ML041130457
| ML041130457 | |
| Person / Time | |
|---|---|
| Site: | Point Beach  |
| Issue date: | 03/22/2004 |
| From: | Vanmiddlesworth G Nuclear Management Co |
| To: | Document Control Desk, Office of Nuclear Reactor Regulation |
| References | |
| EA-02-031, EA-03-057, EA-03-059, EA-03-181, IR-03-007 | |
| Download: ML041130457 (30) | |
Text
Point Beach Nuclear Plant Operated by Nuclear Management Company, LLC 6590 Nuclear Road Two Rivers, Wisconsin 54241 Telephone: 920.755.2321 March 22, 2004 NRC 2004-0030 U.S. Nuclear Regulatory Commission ATTN: Document Control Desk Washington, DC 20555 Point Beach Nuclear Plant, Units 1 and 2 Dockets 50-266 and 50-301 License Nos. DPR-24 and DPR-27 Commitments in Response to 95003 Supplemental Inspection
Reference:
- 1) Letter from Nuclear Regulatory Commission to Nuclear Management Company, LLC dated February 4, 2004, transmitting Inspection Report 05000266/2003007; 05000301/2003007 EA-02-031, EA-03-057, EA-03-059, EA-03-181
- 2) Letter from Nuclear Management Company, LLC (NMC) dated February 13, 2004, Submitting NMC Commitments in Response to 95003 Supplemental Inspection On March 15, 2004, a public meeting was held at the Nuclear Regulatory Commission (NRC)
Region III offices in Lisle, IL. The purpose of this meeting was to formally review the contents of the NMC submittal to the NRC dated February 13, 2004 (Reference 2) that transmitted NMC commitments in Response to the 95003 supplemental inspection (Reference 1).
It was concluded that additional clarification of some of the commitments is necessary to remove ambiguity and to ensure that the commitments are clearly understood. Accordingly, the updated commitment listing contained in the enclosure to this letter is provided. The attached updated commitment list supersedes in total the commitment list provided in our February 13, 2004, letter.
Summary of Commitments The updated NMC commitments are provided in Enclosure 1.
Gary D. Van Middlesworth Site Vice-President, Point Beach Nuclear Plant Nuclear Management Company, LLC Enclosure
cc:
Regional Administrator, Region III, USNRC Project Manager, Point Beach Nuclear Plant, USNRC Resident Inspector - Point Beach Nuclear Plant, USNRC
27 Pages Follow ENCLOSURE 1 Updated Commitments In Response to 95003 Supplemental Inspection
Page 1 of 27 HUMAN PERFORMANCE FOCUS AREA: Human Performance Action Plan: OR-01-001
Title:
Improve Human Performance and Work Practices Objective Action Plan Steps to be Completed Summary & Status of Action Steps Complete Date Methods to Verify Objective Met Human Performance infrastructure is established to facilitate improved station performance OR-01-001.22 This Action Plan provides the infrastructure to improve human performance at PBNP. This plan is complemented by Action Plans OR-01-004 and OR-08-005, which are intended to improve individual behaviors and accountability. Action Plan OR-08-005 was developed to provide additional focus to Human Performance issues in Engineering.
Steps were taken to enhance the infrastructure for improving human performance at PBNP.
These infrastructure enhancements have included procedure revisions, formation of a Human Performance Improvement Team, implementation of the PACE program, that provides a structured method for tracking job observations, and the assignment of Human Performance Improvement Team members in each work group. The PBNP site observation program and the electronic database used to administer the program are implemented by procedure NP 13.6.1 1Q05 Site human performance event clock is >36 days based on rolling 12-month average
<2 human performance LERs in 12-month rolling period Effectiveness review specified in Step OR-01-001.22 Action Plan: OR-01-004
Title:
Individual Behavior Excellence Objective Action Plan Steps to be Completed Summary & Status of Action Steps Complete Date Methods to Verify Objective Met A PBNP Picture of Excellence is developed to require individual behaviors and accountability necessary to sustain performance improvement OR-01-004.1 OR-01-004.24 Action steps to meet this plan objective include communicating and reinforcing the Picture of Excellence to improve accountability and individual behaviors. Action steps to meet this plan objective are to validate the Picture of Excellence and revise the PBNP Human Performance Program to include requirements consistent with the Picture of Excellence.
2Q04 Documented Picture of Excellence Revised procedure NP 1.1.10 consistent with Picture of Excellence
Page 2 of 27 Action Plan: OR-01-004
Title:
Individual Behavior Excellence Objective Action Plan Steps to be Completed Summary & Status of Action Steps Complete Date Methods to Verify Objective Met The PBNP Picture of Excellence is communicated to PBNP employees and the workforce is briefed on the application of and expectations for the program OR-01-004.3 OR-01-004.4 OR-01-004.6 OR-01-004.8 OR-01-004.9 OR-01-004.10 OR-01-004.11 Site Management will use the steps associated with this objective to introduce the Picture of Excellence principles to PBNP employees.
2Q04 Completed attendance sheets at workforce briefings Infrastructure and tools required to execute and reinforce the Picture of Excellence are established OR-01-004.2 OR-01-004.5 OR-01-004.7 OR-01-004.10 OR-01-004.12 OR-01-004.13 OR-01-004.14 OR-01-004.15 OR-01-004.16 OR-01-004.17 OR-01-004.26 OR-01-004.28 OR-01-004.34 OR-01-004.35 Site Management will use the steps associated with this objective to communicate the infrastructure and tools required to ensure that the Picture of Excellence is established. The steps taken include the development of a database to monitor human performance, incorporation of ACEMAN into daily plan of the day management meeting, implementation of a daily meeting (D-15) between plant supervisors and individual contributors to communicate about a variety of issues, including human performance. This will be the initial communication of the Picture of Excellence.
Additional actions to improve the implementation of ACEMAN at PBNP include developing a daily communications publication and an ACEMAN observation program.
3Q04 D-15 meetings implemented and monitored using a communications survey ACEMAN job observation card implemented ACEMAN rating system employed at POD and Production meetings NOS assessment of ACEMAN implementation (Step OR-01-004.28)
Page 3 of 27 Action Plan: OR-01-004
Title:
Individual Behavior Excellence Objective Action Plan Steps to be Completed Summary & Status of Action Steps Complete Date Methods to Verify Objective Met Tools to monitor effectiveness of and recognize Picture of Excellence program successes are established OR-01-004.18 OR-01-004.19 OR-01-004.20 OR-01-004.22 OR-01-004.27 OR-01-004.33 OR-01-004.36 Site management will use the steps associated with this objective to monitor the effectiveness of the actions to implement the Picture of Excellence program.
1Q05 Manager job observations conducted to assess ACEMAN implementation and effectiveness (>30 manager observations of the ACEMAN program per month)
ACEMAN indicators reviewed at monthly Management Review Meetings Effectiveness review of ACEMAN program (Step OR-01-004.36)
ACEMAN is effectively used to improve performance of station personnel OR-01-004.36 PBNP will conduct an effectiveness review of the completed actions taken in this focus area (Human Performance). This review will include a review of the identified performance indicators to determine whether the focus area objectives have been met and whether improvements in this focus area are sustainable.
1Q05 Site human performance event clock is >36 days based on a rolling 12-month average
<2 human performance LERs in 12-month rolling period Effectiveness review of ACEMAN program (Step OR-01-004.36)
Page 4 of 27 FOCUS AREA: Engineering Organizational Effectiveness Action Plan: OR-08-005
Title:
Improve Human Performance in Engineering Objective Action Plan Steps to be Completed Summary & Status of Action Steps Complete Date Methods to Verify Objective Met Communicate expectations and provide human performance tools to improve Engineering performance OR-08-005.13 OR-08-005.17 Actions taken to improve human performance in the Engineering group include: (1) An engineering Human Performance Improvement Team has been formed to improve human performance, (2) Engineering personnel have been trained on human performance topics, (3)
Management has established a process for identifying, evaluating, and communicating human performance events to Engineering personnel, (4) An engineering-specific observation and coaching program has also been implemented.
Additional human performance training for engineers is being conducted. Step OR-08-005.17 solicits post-training feedback to determine whether the training has been effectively communicated.
3Q04 Training attendance records Achieve an improving trend in the Engineering Event Clock performance indicator OR-08-005.14 OR-08-005.19 Steps have been included in this action plan to further strengthen the effective use of human performance improvement tools in Engineering.
1Q05 Improving trend in the Engineering event clock performance indicator with a goal of >10 days per rolling 12-month period Effectiveness review (Step OR--08-005.19)
Page 5 of 27 NUCLEAR OVERSIGHT EFFECTIVENESS FOCUS AREA: Oversight & Assessment Action Plan: OR-02-001
Title:
Nuclear Oversight Assessment Objective Action Plan Steps to be Completed Summary & Status of Action Steps Complete Date Methods to Verify Objective Met Improve NOS staffing effectiveness by implementing a rotation policy, assigning assessors to maintain functional area cognizance, and completing the personnel qualification matrix tool OR-02-001.2.A.1 OR-02-001.2.B OR-02-001.2.C This action plan is intended to improve the effectiveness of the Nuclear Oversight (QA) organization in identifying problems and escalating significant issues.
Action steps to achieve this objective are to assign assessors to functional areas, implement a rotation policy and implement a training plan to address staff developmental needs.
The rotation policy has been developed and issued. Training and developmental needs have been identified.
The functional area assignments remain to be performed. The personnel qualification matrix will be used as a guide to assign personnel to assessment activities. A preliminary list of individual functional area assignments has been developed.
3Q04 Rotation policy implemented Assessors assigned to functional areas Qualification matrix tool completed NOS is effective in communicating significant issues to Site Management OR-02-001.4 Development of the intrusiveness methodology procedure is in progress. The intrusiveness methodology procedure uses the problem development process as a format for developing and determining issue significance.
2Q04 Intrusive methodology procedure issued NOS is effective in assuring management response QA findings OR-02-001.7.C The method for statusing and reporting NOS QA findings has been developed. The NOS staff and station management have been briefed on this process.
1Q04 Methodology implemented
Page 6 of 27 Action Plan: OR-02-001
Title:
Nuclear Oversight Assessment Implement integrated assessment of performance OR-02-001.6 A change management plan was developed to implement an integrated assessment of performance. Three exit meetings have been conducted. NMC continues to refine the process using the fleet standard for the NOS portion of the exit meeting.
3Q04 Process implemented as exhibited by:
§ Process developed
§ Incorporate scoring in NOS quarterly exit meetings NOS is effective in identifying major weaknesses within the PBNP organization, ensuring problems are resolved, and ensuring timely implementation of corrective actions to address findings OR-02-001.7.E This action step ensures that the actions taken by NOS to improve performance have been effective.
An assessment (PBSA-03-03) of NOS conducted in June 2003 identified two programmatic findings. These findings included: (1) Nuclear Oversight and line organizations have not established the effective disciplined partnership implied by the PBNP Picture of Excellence, and (2)
Nuclear Oversight-identified issues do not consistently communicate underlying problems (causes and contributors) and their associated risks. A planned follow-up assessment (Step OR-02-001.7.E) will assess if these findings have been effectively corrected.
In addition, as part of the Step OR-02-001.7E effectiveness review, an assessment will be made of Nuclear Oversights effectiveness in identifying major weaknesses within the PBNP organization, ensuring timely implementation of corrective actions and effectiveness in ensuring problems are resolved.
4Q04 Planned independent assessment (Step OR-02-001.7.E) identifies no programmatic repeat findings from the June 2003 assessment (PBSA-03-03)
Improving trend in age of QA findings, such that no more than 3 QA findings are greater than 180 days old and this goal is sustained for >6 months
Page 7 of 27 ENGINEERING / OPERATIONS INTERFACE FOCUS AREA: Engineering Organizational Effectiveness Action Plan: OR-08-007
Title:
Utilize the Quality Review Team Objective Action Plan Steps to be Completed Summary & Status of Action Steps Complete Date Methods to Verify Objective Met Improve the quality of Engineering products OR-08-007.4 PBNP site management directed the formation of a Quality Review Team (QRT) in 4Q02. The team selects a sample of engineering products and grades the quality of work. Feedback is provided via the CAP to the responsible engineer for products that require rework.
1Q05 QRT-directed rework averaged over 6-month period <15%
Effectiveness Review (Step OR-08-007.4)
Action Plan: OR-08-015
Title:
Establish an Engineering Safety & Design Review Group Objective Action Plan Steps to be Completed Summary & Status of Action Steps Complete Date Methods to Verify Objective Met Improve quality of Engineering products OR-08-015.6 OR-08-015.7 In addition to the Quality Review Team, an Engineering Safety and Design Review Group (ESDRG) has been established to improve the quality of engineering products. The ESDRG conducts in-line independent review of engineering products.
1Q05 Effectiveness Review (Step OR-08-015.7)
Page 8 of 27 FOCUS AREA: Training Organizational Effectiveness Action Plan: TR-18-002
Title:
ESP Training Objective Action Plan Steps to be Completed Summary & Status of Action Steps Complete Date Methods to Verify Objective Met A qualified Engineering workforce supports station priorities and schedules TR-18-002.11 Actions have been taken to revise the Engineering Support Personnel (ESP) training program. These actions include: 1) a job analysis for the ESP population to identify the core qualifications required for each position has been completed; 2) a workdown curve for each engineer to complete all required qualifications has been developed; 3) new Training Advisory and Curriculum Review Committees have been established; 4) site policy on training attendance has been established and training attendance expectations reinforced.
1Q05
- Effectiveness review (Step TR-18-002.11)
Page 9 of 27 FOCUS AREA: Engineering Organizational Effectiveness Action Plan: OR-08-017
Title:
Operations and Engineering Interface Objective Action Plan Steps to be Completed Summary & Status of Action Steps Complete Date Methods to Verify Objective Met Improve the interface between Operations and Engineering to ensure that the station priorities are reflective of actions necessary for achievement of equipment excellence OR-08-017.1 OR-08-017.2 OR-08-017.4 OR-08-017.5 OR-08-017.6 This new plan focuses on improvement activities that reside in other Excellence Plan Action Plans, including implementation of the Design Engineering Review Board, and Operable But Degraded/Non-conforming Backlog Reduction Plan. The Operational Decision Making Model has been incorporated into this plan.
The Plant Health Committee (PHC) will be the driving force for the successful execution of this Action Plan by engagement of Operations and Engineering personnel using the operational decision making model to review system health reports, engineering programs, proposed modifications and to recommend corrective actions to equipment -related issues.
Responsibilities for the PHC are defined in NMC fleet procedure PF-E-PHC-01. The PHC is the site focal point for equipment reliability decisions. The PHC is responsible to review system and program health reports, assess current site conditions, and respond to emergent issues.
(Continued on next page) 2Q05 Operational Decision Making Model is implemented Self assessment of effectiveness of Plant Health Committee (Step OR-08-017.2)
Self-assessment of effectiveness of Design Engineering Review Board (Step OR-08-017.4)
Operable but degraded/
nonconforming condition backlog reduced to <20 Seven of the existing 13 Maintenance Rule (a)(1) systems will be transitioned to (a)(2) status by the end of 2Q05 Corrective work order maintenance backlog <25 Elective work order maintenance backlog <275 Operations procedure feedback backlog <450 feedbacks Maintenance procedure corrective feedback backlog
<225
Page 10 of 27 Action Plan: OR-08-017
Title:
Operations and Engineering Interface n (continued)
Objective Action Plan Steps to be Completed Summary & Status of Action Steps Complete Date Methods to Verify Objective Met (Continued from previous page)
The current schedule is to transition seven of the 13 existing Maintenance Rule (a)(1) systems to (a)(2) status by 2Q05. This schedule, however, may be subject to change if new system issues occur or are identified on any of the seven systems that would require a revision to the system (a)(1) action plan. If this occurs, the respective (a)(1) action plans will be changed accordingly. The following is the current projected dates when the seven systems will transition to (a)(2) status:
Condensate and Feed - 2Q04; Nuclear Instrumentation - 2Q04; Reactor Protection -
4Q04; Cable Spreading Room Heating, Ventilation & Air Conditioning - 4Q04; Metering, Relaying and Regulation - 2Q04; Crossover Steam Dump 4Q04; Vital Instrument Bus (120 V) - 3Q04.
OPERABLE BUT DEGRADED/NONCOMFORMING BACKLOG FOCUS AREA: Engineering Organizational Effectiveness Action Plan Number:
OR-08-016
Title:
Reduce Operable But Degraded / Nonconforming Backlog Objective Action Plan Steps to be Completed Summary & Status of Action Steps Complete Date Methods to Verify Objective Met Reduce the backlog to meet the NMC goal OR-08-016.3 OR-08-016.4 OR-08-016.5 The Plant Health Committee will be a driving force to reduce the backlog of operable but degraded and operable but nonconforming conditions at PBNP. The staff is executing a workdown curve that will reduce the backlog to 20 or less by 3Q04. This action plan will also reduce the number of operable but degraded/but nonconforming conditions, which are older than one fuel cycle, in accordance with the NMC fleet procedure.
3Q04 Operable but degraded/
nonconforming condition backlog <20
Page 11 of 27 EMERGENCY PREPAREDNESS FOCUS AREA: Emergency Preparedness (EP)
Action Plan: OP-09-001
Title:
Improve EP Infrastructure (Processes, Programs)
Objective Action Plan Steps to be Completed Summary & Status of Action Steps Complete Date Methods to Verify Objective Met Enhance knowledge of EP staff OP-09-001.12 OP-09-001.15 This action plan is intended to improve overall ownership and effectiveness of maintaining the Emergency Preparedness program.
An EP Advisory Committee (EPAC) has been established that includes representatives of the site leadership team. The EPAC is chartered to provide site leadership oversight to support EP activities. The EPAC currently consists of the managers from Radiation Protection, Operations, Maintenance, Chemistry, EP, Engineering, and Human Resources.
The vision and mission for Emergency Preparedness Program have been developed and have been communicated to site personnel.
A structured approach to ERO staffing of key positions has been implemented. An ERO training advisory committee has been established. An EP staff training program has been developed.
Training and qualification of EP staff members is in progress in accordance with the pre-defined schedule.
1Q05 Qualification cards for EP staff members completed in accordance with defined schedule Effectiveness review (Step OP-09-001.15)
Define Emergency Preparedness staff roles and responsibilities OP-09-001.11 OP-09-001.15 Staff roles and responsibilities have been delineated. To date, EP-related call-ups have been assigned to an individual having primary responsibility for activity performance.
Qualification of backup activity performers is in progress.
1Q05
>80% of EP tasks (callups) performed by Emergency Planning staff members have a primary and backup person assigned Effectiveness review (Step OP-09-001.15)
Page 12 of 27 Action Plan: OP-09-001
Title:
Improve EP Infrastructure (Processes, Programs) (continued)
Objective Action Plan Steps to be Completed Summary & Status of Action Steps Complete Date Methods to Verify Objective Met Corrective Action Program (CAP) in Emergency Preparedness is implemented in accordance with station procedures and standards OP-09-001.15 EP staff personnel have received training in CAP expectations and implementation. A CAP liaison has been assigned to support EP. A number of CAP documents such as evaluations and corrective actions have been re-reviewed for adequacy.
1Q05 Quarterly CAP Trend Report tracks effectiveness of CAP in Emergency Preparedness and demonstrates >95% on-time corrective actions completed; and >60% self-identification for CAPs.
Effectiveness review (Step OP-09-001.15)
Action Plan: OP-09-003
Title:
Revise Emergency Plan Implementing procedures Objective Action Plan Steps to be Completed Summary & Status of Action Steps Complete Date Methods to Verify Objective Met Revised Emergency Plan and supporting procedures are aligned OP-09-003.13 This action plan completes a review of the Emergency Plan to assure compliance with 10 CFR 50 Appendix E and NUREG-0654. A team of plant personnel performed a review of the Emergency Plan and supporting procedures and revised to assure alignment. These procedures have been revised and issued.
3Q04 Effectiveness Review (Step OP-09-003.13)
ERO is trained on Emergency Plan and procedure revisions OP-09-003.13 Training on the revised Emergency Plan and implementing procedure revisions has been completed. The revised procedures have been issued.
3Q04 Effectiveness Review (Step OP-09-003.13)
Page 13 of 27 Action Plan: OP-09-004
Title:
Upgrade Emergency Action Levels (EALs)
Objective Action Plan Steps to be Completed Summary & Status of Action Steps Complete Date Methods to Verify Objective Met Develop an EAL scheme that is consistent with NEI 99-01 and submit to the NRC OP-09-004.7 OP-09-004.8 OP-09-004.9 OP-09-004.10 OP-09-004.11 OP-09-004.12 OP-09-004.13 This action plan will upgrade PBNP EALs to the NEI 99-01 scheme and submit the upgraded EALs to the NRC.
Once drafted, the EALs must be reviewed and approved by the Plant Onsite Review Committee as well as State and Local governmental agencies. Following these approvals, the EALs will be submitted for review and approval by the NRC. Following site approval and submittal to the NRC, training will be conducted on upgraded EALs. The site will be prepared to implement the upgraded EALs within 90 days of NRC approval.
2Q05 Revised EALs submitted to NRC Implementation of revised EALs within 90 days of the date NRC approval is obtained Action Plan: OP-09-005
Title:
Control/Maintenance of EP Required Equipment Objective Action Plan Steps to be Completed Summary & Status of Action Steps Complete Date Methods to Verify Objective Met EP equipment and facilities are documented and controlled OP-09-005.4 OP-09-005.5 OP-09-005.6 OP-09-005.7 OP-09-005.8 OP-09-005.9 OP-09-005.10 OP-09-005.11 OP-09-005.12 This action plan improves configuration control of EP equipment including equipment located at the emergency response facilities.
A matrix has been developed to document equipment needed to support emergency response. EP equipment is being assessed to assess its reliability and maintainability.
Equipment call-ups and alarm response procedures will be updated 2Q05 Procedures and processes are in place to control EP equipment and facilities Effectiveness review (Step OP-09-005.12)
Page 14 of 27 CORRECTIVE ACTION PROGRAM FOCUS AREA: Corrective Action Program Action Plan: OP-10-001
Title:
Improve CAP Action Request Screening and Prioritization Objective Action Plan Steps to be Completed Summary & Status of Action Steps Complete Date Methods to Verify Objective Met Senior plant management owns CAP screening OP-10-001.14 Management has taken steps to improve the CAP screening process to provide focus and improve management oversight of the program.
Benchmarking of the CAP screening improvements has been performed. CAP screening team members have been briefed on their roles and responsibilities. An external assessment of the CAP screening process will be performed to ensure effectiveness of the screening process.
4Q04 Assessments indicate no significant CAP prioritization errors. Goal is to have:
§ No level A events misclassified
§ >90% of B level events properly categorized Action Plan: OP-10-004
Title:
CAP Resolution Effectively Addresses Problems Objective Action Plan Steps to be Completed Summary & Status of Action Steps Complete Date Methods to Verify Objective Met A Technical Review Panel is established (and in place until the Site VP and Plant Management agree the need no longer exists) to review selected corrective actions to ensure the actions taken effectively resolve the issue OP-10-004.12 A Technical Review Panel was established to perform a multi-disciplined review selected corrective actions to ensure that the corrective actions taken effectively resolve the condition identified. PBNP management has included a step in this action plan to validate the effectiveness of the Technical Review Board.
3Q04 TRP is established by charter Meeting notes documenting periodic TRP meetings Effectiveness Review (Step OP-10.004.12)
Issue owners are assigned to significant issues OP-10-004.12 OP-10-004.15 In order to ensure that there is individual accountability for corrective actions for station issues, a method to assign an Issue Owner has been developed. PBNP management has included a step in this action plan to validate the effectiveness of this enhancement to the CAP Program.
3Q04 Issue Manager Procedure (NP 1.1.11) issued NOS assessment of procedure compliance and effectiveness of issue manager program Effectiveness Review (Step OP-10-004.12)
Page 15 of 27 Action Plan: OP-10-004
Title:
CAP Resolution Effectively Addresses Problems (continued)
Objective Action Plan Steps to be Completed Summary & Status of Action Steps Complete Date Methods to Verify Objective Met Station personnel are aware of their roles and responsibilities in the Corrective Action Program (CAP)
OP-10-004.12 PBNP management has taken actions to ensure that station personnel are aware of their roles and responsibilities as they pertain to the Corrective Action Program. PBNP management has included a step in this action plan to validate the effectiveness of this enhancement to the CAP Program.
3Q04 Employee briefings completed New employee training program revised Employee Surveys Effectiveness Review (Step OP-10.004.12)
Managers monitor and improve the health of the CAP Program at a station and an individual department level OP-10-004.14 OP-10-004.16 PBNP will take steps to expand the CARB membership include representation from all major site work departments in order to improve management oversight of the CAP. The station will create department level indicators for the key attributes of a healthy corrective action program. The departmental level indicators include such items as: self-identification rate, evaluation age, evaluation quality, corrective action age, and backlogs. Effectiveness reviews will be utilized to monitor the effectiveness of actions.
1Q05 CARB membership expanded Department level indicators show improving trends Ratio of effectiveness reviews to A & B level CAPs Effectiveness review (Step OP-10-004.14)
Corrective Action Program improvements have led to timely corrective actions that resolve problems OP-10-004.12 OP-10-004.14 Measures have been established to review corrective actions to ensure the corrective actions are effective in resolving problems.
1Q05 CAP throughput (number of open CAPs) <2500 CAPs Average ACE Quality grade is
>85 sustained over a 3-month period Average RCE Quality grade is
>85 sustained over a 3-month period Corrective Action Implementation Effectiveness indicator >80 Effectiveness Review (Step OP-10-004.14)
Page 16 of 27 Action Plan: OP-10-005
Title:
Improve CAP Trending and Use of Trending Objective Action Plan Steps to be Completed Summary & Status of Action Steps Complete Date Methods to Verify Objective Met CAP Trend Reports reflect Station Performance and identify adverse trends OP-10-005.12 OP-10-005.13 A method was developed to trend code CAPs in a timely manner. Quarterly trend reports were issued throughout 2003. The station will perform an effectiveness review of the use of CAP Trend Reports to correct emerging issues. An effectiveness review will be performed to ensure that periodic reports are issued and reviewed by plant management, and that declining performance trends are identified and actions are taken to correct performance.
1Q05 Declining trends are identified in quarterly CAP Trend Reports and actions initiated to correct performance Effectiveness review (Step OP-10-005.13)
Page 17 of 27 Action Plan: OP-10-006
Title:
Effective Root Cause Evaluations Objective Action Plan Steps to be Completed Summary & Status of Action Steps Complete Date Methods to Verify Objective Met Reduce recurrent problems through improved root cause quality OP-10-006.14 OP-10-006.15 PBNP has developed a standard for grading Root Cause Evaluations (RCE) and a checklist for Corrective Action Review Board to review RCEs. A performance indicator was established to monitor RCE quality. A continuing /refresher training course for Root Cause Evaluators will be established to ensure that RCE quality remains high. An additional close out effectiveness review by independent assessors will be performed to ensure that the actions taken to improve RCE quality have been effective.
1Q05 Average RCE Quality Grade is
>85 sustained over a 3-month period Effectiveness Review (Step OP-10-006.15)
Individuals receive instruction to become root cause evaluators and team leaders OP-10-006.12 OP-10-006.14 OP-10-006.15 PBNP has provided refresher briefing and developed a Root Cause Evaluator (RCE) certification standard. Additionally, a process to certify Root Cause Evaluation Team Leaders was developed. A continuing /refresher training course for Root Cause Evaluators will be established to ensure that RCE quality remains high. An additional closeout effectiveness review by independent assessors will be performed to ensure that the actions taken to improve RCE have been effective.
1Q05 Certification records of those selected Documented self-assessment of use of multi-disciplinary teams (Step OP-10-006.12)
Effectiveness Review (Step OP-10-006.15)
Page 18 of 27 Action Plan: OP-10-010
Title:
Operating Experience (OE) Improvement Plan Objective Action Plan Steps to be Completed Summary & Status of Action Steps Complete Date Methods to Verify Objective Met Expectations are clearly communicated OP-10-010.1 OP-10-010.19 Expectations are formally delineated in procedures OEG-007 and NP 5.3.11.
A review will be conducted to determine whether the actions taken have been effective.
3Q04 Procedures reviewed and issued (OEG-007 and NP 5.3.11)
Effectiveness Review (Step OP-10-010.19)
OE is contained within a single database OP-10-010.15 OP-10-010.19 This action is complete. The OE program resides in a single database, T-Track.
A review will be conducted to determine whether the actions taken have been effective.
3Q04 Single OE database created Effectiveness review (Step OP-10-010.19)
Procedures for acquiring and processing OE are issued OP-10-010.4 OP-10-010.19 Procedures OEG-007 and NP 5.3.11 have been approved and issued.
A review will be conducted to determine whether the actions taken have been effective.
3Q04 Procedures approved and issued (OEG-007 and NP 5.3.11)
Effectiveness review (Step OP-10-010.19)
OE data is effectively used to improve the quality of work OP-10-010.21 OP-10-010.22 OP-10-010.23 A CAP that was initiated to address circumstances in which OE disseminated at daily production and planning meetings had not been implemented in the field. A second action deals with providing a means such that OE can be easily accessed and filtered for use by maintenance personnel during pre-job briefs. A third item conducts an effectiveness review of implementation of the OE program within the Maintenance Department as well as assessing the overall effectiveness of the Action Plan.
1Q05 OE evaluation quality being tracked Average age of open OE evaluation is <30 days sustained over a 3-month period.
Average age of open corrective actions associated with OE
<120 days sustained over a 3-month period Effectiveness Review (Step OP-10-010.23)
Page 19 of 27 Action Plan: OP-10-011
Title:
Improve Effectiveness of Self Assessment Objective Action Plan Steps to be Completed Summary & Status of Action Steps Complete Date Methods to Verify Objective Met Benchmarking is conducted in formal, systematic methods against industry performance OP-10-011.4.C OP-10-011.9 This Action Plan is intended to strengthen certain elements of the continuous improvement process to drive the overall station improvement process.
A formal benchmarking procedure has been developed. Additionally, a performance indicator to monitor benchmarking effectiveness has been developed.
A review of the revised benchmarking procedure and process will be performed to ensure its effectiveness.
4Q04 Procedure issued which provides a formal structure for benchmarking activities Benchmarking schedule adherence is >80%
Effectiveness Review (Step OP-10-011.9)
Data from the job observation program is analyzed and disseminated to detect adverse trends OP-10-011.3.D OP-10-011.9 Actions taken to date have included self-assessments to identify the specific elements warranting additional attention, implementation of a common database for administering the job observation process, development and issuance of the job observation program procedure that formalizes the process and defines standards, expectations, trending, and reporting observations.
The PBNP site observation program is delineated in procedure NP 13.6.1. NP 13.6.1 requires job observations to be performed by managers and supervisors. The total number of managers and supervisors required by procedure to conduct the job observations is approximately 115.
A review of the site leadership observation program will be performed to ensure its effectiveness.
4Q04 An average of >325 management observations per month (both training and field observations) are conducted over a sustained 3-month period Quarterly analysis of job observation data is prepared and issued Effectiveness Review (Step OP-10-011.9)
Page 20 of 27 Action Plan: OP-10-011
Title:
Improve Effectiveness of Self Assessment (continued)
Objective Action Plan Steps to be Completed Summary & Status of Action Steps Complete Date Methods to Verify Objective Met Quality, focused self-assessments are routinely conducted OP-10-011.5.A OP-10-011.5.B OP-10-011.5.D OP-10-011.5.F OP-10-011.7 OP-10-011.8 OP-10-011.9 Actions taken to date have included revising the administrative procedure and process used to conduct self-assessments. The NMC fleet process for performing focused self-assessments has also been adopted.
Actions remaining to be completed include implementation of a site-wide integrated assessment reporting process, establishing a process whereby performance indicators relevant to each plant department are routinely reviewed by the departmental staff and the conduct of an effectiveness review.
4Q04 Focused self-assessment schedule adherence is >90%
sustained for 2 quarters Focused self-assessment report quality is graded >95%
sustained for 2 quarters Effectiveness Review (Step OP-10-011.9)
Action Plan: OP-10-013
Title:
Resolution of 2003 CAP Self-Assessment Areas for Improvement Objective Action Plan Steps to be Completed Summary & Status of Action Steps Complete Date Methods to Verify Objective Met Self-Assessment of the PBNP CAP program (SA-CAP-2003-01) comments/observations have been resolved OP-10-013.16 A step was included in this action plan to determine the effectiveness of the changes made to the CAP program as a result of the July 2003 self-assessment.
3Q04 Corrective actions completed for findings from SA-CAP-2003-01
Page 21 of 27 CONFIGURATION MANAGEMENT / DESIGN CONTROL FOCUS AREA: Configuration Management Action Plan: OP-14-001
Title:
Improve the Configuration Management Program Objective Action Plan Steps to be Completed Summary & Status of Action Steps Complete Date Methods to Verify Objective Met Reduce the backlog of modifications that have been in closeout greater than 90 days since acceptance OP-14-001.11 OP-14-001.11.A A backlog of work remains to close out previously installed modifications. A backlog reduction workdown curve will be developed and used as a means for station management to monitor progress to assure the closeout goal is met.
2Q05 Backlog of modifications that have been in closeout >90 days since acceptance is reduced to
<20 Configuration Management Program guidelines and procedures to improve configuration management are issued OP-14-001.12 OP-14-001.15 OP-14-001.16.A The scope of work and list of procedures requiring revision have been identified.
Resources necessary to revise and develop procedures have been identified.
New or revised Configuration Management Program guidelines and procedures will be issued per schedule.
Approximately 60 procedures will require revision. All actions in OP-14-001 will be completed by 2Q05 with the exception of Steps 16 and 17. Step 16, which is the work to revise applicable procedures, is scheduled to be approximately two-thirds complete by 2Q05. Step 17 is the final effectiveness review. A progress status review (Step OP-14-001.16.A) will be conducted in 2Q05 to assure satisfactory progress. This progress review will validate that a minimum of 40 procedures have been revised and issued.
2Q05 A minimum of 40 procedures will be revised and issued by 2Q05 (approximately two-thirds of total project scope)
Performance indicators, standards or health reports developed in Step OP-14-001.15 implemented Progress Review (Step 14-001.16.A)
Page 22 of 27 Action Plan: OP-14-003
Title:
Validate Design Basis for High Risk Systems Objective Action Plan Steps to be Completed Summary & Status of Action Steps Complete Date Methods to Verify Objective Met Design Basis Documents (DBDs) for the following high risk significant systems are updated and validated: Auxiliary Feedwater, Service Water, Fire Protection, Emergency Diesel Generators, Component Cooling, 480 V, and 13.8 kV OP-14-003.3 OP-14-003.4 OP-14-003.5 OP-14-003.6.A This plan will update and validate the three most risk significant DBDs by 2Q05 and the seven selected systems over an approximate 2.5 year period.
Owners have been assigned to the selected DBDs. A schedule will be developed for the remaining four DBDs identified in the Action Plan.
A project plan will be created and resourced appropriately such that the AFW DBD validation and update will be completed by 3Q04. The Service Water and Fire Protection System DBD validation and updates will be completed by 2Q05.
2Q05 Interim progress review (Step OP-14-003.6.A)
AFW DBD validation and update completed by 3Q04 Service Water DBD and Fire Protection DBD updates completed by 2Q05
Page 23 of 27 Action Plan: OP-14-005
Title:
Validate and Integrate Calculations and Setpoints Objective Action Plan Steps to be Completed Summary & Status of Action Steps Complete Date Methods to Verify Objective Met Calculations are upgraded to provide a clear basis for safety-related setpoints and to create a cross-reference for setpoints, calculations and procedures OP-14-005.2.D OP-14-005.2.E OP-14-005.3 OP-14-005.4 OP-14-005.5 OP-14-005.6 OP-14-005.7 OP-14-005.8 OP-14-005.9 OP-14-005.10 A project plan has been developed and scope of work determined. The scope of calculations requiring upgrade will be defined and the EOP setpoint bases requiring revision will be identified. A review of safety-related calculations is being performed, including validation of assumptions. The project plan includes requirements to assure the technical bases for safety-related setpoints and calculations are documented.
The primary objective of this plan is to upgrade the subject calculations. The calculation upgrades are to be completed by 2Q05. All of the steps in this plan will be completed by 2Q05 except Step OP-14-005.2.F and Step OP-14-005.11. Step OP-14-005.2.F will implement revised EOP setpoints in emergency operating procedures and this work will be completed by 4Q05. A final effectiveness review, Step OP-14-005.11, will be completed in 2006.
Step OP-14-005.9 is a progress review that will ensure successful completion of work scheduled by 2Q05. By 2Q05, the calculations will be revised, validated and issued. Also, by 2Q05 a cross-reference database will be developed.
2Q05 Calculations revised, validated and issued Cross-reference database developed Progress Review (Step OP-14-005.9)
Page 24 of 27 Action Plan: OP-14-007
Title:
Updated Vendor Technical Information Program (VTIP)
Objective Action Plan Steps to be Completed Summary & Status of Action Steps Complete Date Methods to Verify Objective Met Strengthen the VTIP program and address issues identified in a self-assessment OP-14-007.4 OP-14-007.5 OP-14-007.8 VTIP program management is strengthened by 1) assigning program ownership to the Configuration Management group; 2) revising procedures used to administer VTIP; and 3) completing corrective actions identified in self-assessment PBSA-ENG-02-01.
2Q05 Procedures revised and issued Corrective actions from self-assessment PBSA-ENG-02-01 are resolved AUXILIARY FEEDWATER SYSTEM FOCUS AREA: Equipment Reliability (AFW)
Action Plan: EQ-15-001
Title:
Auxiliary Feedwater (AFW) Appendix R Firewall Project Objective Action Plan Steps to be Completed Summary & Status of Action Steps Complete Date Methods to Verify Objective Met Complete modifications required to resolve Auxiliary Feedwater Pump Room Appendix R issues EQ-15-001.8 EQ-15-001.9 EQ-15-001.10 EQ-15-001.11 EQ-15-001.12 EQ-15-001.13 EQ-15-001.14 Modifications are being installed and will be completed by end of 2Q04. These modifications include the construction of a 3-hour fire rated barrier and fire wrap of certain Appendix R credited electrical conduits. These modifications provide assurance that at last one train of safe shutdown equipment remains free of fire damage following a fire in either the north or south half of the AFW pump room.
2Q04 Modification installed and closed out
Page 25 of 27 Action Plan: EQ-15-015
Title:
Auxiliary Feedwater Electrical Modifications Objective Action Plan Steps to be Completed Summary & Status of Action Steps Complete Date Methods to Verify Objective Met AFW component power supplies meet design basis requirements EQ-15-015.5 A design basis evaluation of the AFW system identified that power supplies to some components did not meet design basis requirements. The purpose of this action plan is to implement electrical modifications to address these issues.
Modifications to correct these deficiencies were installed in 2003. These included modifications MR 03-005, MR 03-006 and MR 03-007.
Closeout of MR 03-006 is complete. The two remaining modifications will be closed out by 3Q04.
3Q04 Modifications MR 03-005 and 03-007 closed out FOCUS AREA: Management Effectiveness Action Plan: OR-05-008
Title:
AFW Root Cause Evaluation (RCE) Corrective Actions Objective Action Plan Steps to be Completed Summary & Status of Action Steps Complete Date Methods to Verify Objective Met The Auxiliary Feedwater Root Cause Evaluation corrective actions are complete and correct the root causes and contributing causes identified in the RCEs OR-05-008.1 OR-05-008.2 OR-05-008.3 OR-05-008.4 OR-05-008.5 PBNP has completed three Root Cause Evaluations related to these issues and corrective actions are being addressed by the PBNP management team through the CAP program. Corrective actions included plant modifications and organizational effectiveness improvements. Necessary modifications for the AFW have been installed and design control processes have been strengthened.
An interim effectiveness review of these corrective actions will be conducted in 3Q04 and a final effectiveness assessment will be conducted in 2Q05 to assure the corrective actions taken are effective.
2Q05 Corrective actions from RCE 01-069 Revision 1, RCE 191 Revision 1, and RCE 202 are determined to be complete and have effectively addressed root causes and contributing causes per Effectiveness Review scheduled pursuant to Step OR-05-008.5
Page 26 of 27 EQUIPMENT RELIABILITY FOCUS AREA: Equipment Reliability Action Plan: EQ-15-011
Title:
Bolted Fault Objective Action Plan Steps to be Completed Summary & Status of Action Steps Complete Date Methods to Verify Objective Met Calculations to support fault protection reflect design basis assumptions EQ-15-011.5 These planned analyses and modifications will improve the protection of in-plant electrical distribution systems in the event of a catastrophic electrical fault.
A large portion of the analysis work has been completed. Modifications to the 480 V electrical distribution system are in progress.
4Q04 Approved calculations Bolted fault project is completed in accordance with project schedule EQ-15-011.3 EQ-15-011.12 EQ-15-011.16 Modifications required to configure the plant in accordance with the design calculations are in progress. A project schedule has been established and will continue through 2007.
By the end of 2Q05, Steps EQ-15-011.1, 3, 4, 5, 8, 12, 15, and 16 will be completed. Steps EQ-15-011.2, 6 and 7 will be partially completed. Work on these steps will include:
(1) Procurement and receipt of motor control center (MCC) buckets; (2) procurement and receipt of MCC bracing; (3) completion of design analysis engineering; (4) determination of scope of power panel/MCC individual breaker replacement; (5) procurement of transformer tap change material, (6) change packages are approved for 4 of 8 MCCs; (7) bracing installed on 1 MCC; and (8) buckets are replaced in 2 MCCs.
To assure satisfactory project progress, an interim progress review (Step EQ-15-011.16) will validate that the actions scheduled for completion by 2Q05 have been successfully performed.
2Q05 Interim progress review (Step EQ-15-011.16) following U2R27 determines work scheduled by 2Q05 is completed.
Page 27 of 27 Action Plan: EQ-15-012
Title:
Manhole and Cable Vault Flooding Objective Action Plan Steps to be Completed Summary & Status of Action Steps Complete Date Methods to Verify Objective Met Implement a solution to keep the cables in Maintenance Rule scope manholes from becoming submerged EQ-15-012.8 EQ-15-012.9 A modification is in the implementation phase to install dewatering equipment in Manholes 1 and 2. Callups will be established to inspect and pump Maintenance Rule scope manholes to preclude long-term submergence of cables.
The modification to install the dewatering equipment in Manholes 1 and 2 is scheduled for installation and acceptance by 2Q04.
3Q04 Modification for dewatering equipment for Manholes 1 and 2 installed and accepted Maintenance call-ups in place to inspect and pump manholes, as determined necessary, for remaining manholes containing Maintenance Rule scope cables Effectiveness review of installed modification (Step EQ-15-012.9)
Action Plan: EQ-15-016
Title:
Determine Condition of Underground Cables Which Have Been Submerged Objective Action Plan Steps to be Completed Summary & Status of Action Steps Complete Date Methods to Verify Objective Met The condition of the underground 480 V, 4160 V and 13.8 kV cables that are safety-related or provide offsite power is understood and monitored EQ-15-016.4 EQ-15-016.6 Condition monitoring has been performed on the subject cables. The cables have been found to be in good condition.
Call-ups will be established to routinely monitor condition of the cables to ensure their reliability. Callups will require periodic energized partial discharge testing of 4160 V and 13.8 kV cables subject to submergence.
1Q05 Effectiveness assessment (Step EQ-15-016.6)
Cable condition assessment reports completed Call-ups are in place for future cable condition monitoring