ML042940219
| ML042940219 | |
| Person / Time | |
|---|---|
| Site: | Davis Besse  |
| Issue date: | 05/03/2002 |
| From: | - No Known Affiliation |
| To: | Office of Nuclear Reactor Regulation |
| References | |
| FOIA/PA-2003-0187, NOP-LP-2001-01 02-01850 | |
| Download: ML042940219 (3) | |
Text
,6/56, 2002 039: 39 4198980691 DBNRCRIO PAGE 03 NOP-LP.2001-01 CONDITION REPORT aCR Number TITLE: COMPROMISED STANDARDS.l 02-01850 The dffectiveness review for CR 1998-0020 (OAD-00-801 59) documents that the preventive actions resulted in reviews being performed that generally determined no substantial changes were required or implemented. The effectiveness review was reviewed by and approved by the SRB. A thorough root cause for CR 2002-00891 would have included a review of these failed opportunities to correct organizational and management weaknesses and consequently proposed more rigorous, effective preventive actions to ensure we actually improve versus deciding everything is fine the way it is.
The publishing of the root cause for CR 2002-00891 to the world despite that fact it clearly does not meet our procedural requirements and expectations compromises our standards. It falsely communicates to the world that we have low standards for our corrective action process, when in fact the majority of our root and basic causes are rigorous and performed in a thorough manner utilizing appropriate root cause techniques.
The Issue of not following our process for processing CR 2002-00891Jspcqmpounded by the fact we have~elected to not enter the preventive actions into the CREST system. This increases the likelihood we will not take timely corrective action since we are not utilizing the normal Aethod for assigning and tracking work.
SUPV COMMENTS I IMMEDIATE ACTIONS TAKEN (Discuss CORRECTIVE ACTIONS completed, basis for closure.)
The purpose of this CR a to request a root cause investigation Into the management culture that allowd us to publish a document to the world that we knew did not meet our expectations. It Is acknowledged that we technically have not violated our procedures yet, because we have not closed theCR in CREST. However, this does not nullify the cultural issues that exist that allowed us to reach our present state.
'QUALY ORGANIZATION USE ONLY IDENTFIED BY (Check one) 0 Self-Revealed ATTACHMENTS
- Quakty Org. Initiated
] Yes 0 Indlvldua!/Woe1c Group
[1 Inlemal Ovesight Qua Org. Follow-up 0 Yes 0 No 2 Supervislon/Managernenl Li External Oversightt Yes R) No
.ORIGlATOR ORGANIZATION DATE SUPERVISOR DATE PHONE EXT.
MCALLISTER A PE 53/2002 MCALLISTER. A 5N12002 7420 SRO EQUIPMENT EVALUp:110N IMMEDIATE ORGANIZATION MODE CHANGE P
REVIEW OPERABLE REQUIRED INVESTIGATION REQUIRED NOTIFIED RESTRAINT L
OYes No O YesNo2 A
Yes 2 No D Yes 2 No WA y yes ElNo A
MODE ASSOCIATED TECH SPEC NUMBER(S)
ASSOCIATED LCO ACTION STATEMENT(S)
N A T
DECLARED REPORTABLE?
One Hour NWA APPLICABLE UNtT(S)
P NOPERABLE (Data/Time)
DYes RINO E
N/A DEwilRqueud Other NA 2 U1 0 U2 0 Beoh R
COMMENTS A
N/A T
l 0
N Current Mode - Unit lI Power Level. Unit I Current Mode. UnIt 2 Power Level - Unit 2 S
WA WA N/A lA SRO - UNIT 1 SRO - UNIT 2 DATE Appraved By Supv N/A
-5132002 Page 2 of 80 I
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as 5LOOIUWJAD VtSNNRCRI PAGE 02 7.0i NOP-LP.2001 41 CONDITION REPORT CR Number TITLE:
CO PROMISED STANDARDS 02-01850 DISC ERY DATE TIME EVENT SYSTEM I ASSET 5002 WA 411fl02 WA NIA NIA EQUIF ENT DESCRIPTION NWA DESC IPTION OF CONDmON and PROBABLE CAUSE (If known) Summartza any attachments. Identify what, when, where why, how.
0 The toot cause completed for CR 2002-00891 (Significant Degradation of the Reactor Pressure R
Ves el Head) did not comply with the procedural requirements of NOP-LP-2001 and the Davis-Bes e Condition Report Process Programmatic Guideline. The quality of this root cause report is G
sign cantly below that of root and basic causes that have been rejected by the Corrective Action I
Reve Board (CARB).
N Sorfe of the deficiencies in CR 2002-00891 root cause report are as follows:
A Th re Is no connection between the data collected, the Identified causes, and the preventive T
acti ns. The conclusions reached are disconnected from the data presented, with no supporting data i
for rany of the conclusions.
o
- Pr ventive Actions do not adequately prevent or mitigate the causes Identified. For sample, there N
is n action to eliminate the alloy 600 material for the CRDM nozzles, therefore PWSCC cracking of the tozzles will continue.
- Proventive actions do not exist for some of the identified causes. For example, no preventive actin is proposed for correcting the fact that engineering supervisors are reassigned to outage tasls and therefore not available to provide adequate supervisory control during outages.
- Tlhe Management portion of the Investigation was not performed by qualified individuals, nor was a root cause technique employed for this portion of the Investigation.
- Tie Management portion of the Investigation was superficial and did not adequately investigate why, the corrective actions from CR 1998-0020 (Lack of comprehensive actions for RC-2 boric acid wasWage) were not effective In preventing this event.
The root cause report correctly Identifies that "rigorous adherence to the corrective action process wotId have provided an opportunity to address head leakage at an earlier time.w Likewise, if we rigorously adhere to the corrective action process In the investigation of this condition report, we woo4d be much more likely to Identify the true root causes and implement effective preventive actions.
CR 998-0020 (Lack of comprehensive actions for RC-2 boric acid wastage), was Initiated to con uct an independent review of the management Issues associated with the RC-2 packing leak.
The CR identified the root causes as 1) Less than adequate (LTA) Management exp ectations/standards that resulted in: LTA problem solving and condition evaluations, LTA decision making, LTA RCS leakage standards, LTA procedure requirements for boric acid corrosion cortrol, Lack of Nuclear Assurance oversight of a slgnfficant Issue. 2) LTA Management follow-up and monitoring of emerging issues that resulted In: being reactive, rather than proactive, over-relitnce on the Corrective Action Program to manage a significant Issue, Lack of priorities for cortpletlng work considering the significance and potential consequences of the condition. 3) LTA vertical/lateral integration (pertinent information not transmitted) that resulted In: incomplete and misleading communication, Incomplete awareness of the boric acid buildup, lack of management awareness of the extent of condition results, responsibilities of personnel not well defined.
Contributing Causes listed were: 1) LTA Supervisory Oversight that resulted In: not following propedures and maintenance work orders, poor field work practices, poor job planning. LTA work corlpletion as planned, poor tracking of work progress or follow-up. 2) LTA training and qualifications that resulted In: low experience with boric acid leakage, little appreciation for the rapid boric acid corrosion effects. These causes appear to have still been present for the condition do4umented on CR 2002-00891.
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