ML041110829
| ML041110829 | |
| Person / Time | |
|---|---|
| Site: | Cook  |
| Issue date: | 04/20/2004 |
| From: | American Electric Power Co, Indiana Michigan Power Co |
| To: | Office of Nuclear Reactor Regulation |
| References | |
| Download: ML041110829 (6) | |
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--thet D'ant Corrective Action Program Poad tc\ Excellence
- ---== -Road to Excellence Inconsistent operational performance during the last several years at Cook Nuclear Plant has required extensive corrective actions. Some of the corrective actions were not effectively implemented, resulting in repeat events. A review of these events revealed an underlying common cause.
This common cause was an ineffective Corrective Action Program.
An ineffective Corrective Action Program significantly impacts the ability of Cook Nuclear Plant to develop into a self-improving learning f
organization and implement the Prevention-Detection-Correctionmodel.
A Self-Improving Culture and Learning Organization, and the Prevention-Detection-Correction model, are primary elements required for imprp\#?d performance of Cook Nuclear Plant.
As a result of Cook Nuclear Plants performance history, Mano Nazar, Senior Vice President and Chief Nuclear Officer for American Electric Power, directed the development of a Recovery Plan that focuses on six key areas:
1 Operational Focus Design Basis l Human Performance Organizational Effectiveness 1 Equipment Reliability Self-Improving Learning Organization Cook Nuclear Plants Corrective Action Program is a cornerstone program and is the cross-cutting element that supports implementation of all six focus areas of the Recovery Plan. An effective Corrective Action Program is essential for the station to build the foundation necessary for recovery and the transition to excellence.
Through benchmarking with other nuclear facilities, the Institute of Nuclear Power Operations, and Nuclear Regulatory Commissions requirements, a picture of excellence was developed for an effective Corrective Action Program with thirteen Critical Attributes.
It was necessary to establish the Corrective Action Program Picture of Excellence with the Critical Attributes in order to assess the curre state of Cook Nuclear Plant's Corrective Action Program. A multi-discipline team was formed to perform a Critical Attributes Analysis. I I analysis identified the gaps between the current and desired excellent corrective action programs.
The Critical Attributes Analysis identified gaps tha categorized into three areas.
Process: Gaps associated with program in stn procedure, training, and tools.
Gaps associated with organizational beha attitudes, and values.
Gaps associated with long-standing issues.
Actions were then created to address the identified gap u G of the actions were implemented immediately to effect a positive ste, change in the Corrective Action Program. The actions implemented immediately were interim actions designed to bolster the Corrective Ac Program while the Corrective Action Program Recovery Plan v developed. The interim actions, along with other stop-gap measure:
already in place, would prevent further degradation of the CorrectivE Action Program. Key interim actions implemented are described be Two Step Screening Process - The Condition Report screenir process was revised by adding a second screening meeting performed by members of senior management (Site Vice President, Plant Manager, and department managers). This second screening by the senior leadership team results in an increased involvement and oversight of t"- Corrective Action Program by senior management.
Engineering Fix It Now Team - An Engineering Fix It Now Team was established to provide a dedicated engineering resource to respond to emergent issues. This dedicated resource reduces the distractions t-the engineering organization to allow engineering tn i~~~~ on cnrrnr'tivt action timeliness and quality.
Increased Leadership Focus - Corrective Action Program indicators have been established for use in the daily Leadership Meeting that focuses on timeliness and quality of corr-+i\ts actions and evaluations.
Expanded Corrective Action Review Board Role - I rie Corrective Action Review Board's role has been expanded to include monitoring the Corrective Action Program health in addition to the revie\Ai of selected corrective action products. The board will use established performance indicators, self assessments, and other indicators of the health of the Corrective Action Program.
Early indications of Corrective Action Program implementation weaknesses were identified by external organizations beginning in 2002.
A root cause evaluation was performed following the Nuclear Regulatory Commissions Problem Identification and Resolution Inspection in April 2002. The 2002 root cause evaluation generated corrective actions to Y a d d r ~ the
~ s degrading performance.
Subsequent to the completion of the root cause, the statio experienced a number of planned and forced outages that resultea I decreased focus and oversight on the implementation of Corrective HG Program initiatives. Indications of a degrading Corrective Action Progr, continued. In October 2003, a condition report was initiated to evaluatc the continued declining performance of the Corrective Action Program.
This condition report was screened as a significant conditio idverse tl quality.
The root cause evaluation concluded that there wert !rative root causes:
- 1. A failure of management to maintain a strategic focus on Corrective Action Program performance during periods of competing priority from plant events.
- 2. A failure of evaluators, implementers, approvers, and supervisors to recognize the value of peer checking to ensure and reinforce quality standards and consistent program implementation.
Corrective actions were developed to establish oversight of Corrective Action Program health as the responsibility of the Corrective Action Review Board. Additionally, corrective actions were developed to implement continuous strategic improvement through the use of the Cook Nuclear Plant Recovery Plan.
A Corrective Action Recovery Plan was created to establish the foundational health of the Corrective Action Program. The recovery plan was developed using inputs from the Critical Attributes Analysis and the root cause analysis recently completed. The goal of the Corrective Action Program Recovery Plan is to become a cornerstone program that fostei a self-improving learning organization. The expected improvement is th departments demonstrate ownership of the Corrective Action Program by embracing its use to make improvements in plant performar The Corrective Action Program Recovery Plan is one of ten plans in the Self-Improving Learning Organization focus area of the Site Recove Plan. Other recovery plans in the Self-Improving Learning Organiza that have a direct impact on the Corrective Action Program are:
Self Assessment Safety Conscious Work EnvironmenVSafety Culture Benchmarking Learning Organization Attributes Operating Experience
Implementation of the Corrective Action Program Recovery Plan will achieve the following results:
a Effective Senior Leadership oversight of th -.. of the Corrective Action Program.
Organizational ownership of the Corrective Action Proyldm at all levels with a recognized value of using the Corrective Action Program to improve station performance.
Performance indicators established to mor "-1r iorrective Action Program Effectiveness.
Evaluations of conditions adverse to qualit .re performed in a timely manner with quality.
Prescribed corrective actions are performed in a timely manner with quality.
To ensure effective communication of our issues with the plant staff and other stakeholders, a communication plan was developed. The communication was performed using different methods. The key messages were provided to the director and leadership team. The messages were then rolled out to the plant staff through department and .
section staff meetings. The messages have also been communicatec during All-Hands Meetings and the Plan-It newsletter. The k e f iessages of the communication plan were:
Cook Nuclear Plant has a new senior and site vice president who are a
committed to continuous improvement using the Corrective Action was d Program. A proven approach to recovery is being established that maximizes prevention and detection, provides a leader?hi3 model and accountability, and is sustainable.
- 2. The current station performance is caused by an inenecwe Cor1 rive Action Program due to ineffective, overdue, and imw-erly CIOS~U out corrective actions and evaluations.
The importance of the Corrective Action Program is to drive C Nuclear Plant to performance excellence. As such, effective vonitoring of corrective action performance will be establishe The Corrective Action Program Recovery Plan represer roadmap to an effective Corrective Action Program. The actions de in the recovery plan were developed using a systematic approach.
ensure the recovery plan is meeting the expectation to improve tht:
effectiveness of the Corrective Action Program, periodic reviews will bf performed by the Corrective Action Review Board.
The Corrective Action Program health has improved since implementing the interim measures and actions from the Corrective Action Program Recovery Plan. Noticeable improvements have been made in prioritization of evaluations and corrective actions based on significance,
-0mpletion of evaluations and corrective actions prior to dun dates. --A dfective monitoring of the Corrective Action Program.
While the improvements noted are promising, we ha ade the progress we had anticipated. Accordingly, we are adjusting our Corrective Action Program Recovery Plan to place more focus on reducing the backlog of condition reports, implementing an effective trending program, improving the self-identification ratio of condition reports, improving the effectiveness of problem resolution, and elimi ting a backlog of effectiveness reviews. With the increased focus in th ;e areas, we project that we will have a fully functioning and effectiv Corrective Action Program by the end of the second quarter of 2004.
With the completion of the activities in the Corrective Action Program Recovery Plan, the foundation will be established for transitio 3 the Corrective Action Excellence Plan. A transition team is currently being staffed to identify the actions needed to take the recovered Corrective Action Program to the next level. The goal is to establish and commen implementation of the Corrective Action Program Excellence Plan in the 3 r d quarter of 2004.