions about our Safety 9 Culture. They could say, "Yes, everything is fine. We 10 want to start up. Were good to go. Let us start up", but 11 instead, I think that perhaps the survey may indicate that 12 the people are willing to raise concerns, to voice their 13 concerns even at a personal hardship that we may still be 14 shut down for awhile until we address those concerns.
15 So, this document that you have here, although it 16 identifies some concerns and management is undertaking 17 efforts to figure out why these numbers are the way they 18 are and fix those, this document may also be a very good 19 indicator of the Safety Culture here at Davis-Besse, that 20 people are willing to suffer personal loss in order to do 21 what is right and do what is safe.
22 Thank you.
23 MR. GROBE: Thats a good 24 perspective. Thank you.
25 Other questions or comments?
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102 1 Okay. Lets go to the phone lines one final time.
2 Operator, any additional questions from your end?
3 OPERATOR: Thank you. Once 4 again, does anyone have a question?
5 We have no questions at this time.
6 MR. GROBE: Okay, very good.
7 Thank you very much.
8 With that, this meeting is adjourned. Thank you.
9 (Off the record.)
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103 1 CERTIFICATE 2 I, Marie B. Fresch, Registered Merit Reporter and 3 Notary Public in and for the State of Ohio, duly 4 commissioned and qualified therein, do hereby certify that 5 the foregoing is a true and correct transcript of the 6 proceedings as taken by me and that I was present during 7 all of said proceedings.
8 IN WITNESS WHEREOF, I have hereunto set my hand and 9 affixed my seal of office at Norwalk, Ohio, on this 9th day 10 of January, 2004.
11 12 13 14 Marie B. Fresch, RMR 15 NOTARY PUBLIC, STATE OF OHIO 16 My Commission Expires 10-10-08.
17 18 19 20 21 22 23 24 25 MARIE B. FRESCH & ASSOCIATES 1-800-669-DEPO