ML042080166
| ML042080166 | |
| Person / Time | |
|---|---|
| Site: | Vermont Yankee File:NorthStar Vermont Yankee icon.png |
| Issue date: | 04/20/2004 |
| From: | Bronson K Vermont Yankee |
| To: | Office of Nuclear Reactor Regulation, Vermont Yankee |
| References | |
| FOIA/PA-2004-0267 | |
| Download: ML042080166 (6) | |
Text
'Message Page I of I Sienel, Beth From:
Bronson, Kevin Sent:
Tuesday, April 20, 2004 4:24 PM To:
VTY - All Users
Subject:
Half Way Home
- All, Please open and read the attachment at your first opportunity.
We have a lot of successes in this outage that we should be proud of to date, and we have some information that we can use to make us even more successful going forward.
- Thanks, Kevin
,,. $IC V
NfAX
RFO-24 Performance 03/29 - 04/19 (A bit more than) Half Way Home As of April 19, we have completed 16 days of RFO-24, putting us officially at (a bit more than) the half way point. In other words, we're more than half way home to successful completion of a very demanding outage; more than half way home to starting up and returning to normal power operation. So, how have we done to this point, and upon what should we focus as we traverse the backside of this outage?
Again, let's review our Primary Goals:
- SAFETY First
- QUALITY of Work
- EFFICIENCY of Schedule It is critical that we remind ourselves and our teammates of these primary goals, often and always. Specifically, it is important.to consider how each primary goal relates to all of our individual goals.
- Safety is our first and foremost priority. This includes Personal (industrial)
Safety, Plant and Equipment Safety, and Nuclear Safety. No matter what you might personally be doing, from installing stator bars in the main generator, to erecting scaffolding, to walking across the parking lot, SAFETY must always be your overriding thought.
- Qualitv of work goes without saying. There is ALWAYS time to do the job right-the first time. The quality of your work is a direct reflection of...YOU. You have been selected to be a member of this RFO-24 Team because of your professionalism, your skill, and your expertise. The quality of the work getting completed, and the quality of run that we will experience during Cycle 25 lies directly in your hands.
- Efficiency as a team depends upon each of us being as efficient as we can possibly be. With SAFETY as your predominant thought, and QUALITY without exception in everything you do, EFFICIENCY becomes the catalyst that pulls together your efforts and those of your teammates to make this outage a success.
Once again, we have taken a look at our CR database to see what it's telling us in three key areas: Safety, Rad Worker Practices, and Human Performance (HU).
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SAFETY There have been a total of 106 CRs written through April 18 that have been flagged as having Industrial Safety aspects. Of these:
- Thirtv-Three documented unsafe behaviors on behalf of workers. Such behaviors have spanned a spectrum from improper use of ladders and fall protection, to lack of PPE, to unsafe behaviors in the parking lot. This is a point to take note.
Unsafe behaviors, allowed to go unchecked, will result in someone getting hurt.
Remember, if someone coaches you on correction of an unsafe behavior, thank them. Coach others if you see them doing anything unsafe. We do it because we care.
- Thirty have been written to identify potential safety hazards. We are continuing to identify and fix conditions that might set someone up to get hurt. This is excellent, considering that such CRs are great examples of using a QUESTIONING ATTITUDE and of caring enough for ourselves and our teammates to identify these issues so that they can be eliminated.
Seventeen identified conditions where folks have gotten hurt. Two of these have been significant enough to be considered OSHA Recordable incidents.
Fortunately, both of the individuals involved in these incidents are back at work.
Remaining injuries have required only minor first aid as a remedy.
So what's this telling us about our safety practices so far?
We're continuing to do a GREAT job of reporting issues that have arisen. Overall, we've had a very safe outage, a testament to the fact that SAFETY is our primary goal, and that we are PAYING ATTENTION while doing our work. It's unfortunate that a few minor injuries have occurred. The message here is-injuries CAN happen-as soon as you let your guard down and stop paying attention. Remember the primary means by which to avoid getting hurt: PAY ATTENTION and FOCUS on what you're doing.
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HUMAN PERFORMANCE We've had five ERRORs thus far:
- CR 2004-0892-Inadvertent Overfilling of the Reactor Cavity.
- CR 2004-1087-Worker Receives a Two-Inch Laceration to His Scalp
- CR 2004-1163-Switchyard Test Reveals Incorrect Wiring (79-40 Breaker)
- CR 2004-1235-Worker Receives Electrical Shock While Moving Relay
- CR 2004-1296-Worker Injured by Slipping on Temporary Stairs Amongst this list of ERRORs, the following HU TRAPs (and lack of TOOL use) existed:
- Distraction/Interruption
- Multiple Tasks
- Overconfidence Failure to Follow Procedure
- Lack of Self Checking
- Lack of Peer Checking
- Lack of Formal Communication
- Not Paying Attention This proves that (1) ERRORs can actually happen, (2) TRAPs are everywhere, and (3) using the TOOLs uncompromisingly is the best means of keeping yourself error-free.
So beyond this, how are we doing?
As outlined in HUgo's Notes, Precursor Rate has been trending upward since April 7, and our Error Rate has trending upward since April 1 1. These numbers go hand in hand. It's a statistical fact that if you make more mistakes at the precursor level, you will have more errors. The good news is that we are identifying many precursors at very low thresholds.
The value in this is that we can learn and correct, thereby minimizing the potential for errors of the same nature.
There has been a phenomenal amount of work taking place. Overall, we have done an excellent job. The numbers behoove us, however, to recognize the importance of a renewed FOCUS on use of the HU TOOLs. There have been a total of 239 HU-related CRs written during RFO-24 thus far. Insights from the database include:
Seventv-two CRs have been written to document issues where a procedural requirement., standard, or expectation was not appropriately followed. It is important to remember that you are required (and expected) to comply with all procedures, documents, standards, and expectations that apply to whatever you're Page 3 of 5
doing. This is the concept of PROCEDURE USE. Two important things to remember here: (1) Don't assume anything, and (2) ASK QUESTIONS.
- Forty-two CRs have identified instances where there was inadequate attention to detail, or where folks failed to ask questions. Four of our five ERRORs have involved this element. PAYING ATTENTION and ASKING QUESTIONS are baseline requirements for success.
- Twenty-two CRs have documented issues with less than perfect handoffs, coordination, or scheduling. We've been doing a great job of documenting these issues so that we can learn from them. Most of these have been flagged as "Outage Critique" items, so that we can improve for future outages. The keys to minimize these types of issues are to (I) Look ahead, and (2) COMMUNICATE, COMMUNICATE, COMMUNICATE.
- Twentv-one CRs have documented issues with security badges. Most of these involve lost badges where the badge clip has become disengaged, causing the badge to release and fall from the lanyard. An adverse trend CR is being written to document this overall issue, and to explore the opportunity for a different type of badge clip going forward.
One additional issue that continues to arise is FME. We've had a total of twenty CRs written on different aspects of FME. While we continue to do work, we are now also beginning to demobilize. As we do so, it is very important to minimize the amount of stray "stuff' lying around. By paying attention to what we're doing, picking up after ourselves, and making a concerted effort to remove and stow / throw away all stray items and materials, we can minimize the potential for stray materials to become foreign materials.
We've had a few other issues arise, but none that have hit the radar screen to cause significant concern. Here's the main thing to remember about HU: Error precursors are just that-precursors to more significant mistakes (Errors or Events). We've seen clearly during this outage that if the precursor rate goes up, the error rate will follow. By renewing our FOCUS on HU such that we keep precursors to the lowest possible number and least level of significance, we minimize our chances of something more significant going wrong.
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RADWORKER PRACTICES We have continued to have exceptional performance in this area. We are currently slightly above our ALARA goal; however, we have the opportunity during the next couple of days to make great progress in this area with our performance in the drywell.
The great news is that we have only had twenty-five CRs written in this area. The numbers in the database include:
- Eight CRs have documented inappropriate rad worker practices (improper frisking, reaching across contaminated boundaries area, etc.)
- Six CRs have involved personnel contaminations.
- Six CRs have been written to identify administrative issues such as individuals working on the wrong RWP, posting issues, etc.
This is a point where we say, "Keep up the good work!" Continue to do everything possible to minimize dose. It's important that we continue to PAY ATTENTION and to coach one another in our radworker practices.
In Summation We assembled a top notch team for this outage, and YOU are a valuable member of that team. It is clear that we are continuing to PAY ATTENTION. As we now continue down the backside of the outage; as we continue to do work while beginning to demobilize, it is important that each of us renew our commitment to use of the HU TOOLs. Continue to FOCUS, continue to ASK QUESTIONS, and continue to make the Team's Top Three Priorities YOUR Personal Top Three Priorities: SAFETY first, QUALITY without exception, and EFFICIENCY in all that we do.
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