ML043240230
| ML043240230 | |
| Person / Time | |
|---|---|
| Site: | Millstone, Davis Besse  |
| Issue date: | 11/12/2004 |
| From: | Dan Collins Dominion Nuclear Connecticut |
| To: | Office of Administration |
| References | |
| 69FR61049 00001 | |
| Download: ML043240230 (124) | |
Text
NRCREP - Public Comments - RIS on SCWE; 1 il Page iii NRCREP -Public Comments RIS on SCWE Page d1&3 hd 1111zle>/
k I From: <David_MCollins dom.com>
To: <nrcrep~nrc.gov> /6//v/fi4 Date: Fri, Nov 12, 2004 11:39 AM
Subject:
Public Comments - RIS on SCWE ft // 4 Mr. Lesar Attached find comments on:
Draft Regulatory Issue Summary 2004-xx Establishing and Maintaining a SCWE (See attached file: Comment on NRC SCWE RIS Nov 04.doc)(See attached file:
Sen Voinovich Scolds NRC.doc)(See attached file: Davis-Besse workers' repair job hardest yet .doc)
(See attached file: Ensuring Safe Cultures Draft 11-11 -2004.ppt)
David M. Collins Engineering Analyst Millstone Power Station Dominion Nuclear Connecticut Phone 1-800-269-9994 x3710 Fax 860-437-5916 CC: <LLJ~nrc.gov>, <WilliamJ_Hayes~dom.com>
Cc - ,9'3 62kg.t.
'5 S WAf )
4 -
3 r_Cz, .
c:\temD\GWI00001.TMP c:\temD\GWIOQOO1 .TMP Page 11!1 Page Mail Envelope Properties (4i94E732.CA2: 5: 31906)
Subject:
Public Comments - RIS on SCWE Creation Date: Fri, Nov 12, 2004 11:36 AM From: <David_M_Collins@dom.com>
Created By: David_M_Collins@dom.com Recipients nrc.gov twf2_po.TWFNDO NRCREP nrc.gov owvf4_po.0WFN_DO LIJ CC (Lisamarie Jarriel) dom.com William_J_Hayes CC Post Office Route twf2_po.TWFNDO nrc.gov owf4_po.0WFN_DO nrc.gov dom.com Files Size Date & Time MESSAGE 490 Friday, November 12, 2004 11:36 AM Comment on NRC SCWE RIS Nov 04.doc 39936 Sen Voinovich Scolds NRC.doc 27136 Davis-Besse workers' repair job hardest yet .doc 26112 Ensuring Safe Cultures Draft 11-1 1-2004.ppt 714240 Mime.822 1107712 Options Expiration Date: None Priority: Standard Reply Requested: No Return Notification: None Concealed
Subject:
No Security: Standard
I NRCREP .-Co miment -onNRC SCWE RIS Nov 04.doc Pag.1 NRCREP Commeriton NRC SCWE RIS Nov 04.doc Page 1j David M. Collins 6 Katherine Rd, Old Lyme, CT 06371 November 11, 2004 Michael T. Lesar, Chief, Rules and Directives Branch, Office of Administration, NRC Public Comments:
Proposed Generic Communication (RIS) Establishing and Maintaining a SafetV Conscious Work Environment
Dear Mr. Lesar,
Congratulations on your hard work, I think this new guidance is a great improvement and will be very helpful. I do have some suggestions.
The RIS summary says:
In March 2003 the Commission directed the staff to develop further guidance that identified best practices to encourage a SCWE. The guidance is based on the existing guidance provided in a 1996 policy statement.
I make my comments based on an assumption that the new guidance is being proposed to replace the 1996 guidance, as the 1996 guidance did not appear to adequately ensure the development of an acceptably healthy SCWE at Davis Besse, and presumably at an unknown number of other U.S. plants.
ATTACHMENT 1 I believe since Davis Besse the NRC has assumed a more hands on proactive role. I would like to see an updated, more detailed description here of the NRC's current approach to SCWE, the actions the NRC takes to ensuring adequate safety cultures and SCWEs in the industry.
INTRODUCTION Suggest you reword "implementation of this guidance may not improve a SCWE without additional efforts by site management". Makes the RID seem ineffective.
Say something like " implementation of the guidance in the RIS is expected to help foster a more healthy organizational SCWE."
- NRCREP - Commenet on NRC SCWE RIS Nov 04.do-c_- Pa-e2 NRCREP Comment on NRC SCWE RIS Nov 04.doc Page 2 II ELEMENTS OF A SCWE SCWE Policy Schein says
- "Leaders Create Culture" INPO says (human performance fundamentals course) "Safety Culture Is The Central Role Of Leadership" The maintenance of the cultural environment (SCWE) should be identified as the responsibility of the leadership (management) team SCWE Traininq Excellent IMO that your recommendations for training include expectations for management behavior. This is key.
I suggest you reference INSAG 15 and two of the INPO Human Performance Fundamentals training chapter 2 job site and the individual and chapter 4 leadership as these documents provide a lot of specific guidance for managers (and workers) on culture positive from which this training can be developed.
SCWE Incentive Suggest you break the last paragraph in this section into a separate topic called "Maintaining a Blame Free Environment" and put it under training.
A blame environment is a major enemy of SCWE and a healthy reporting culture. Davis Besse's inability to eliminate the environment of blame (in fact it increased after the event) in my view is the major factor that keeps the SCWE there from improving.
Millstone was the opposite - it was shoot the messenger. Blame Environment sends a message "if I find out you screw up, I will kill you." Shoot The Messenger sends a message "if you point out that I screwed up, I will kill you." Both destroy the potential for a healthy reporting culture. I think most plants are educated enough to at least avoid the appearance of STM but many (like Davis Besse) feel they need to prove to the NRC that they are tough on safety by blaming, reassigning and terminating staff. This was a huge HU / SCWE mistake that continued at Davis Besse through recovery right under the nose of the NRC.
Avoiding a blame cycle is a huge SCWE management issue that needs to be much better understood, so I recommend you steal the "blame cycle" graphic and text from INPO HU Fundamentals chapter 4 leadership and add it to your RIS.
NRCREP - Comment on NRC SCWE R'IS Nov 04.doc Pager3II
'NRCREP Comment 6n NRC SOWE RIS Nov 04.doc Page Tools to Assess the SCWE Survey and Interview Tools A survey of manager behaviors encouraging the workforce to raise concerns should be viewed as a Primary SCWE management tool. Very good that it is included, but it should be a separate item, and highlighted as a primary tool.
Below is Leon Olivier's simple leadership team safety culture formula that developed robust worker/manager trust relationships and SCWE during recovery and beyond.
- 1. Care about quality
- 2. Care about workers Olivier required that all leaders continually show care and respect for all individuals, and continual care and concern not just for safety issues, but for all quality issues. Almost every culture and SCWE problem at Millstone, Davis Besse and elsewhere, can be traced back to these two issues - a lack of concern for people, and a lack of concern for quality.
Olivier demanded these qualities from every member of his leadership team. The qualities were monitored by leadership surveys, and leaders who proved unable to exhibit these qualities were replaced. This drove the safety culture and SCWE to a very high level, which many people felt was at that time the healthiest safety culture and SCWE they had ever observed in the industry.
After restart the surveys, group administering the surveys, and the pressure on managers were all considered extraordinary measures and were discontinued. Once the SCWE reached an apparently healthy level, the NRC did not require continuation of these measures. I discussed this with then Millstone senior NRC resident Dave Beaulieu. We both agreed that after recovery, there was nothing in place to prevent what occurred there from occurring again.
Had the relatively simple measures used at Millstone to Mianage the quality of the SCWE been institutionalized and across the industry, my belief is that the BAC event at Davis Besse would very likely have been avoided. Since 1996 I have been trying in various forums to get people to better understand the connections between leadership behavior, safety culture and SCWE performance, and encourage the NRC to become more proactive. Recently I have been communicating with Senator Voinovich's aide Brian Mormino on this issue.
Based on my Millstone observations, short of a regulatory requirement I doubt many managers (probably no managers) will voluntarily implement the surveys recommended in the RIS. Have you ever voluntarily asking the passengers in your car to criticize the safety of your driving? It is not human nature to do this - don't expect many managers
INRCRE0P - Comment on NRC SCWE RIS Nov 04.doc Page'41 NRCREP Comment on NRC SCWE RIS Nov 04.doc PgQ44 to do these surveys.
Elihu Goldraitt, author of the hugely popular business book The Goal, says in his book The Theory of Constraints:
..but there is one thing we absolutely cannot tolerate - constructive criticism.
That being said, to manage safety culture quality as it truly needs to be managed, there is no question that industry managers must learn to tolerate constructive criticism from workers, to listen with care and concern to the workforce human issues, and by way of accomplishing this to embrace these sort of leadership culture surveys.
To this end there needs to be more understanding, training, and guidance in this area.
To be implemented on the scale needed, this will ultimately have to come in the form of a Reg Guide or a NUREG that all the plants commit to. This will need to be implemented coincident with the addition of the topic of safety culture to all of the licensee QA Program Topical Reports.
First there is a tremendous amount of awareness that needs to be raised. Safety culture is a human performance safety system strongly related to safety of operations, and something that very much requires quality assurance. When I present my views on what is needed to manage safety culture quality, human performance professionals in the audience nod enthusiastic agreement, and from the remainder of the audience I get mostly blank stares.
Only the HU professionals can see clearly where we need to go. Also, almost all the people who were at Millstone through recovery see it, and those people I have met who are currently fixing cultures at FENOC and PSEG plants see the need for this, but the great majority of the industry as yet does not.
To summarize my main point, the NRC needs to develop safety culture quality regulations. A major barrier to such development is the current position of the NRC, which seems to be that any such regulation would somehow:
- 1. Cross "the line" and get the NRC into managing the plants
- 2. Be necessarily subjective.
My observation is that effective objective safety culture regulation will be simple and straightforward, will not require significant plant resources, will not require any additional NRC resources, and will not involve the NRC managing the plants beyond what the current scope of the ROP already provides.
That the NRC cannot see how simple, objective, and non-resource intensive safety culture regulation can be is only because the NRC has not yet studied safety culture adequately.
NRCREP - Comment on NRC SCWE RIS Nov 04.doc Page 5d1 NRCREP Comment on NRC SCWE RIS Nov 04.doc Page 511 Here is a quote from a December 2002 Plain Dealer article from ACRS member Dr.
Apostolakis, then ACRS Chairman:
"For the last 20 to 25 years, " he said, 'This agency has started research projects on organizational-managerial issues that were abruptly and rudely stopped because, if you do that, the argument goes, regulations follow. So we don't understand these issues because we never really studied them."
I would be happy to work with the NRC on developing safety culture / SCWE quality regulations. For my ideas on safety culture management, you are welcome to review the attached powerpoint presentation titled:
Ensuring Safe Cultures in High Hazard Ventures, an Integrative Approach So far I have discussed my concept of objective safety culture regulation only with Dr.
Apostolakis, but I hope to add this to my presentation in the future. I hope to also include a discussion of regulation in the article I am currently writing for the Elsevier journal Reliability and System Safety at the suggestion of editor Apostolakis.
Again, congratulations on your hard work, I think this new guidance will be very helpful for improving the management of SCWE in the industry.
Sincerely, David Collins Millstone 1-800-269-9994 x3710 david_m_collins@dom.com c:
Lisamarie Jarriel, Agency Allegations Advisor, Office of Enforcement, NRC
Page ill
'NRCREP - Sen Voinovich NRCREP - Se~n Scolds NRC.doc Voinovich Scolds NRC.do -Page 1 Sen. George Voinovich scolds the government's nuclear watchdog agency Friday, May 21, 2004 Tom Diemer Plain Dealer Bureau Washington- Sen. George Voinovich scolded the government's nuclear watchdog agency Thursday, telling its leaders they should more closely police safety activities of workers inside nuclear plants, like Ohio's Davis-Besse.
'I want to know if you are dedicated to making sure it doesn't happen again," he said, referring to the pineapple-size hole discovered in the Davis-Besse reactor lid in early 2002.
"We are going to talk about safety standards," he lectured the Nuclear Regulatory Commission. "If you won't do it, I'll pass legislation to get it done."
Voinovich got the commissioners' attention at a hearing of his Environment and Public Works subcommittee. But they resisted his demand for a new regulation, imposing a "safety culture" standard on nuclear plants to allow inspectors to measure whether workers and management are putting safety first.
"We're not in the business of managing utilities," said Nils Diaz, chairman of the commission. A rule tracking the interaction of managers and workers on safety issues "could be very, very subjective," added Commissioner Edward McGaffigan.
Voinovich, whose subcommittee has jurisdiction over the NRC, called the hearing in part to examine a highly critical General Accounting Office report which said the nuclear commission should have spotted the corrosion in the Davis-Besse reactor lid before it became a risk to the public.
Diaz said the NRC has reviewed its oversight at Davis-Besse and has implemented 16 recommendations, including an upgrade in training of inspectors. There were 51 recommendations. The commission had two inspectors at Davis-Besse during the more than four years it took for the rust hole to develop. Recent testing by the NRC showed the lid was as close as two months to bursting when the company stumbled on the hole in March 2002.
The GAO said in its report the nuclear regulatory body miscalculated the risk of suspected reactor leaks at Davis-Besse in November of 2001, leaving the plant on line and running. The commission had other long-standing shortcomings in its oversight of America's 103 nuclear plants, the report said.
.I . -_ I I NRCREP - Sen Voinovich Scolds NRC.doc Page 2i 2II NRCREP - Sen Voinovich Scolds NRC.doc Page Diaz conceded the NRC dropped the ball on communication and technical know-how at the FirstEnergy Corp. plant in Oak Harbor, just east of Toledo.
"Clearly, Davis-Besse was our worst hour," said McGaffigan. "One of the major lessons learned - and we should have already learned it - is we have to have excellent people everywhere."
The NRC has ordered Akron-based FirstEnergy to assess the safety culture at Davis-Besse annually for five years and report its findings to the government. But other nuclear plants do not face that requirement.
Voinovich was not satisfied. After the rust hole was disclosed in 2002, he said he got nervous phone calls. "George, what is going on? I thought things were fine,"
he said he was asked.
"People ought not to go to bed worrying about the safety of our nuclear power plants," he told Diaz.
Diaz said he disagreed with some of the criticism by the GAO, the investigative arm of Congress, because the observations were outdated and had already been addressed. He said the commission has stepped up recruitment efforts as its work force ages.
The chairman of the full committee, James Inhofe of Oklahoma, said that although "recent events have tested the NRC, he was "generally pleased with how the commission has responded."
Rather than harp on the accident-waiting-to-happen at Davis-Besse, Inhofe said he was disappointed the NRC is not more optimistic about the future of nuclear power. Diaz had said he doubted that nuclear energy could increase its 20 percent share of the nation's electricity output over the next 15 years.
But David Lochbaum, a nuclear engineer testifying for the Union of Concerned Scientists, was even gloomier about the future.
"The NRC's regulatory impairments make nuclear power's cost and risk higher than is necessary," Lochbaum testified. "Left unchecked, the only question is whether economics or disaster will bring down the curtain on nuclear power in America."
To reach this Plain Dealer reporter:
tdiemer@plaind.com, 216-999-4212
I NRCREP - Davis-Besse workers' repair job hardest yet .doe Page Page 1 l1 1II INRCREP Davis-Besse workers' repair job hardest yet .doc Sunday, December 29, 2002 Davis-Besse workers' repair job hardest yet Employees must fix plant's damaged attitude on safety THE PLAIN DEALER, Cleveland, OH By John Mangels and John Funk FIRSTENERGY CORP. Randy Fast, Davis-Besse plant manager, holds a "town meeting" with employees at the reactor complex Dec. 19 to discuss issues related to the plant's restart, including the need for a safety-minded culture. FIRSTENERGY CORP. Randy Fast, Davis-Besse plant manager, holds a "town meeting" with employees at the reactor complex Dec. 19 to discuss issues related to the plant's restart, including the need for a safety-minded culture.
For more than two years, the radiation detectors at the Davis- Besse nuclear power plant insistently signaled that something was wrong inside the hulking gray bunker that houses the reactor. The plant's response to those repeated warnings signaled something as well.
The twin monitors constantly sniff the muggy air inside the containment building, searching for signs that the reactor's vital coolant might be leaking. And from 1999 to 2001, the detectors' air filters - which normally require monthly changing - were clogging as often as every day with a fine yellow-brown dust. Consultants identified it as coolant residue and rusting metal, likely carried aloft by steam.
Although they suspected a coolant leak somewhere, Davis-Besse personnel couldn't find one.
Instead of pursuing its cause, they moved the monitors' intakes to a different spot. They even bypassed one of the devices' three sensors because it kept triggering alarms.
To experts like Mario Bonaca, a top adviser to the Nuclear Regulatory Commission, the Davis-Besse detectors weren't just registering a leaking, rusting reactor lid, but a corroded attitude toward safety, too. "Those were almost daily events," the nuclear industry veteran fumed at a recent meeting. 'Didn't somebody scratch their head and say, 'Why are we overriding these indications?' "
No one did, not the FirstEnergy Corp. managers of the Toledo- area reactor, not the NRC inspectors who were based there, not the analysts for the nuclear industry who gave the plant a clean bill of health. Despite years of obvious signs, the widespread breakdown at Davis-Besse of the "nuclear safety culture" escaped everyone's notice.
"There clearly were some issues with safety culture at that plant that had not been recognized by us, and not recognized by the top- most management of FirstEnergy," said NRC Chairman Richard Meserve. As he told an industry group in November, "the Davis-Besse episode presents the fundamental question as to whether the NRC's approach to assuring an adequate safety culture is sufficient."
Until now, the agency's inspections and rules have focused on hardware and procedures. The NRC has shied away from directly regulating the fuzzier concept of an appropriate safety mindset at the nation's 103 commercial nuclear plants - influenced, in part, by the industry's position that such attention would be meddling in management affairs.
But the shock waves from Davis-Besse have given new urgency to the safety culture debate
I NRCREP - Davis-Besse workers' repairjbhardestye c pa9 2 inside White Flint, the NRC's fortress- like Rockville, Md., headquarters. Some members of the Advisory Committee on Reactor Safeguards, an influential panel of scientists and engineers that counsels Meserve and the four other NRC commissioners, have recently voiced concerns about a possible gap in safety culture regulation. The group will make recommendations this spring.
Meanwhile, the NRC must tackle the more immediate problem of making certain that something it does not yet know how to measure has been restored at Davis-Besse - before the idled plant is allowed to restart.
High stakes Plumbing an organization's culture sounds better suited for a Harvard MBA thesis than for America's nuclear overseers. But the relative priority that workers and managers give to safety-mindedness is perhaps nowhere more important than at a nuclear plant, where an accident can affect millions of people.
"If it's an industry with catastrophic potential, any lapses are magnified," said Yale University sociologist Charles Perrow, author of "Normal Accidents," a book examining technological risk.
With their immense complexity and domino-chain processes, nuclear plants have a built-in propensity for accidents, Perrow argues.
So the organizational sins that might only result in a bad burger or a burned finger at McDonald's - sloppy work, poor supervision, ignored warnings, unnecessary risk-taking - have profoundly greater consequences at a place like Davis-Besse.
The nuclear industry's opposition to formal regulation of the safety culture doesn't mean it thinks the concept is unimportant - quite the opposite. A confidential report in September by the industry's research arm, the Institute for Nuclear Power Operations, analyzed the 20 most significant "near misses" in American nuclear history. (Davis-Besse made the list twice, for its reactor lid hole in 2002 and a 1985 incident in which coolant pump failures brought the reactor's radioactive fuel rods to within two hours of melting.)
The study found that the most commonly reported cause - named in 14 of the 20 mishaps - was plant personnel lacking "an appreciation of the risks associated with their actions" and taking "a non- conservative approach toward reactor safety."
The term nuclear safety culture was introduced after the Chernobyl disaster in 1986. Pinning down exactly what it means has proved elusive.
"I think if you were to talk with five different people about what safety culture is, you'd probably get five different answers," Meserve said in a recent interview with The Plain Dealer.
George Apostolakis, a respected Massachusetts Institute of Technology nuclear engineering professor who chairs the NRC's safety advisory panel, goes further.
"We really don't understand what an adequate safety culture is and how to measure it,"
Apostolakis said. "Some of my colleagues with long experience at nuclear plants tell me they walk into a facility, and 10 minutes later they know whether they have a good safety culture. But they can't tell me why."
Safety before profit The general consensus is that the safety culture is a blend of attitude, behavior and values: a commitment to excellence; a questioning outlook; personal accountability; a willingness to raise or listen to safety concerns and fix them; a belief from the boardroom down to the broom-pushers that safety comes before everything, including profits.
INRCREP - Davis-Bess'e worke'rs' repair job hardest yet .doc
_ _ --- _____~ Page ag- 3-A 1
NRCREP_ - avsBes
_ --- wokes repair jobhadet_ et.dc
- .1__ -
David Collins, an engineering analyst at Connecticut's Millstone nuclear power station who studies safety culture, likens it to the moral and ethical code that guides doctors: "An attitude that ensures the [nuclear] technology first does no harm." How do you measure an attitude, though?
The NRC historically has avoided much work in the area, to the great frustration of people like Apostolakis, the agency's top safety adviser.
"For the last 20 to 25 years," he said, "this agency has started research projects on organizational-managerial issues that were abruptly and rudely stopped because, if you do that, the argument goes, regulations follow. So we don't understand these issues because we never really studied them."
Instead, the agency has staked its confidence on the ability of its routine equipment inspections and program reviews to act as an indirect barometer of safety culture. If its inspectors find a backlog of maintenance work, the NRC's thinking goes, or repeated failures by engineers to get to the bottom of a stuck valve, that should trigger alarms about an appropriate safety attitude and prompt greater agency scrutiny.
Going any further to impose specific safety culture requirements, the nuclear industry has argued, would force a cookie-cutter approach on plants that are as different as the Southerners or Rust Belt natives who populate them, robbing managers of the flexibility to achieve safety in the way that works best for their employees. A government regulation might also undercut the notion that nuclear plants themselves have the primary responsibility for safety.
Troubling events at the Millstone plant in the 1990s raised questions about utilities' commitment to safety culture and the NRC's capacity to catch its decline. Amidst equipment failures, internal warnings of a "cultural problem" and several dozen claims that workers were penalized for bringing up safety issues, the three- reactor complex landed on the NRC's "watch list" of problem plants in 1996.
The plant's owner, Northeast Utilities, shut it down for repairs and other operations. After Time Magazine exposed Millstone's flaws, the agency ordered Northeast to prove it had a comprehensive plan to ensure that workers who aired safety concerns wouldn't face retaliation before it could restart the reactors. In essence, the NRC demanded that Millstone establish an aspect of safety culture, without saying how to do it.
"Fortunately, Millstone was able to get the right people in there and work with management, with all the consultants we had, to come up with some kind of definition of safety culture," said Paul Blanch, an engineer and former Northeast whistleblower who was brought back to help address the problems.
The two-year effort required replacing about 40 managers and developing programs to re-educate those who remained on how to handle safety complaints and employee concerns.
Workers and bosses had to learn to communicate and rebuild shattered trust.
"There were dramatic examples of people changing," but progress was halting and fragile, said MIT management professor John Carroll, who has studied the Millstone case. The lengthy shutdown cost Northeast more than $1 billion; in 1998 the utility decided for economic reasons that only two of Millstone's three reactors would return to service.
The Davis-Besse shock
NRCREP - Davis-Besse workers' repair job hardest yet doc Pag~e 4 NRCREP Davis-Besse workers' repair job hardest yet .doc Page4 The Millstone debacle was supposed to have heightened the nuclear industry's awareness of the safety culture issue.
The NRC also believed that its new approach to monitoring the nuclear fleet, launched in 2000, would be a more sensitive, less subjective indicator of how well reactors were operating. While the revamped Reactor Oversight Program still didn't directly rate plants' safety culture - or workers' ability to report safety concerns - the refocused inspections were supposed to be able to detect problems in those areas in plenty of time to avert a crisis.
Which is why Davis-Besse came as such a shock to regulators and the industry: Until the day the hole in the reactor lid was found in March, the plant got uniformly high marks from the NRC's inspections and, reportedly, the confidential ones done by the Institute for Nuclear Power Operations that deal even more directly with safety culture.
"It's a major failure of the system, in my view," Apostolakis said.
Even before the Davis-Besse event, the NRC was warming to the idea of requiring that all reactor operators put in place safety- conscious work environment programs to ensure employees' freedom to raise concerns. Senior agency officials have recommended such a rule, and the commissioners will take up the matter soon.
But a broader regulation mandating that plants have - and that the NRC verify - an adequate safety culture is much less likely any time soon. NRC rulemaking is typically a years-long process.
And the Nuclear Energy Institute, the industry's powerful lobbying arm, would oppose safety culture-related regulations because it believes that current rules are adequate, that new ones would be subjective and that Davis-Besse was a unique event, not a fleetwide problem.
"The NRC is excellent at regulating hardware. It's very difficult to regulate mindset," said Ellen Ginsberg," the industry group's deputy general counsel.
While that may be true, Meserve insists that the NRC is "not taking anything off the table" in its consideration of safety culture options.
"I can't tell you that we should change the way we do things," he said. "If we were to find tools" to measure a plant's culture objectively, 'I think a lot of concerns of regulation in that area would diminish."
Do they care?
One such tool may spring from the advice that a legendary football coach offers leaders. Lou Holtz suggests that whether a business succeeds depends on how the boss measures up to these employee questions: "Can I trust you? Do you care about me? Are you committed to excellence?"
Collins, the Millstone analyst, realized from his experiences during the plant's recovery that workers' feelings about managers are a strong meter of the organization's culture. With input from MIT's Carroll, he fashioned a survey based on those themes. He and others believe that it can pinpoint trouble spots where leadership - and by extension, safety culture - have slipped.
Collins, who already has done a test run of the survey at Millstone, suggests that the survey could be done at least yearly, with the NRC reviewing summary results. If employee confidence fell below a certain level, the agency and utility could discuss remedies, with a time period for improvement before the NRC stepped up enforcement. In short, a measuring tool.
NRCREP - Davis-Besse workers' repair job hardest yet .doc _ Page 5 Davis-Besse has undertaken its own employee surveys since the shutdown. Though not based on Collins' model, they are one of the indicators that the NRC panel overseeing the plant's rehabilitation will use to judge its readiness to resume operating. Most are based on how well workers and managers perform while under the NRC's magnifying glass.
"That's the only way the NRC can make a (safety culture) determination - looking at decisions and whether they're made conservatively," said Andrew Kadak, an MIT nuclear engineering professor and former nuclear CEO.
"I don't know how to measure safety culture," said the NRC panel's chair, Jack Grobe, who's been through several restarts of troubled plants. Nonetheless, he is confident there are reliable proxies. An important one is the reports that workers file alerting their bosses to equipment problems or conditions needing attention.
"That's the guy in the field, having an itch," Grobe said. "How he writes it down, how the company responds to that, how they identify corrective actions and follow through - that is one key indicator."
Davis-Besse's response to the discovery several months ago of evidence that the bottom of the reactor - in addition to the lid - might also be leaking is another telling sign, Grobe said.
Chemical tests of rust on the vessel's base couldn't rule out that it came from bottom leaks rather than from running down from the lid. Instead of waiting for the NRC to tell it what to do, FirstEnergy on its own proposed a much more extensive test.
To Grobe, that was a watershed of sorts, a hint that Davis- Besse's wilted safety culture might be reviving. "It's very clear to me that the people in the plant (now) feel very comfortable raising difficult issues, in a very direct way."
But the recovery, which has already cost FirstEnergy nearly $400 million, will be long and difficult, warns Millstone veteran Blanch. "We really objectively did not observe significant improvement for more than two years," he said. "And it was a monumental effort."
For complete Davis-Besse coverage, go to www.cleveland.com/ davisbessel To reach these Plain Dealer reporters:
jmangels@ plaind.com, 216-999-4842 jfunk@plaind.com, 216-999-4138
NRCREP - Ensuring Safe Cultures Draft 11-11-2004.ppt Page 1 I A, , - . In ____A HAS =w_5nT x . I_
., . , .N
- . ,., . . . T- ; I.; .. L
. l= . l ._ _ . ... _ .. ,
-he W B
- l _l
'-'- ',,0l ll l l
'.ff'- '; a.; I g !l 0
- l SX !1
.,.u S N l In n
- . . :-'" 1,.'. s l 1!
E - £ . , U . :-: S i. w l- ] 1 000 T<.d--
S11 11 Il
' d' '--' g l _
NRCREP-Ensuring Safe CulturesiDraft i-11-2004.ppt Page 2'I i NRCREP- Ensuring SafeCuitures Dr 1-11 00 0 t
- .- : .. .. , - ,.. :- 4,. =:--: . _- : . ._ . : ffit i-- .= --: . A
- fs.. . . : . ;: -:;
;'X'-f: E lE*'-
",,'.',:,'.,, l X,,.,. , I
',':'"'-''' l ! .',.., .', 1
- iX,,rS
- S R 0' 0 Be 0 ; f ' '-I ' i N l l , ,,- 0
- 'D---Q-E,' l E An S l :' 1
-,fff:',J, S
0 0! g 0-.
F Sl 't;S l
F E 2'qNlstgl$>d Al= l -
l- ' ' 9 f
Er X I I
,, AD.,. .,,X. A.,,; l g .. f- - 0 ':: t :
0: D X, w , ',1
- R l l l e f 0 i0; -i'-; E ; ! l i ! iLf : :;
1 NRCREP - Ensuring Safe Cultures Draft 11-11-2004.npt Paae 411 Izi r ,
. :r, , ':,
NRCREP - E Cultures Drf _1-Sae nurn __
=~__ _Eag2l oni
Paqe1 6-NRCREP- Ensuring Safe Cultures Draft 11-11-2004 ont
'^wt'^'*'^''-..g_.,.-.,... ',rr, ,,
111 - l
-., X,-- E z ZZ m__
_ -_ l liN _ _
. ,. ;. lim aw i
- -f-.0-.-, 6 B5 11 0
wae l0 ll *
',' ' . ':" .W l 0 _
--l . 1S1-- l l11t1 --- I i l S 111 l
-- F. i _ _
.. . L-.'. i l _ _ _ 1R11-ll f t.',; -"- B l l E 1! n i H 1
-- : .-.;. " Z0 Z ff 1_ Iwffi_ EE_ EH
',f-f '. . .,:'
l l, - . - . -
- l _
- I l
, . S , _
- . ,:; l l - 7 . . . 7
, .i ---.
- W , .- , :, C f : D
- - t; .-;. l l
- ---.---:f 0-e .- .
l E R l
!l l .......
.0;- -- -Xa
, t- X.-so
- ~i
, X
- Wt
Page 7 NRCREP-Ensuring Safe Cultures Draft 11-11-2004.ppt q :: .
MAN,0
- "7
~~~~~Y
NRCREP- Ensuring Safe Cultures Draft1 1-1 o4.ppL Pag_ I NRCREP - Ensurina Safe Cultures Draft 11-11-2004 Fa pp
....... t . . t A .. ................... .........- . Ad............ . . Page n
. . . . . . . . . . I
INRCREP-- Ensuring Safe Cultures Draft 11-11-2004.ppt AcPage 10 It
- P . .S, Pa. a_
3 l.,3
NRCREP - Ensuring Safe Cultures Draft1i -1i -2004.ppt--
INRCREP - Ensuring Safe Cultures Draft 11-11-2004.nDt 7; ;;mjl l . - ,
NRCREP - Ensuring Safe Cultures Draft 1-1 1-2004.ppt Page 1311 I
= I-
INRCREP - Ensuring Safe Cultures braift -1i-2oo4.pi Page14 1~~~ I Ia" o sa
-I_,
.I- -Z:
NRCREP - Ensuring Safe Cultures Draft 11 2004.pp1 -ge ,,
A. A. T; P: : -: - S . -
.,: . - -: ^
A;:: - .
fbNRCREP - Ensuring Safe CuturesDraft 1-11-2004.PPt - Page 16 NRCREP - Ensuring Safe Cultures Draft 11:1 i-2004.ppt 7-Pagwe 1 N:
I i NRCREP - Ensurina Safe Cultures Draft 11-11 -2004.nnt Pace 181 7j
'7 it
- r
Page 19 i t NRCREP - Ensuring Safe Cultures Draft 11-11 -2004.ppt .
. w<.w . .tz1ng_*b0t.z_.
=
- 0. ; 9 . -' . .'; - ' -
- - ' l. - '.. _t . :.
J - ;. '.0. ' -r :.t '.,'s-.t .- - -..-.._F . iX :._.
I l * - _ -, :v.
a ! 1E l ' 11 _l *
'-f:: - - .;.-.
i l l l-,"-,,
l 2 l ! l
- 5
- t'0-,;,'-,
0f ges - 5
-e.Q?-),;e a& t>
- -z g g 2z1 22 l-=-u
!11 _l l;l[>A3lil l l 11E i lIl il --l li_of;t l I ];lAili!ltoselE^X;lEo<sS : e _ ;-
S v V
= 0 p l 0 p 11 l
.; 31 0
' 0-l l e u
,. tt,,,,
0; 00D'_'S'.'; N 0 t0V
0 ;V4'1R l fi t; :
.Page 201 1 NRCREP - Ensuring Safe Cultures'Draft 11-1 1-2004.ppL
- NRCREP- E0surin Draft' i'-i^'2004.ppt Cultures gSafe P 21
NRCREP - Ensuring Safe Cultures Draft 11-11-2004.ppt - W _____ Page 22 ge 23 I iNRCREP - Ensuring Safe Cultures Draft 11 -1 1-2L04.ppIt -
.- .;..;-, :tf..-SEnE-=::.
- . ,:00....- :g-E
. NRCREP - Ensuring Safe Cultures Draft 11-11 -2004.ppt I-Pace 2-1 IiNRCREP Ensuring Safe1Cuitfres Draft1-11-0^ t P 3*** .s S I-
- 6 6
- . . : - - : I :
RCREP Ensn Safe Cultures D 1-i 1-2004.ppt_
1rt Page 2
,:~~m If. U '
NRCREP-Ensuring Safe Cultures Draft 1:-1 1-2004ppt _ _,
.Jw&., .And .. .rBy .5SAn,._.
._ =
U..'
-I
- I Eli's m:E 3 6 0-S 3.
NRCREP- Ensurng Safe Cultures Draft i1-11-2004 ppt Pe 9 2
- r "l
oty
lNRCREP - Ensurina Safe Cultures Draft 11-1 1-2004.Dnt Page 29
'4
'N 4y
.4W ,0
NRCREP - Ensuring Safe Cultures Draft 11-1 1-2004.ppt Page 30 P
A.
e i'
1
- NRCREP- Ensuring Safe Cultures Draft 11-11-2004.ppt Panei 31
'tV ','
- 4 aY
lINRCREP - Ensuring Safe Cultures Draft 11-11-2004.pnt Page 321
,IKRCREP- Ensuring Safe Cultures Draft 11-11-2004.ppt PaIe 3311
.6
- n *'
lNRCREP - Ensuring Safe Cultures Draft11-11-2004.ppt Pae34e 1
", ,'Y I- - - -- .2 -- - I - I - I - - - . .1 I - - I II - I - - .1 71 - I ,- - .11
- "- 1-1.I11 I - - - . - -- . ..- - . . - -- . - I--,- - - .I iNRCREP - Ensurina Safe Cultures Draft 11i1 -2004.prt Paae 35H 1
I i
NRCREP - Ensuring Safe Cultures Draft 11-11-2004.ppt . ; .
_. x.
Page 36 e :: . _._ : =k ' D / W. ' _ _. ' = t< t _.x'. _F. s_ .__ s _ _1 '.L.: ' J E: _._r._. _. . - W.s_ _ : , _ ' ti. .X£z . _ .--. a .r
. ___@_E_
1=
3_=
W._..,.._
t:.x E
.t:...G..
..t.
E l l l Z l l _ l l l l l , l . .
f: 0 :-- :- :: -- : X E g X u a = l I 1' I l l I - .0 i 0 .0
$ ;? -- B B i g g g ll l l i l _l--d 0
.'0,V,',-': E E l l l ] 111 ]i l l - l l l _-F 0 't' 0 0 ,. .,94 l l ,-, I' X,:
'd:0-- '-' Da"' ' D:s.':-4 4 l l : '-d ' ' ' -
, ,, Xf, ,,,,, 101 I l ---. S0-- E0 -
- - -" i ' dd -. ' " l g : ' . . ,
I l gE1E=--
t.-- - - -; li l SL _-a___ : N -
0, 0'40 0: -- ' l l -, .: . :
- t 0
.: ;--.- .0 - .i . i1_ I s ° 31 . 0 ,-: ,,
- f. 1111! 1111 l^1i1S000:nX tr. 0 .,. s 11 l lll_l 4- ;
NRCREP - Ensuring Safe Cultures Draft 11-11-2004-ppt Page37]
- - - z X : :: - - 4 - - .- :
5; f f - . . .. ; . ; -- v -
g - . f . . ; - L -
10 !11 _ _ _ I _ .-- , ,,;. -X 31 l _ i l _1 l 111 1 -t
. 11 E _ E li I 11E1 11 - - X - S
..;...-- ll l l l 1-1E 1R' f.E
'\:,'
--,, \\\0- ,-L;., i l l s z z 1E I s- --' * - S'
'cV-',,,=,,',' S l l l l _ 0' ry 1' IE l E_I
., . ' s l l i i .
. l l l
.0; L' f 1 l -. KEs; i I E , X-.; '-t
$'." 'di' S' : l I ';0300 :t;t
NRCREP - Ensuring Safe Cultures Drafil-11-2004ppt '-f e 1 0
a ii
NRCREP - Ensuring Safe Cultures'Draft 11-11-2004.ppt -Page 39 .
4
- %'t'
I4 NRREfP - Ensuring Safe Cu Draft 11-112
-P2o4.pp < - Page40
.I3 6 Wi SN
.45
NRCREP 20
- Ensuring Safe CuIfeiis Draft 1l 04.ppt -
x.:Z__Y. VYt,YY _
- -Y- -V- -,
- Page 41
.__.VYYB_Y.Ea2Y,.4. I_^,,Y l i ___5 X,\D - :
- f -- , li ig l f -:CE ,-f:: --- 0'; :,: iN ig l g l ll_ lil i iElD : . '-f:
n.0I11 I iS- !!lES3a-t: 0 0,f,'.V;
-- f i 11 1-1211
',X,,-. :, i l i^s ft.
llEil ':,t
l X X I
X,-,t -, l ll N- ,, a-,,X,, 1,
-t0 s ,,, l d 0' ','X ff
- .-::f-::.ff .-.-:
I X 2 i 11 V X
1_--.S I
,l
',"'; 0,; N l j ft 0 Ci-s: ffi l g l f ') V:f
NRCkEP 1- Ensurn I
Safe CuItures Draft 11 11-2004.pnt 'Paae42 fe.
. I 4-
,f: II
Cultures Draft ...11-11-2004.ppt - Pag NRCREP - Ensurings. Safe . .. ......... 4.,
A. . ._ ...........
............. >.. ............. p..
. -'> e o i-t q-i~ti" '
EnsuringjbNRCREP Safe Cultures
- 0 fi--2004.ppt Page 44j IMM=
NRCREP - Safe Cultures Draft 11-11-2004.ppt
_Ensuring age 4511 I
I
[1ikI .t11-ure"s`Dr04 1204Dt Paae 46 II I NRCREP - Ensurinci Safe Cultures Draft 11 2004.pnt Pace 4611 a=sJi -
t
NRCREP-Ensuring SafeCulturesDraftl-11-2004.ppt - Page 4p 7
i RNRCREPiErnsurin-a Safe Cultures Draft 11-11-2004.Dat Paae 4811
- ,/
IIPage 49 NRCREP- Ensuring Safe Cultures Draft 11-11-2004.ppt
NRCREP - Ensuring Safe Cultures Draft 11-11-2004.ppt - -. Page 50I 4 -
-'en t
NRCREP - Ensuring Safe Cultures Draft 11-11-2004.ppt- a 51 Page NI -
V A
NRCREP - Ensuring Ad. c._.., ..Safe -Cultures Draft 11-11-2004.ppt
..w.. ...............
.w~:
r.dok
.._*w_
a.
_].
_..i,-,-u.--
wnr wz Page 2jj
r.: _ _ 7 .: .. Z, _.-: ., X., .@. w. - ... n. i.: gR4:,__ ]^ H . i__ .,
_^ . ^ .... _ _ %,-__............ : r. _.,._ .,2_:t:_ M:. z. ............................
_ .: . ._t ,, , L_ ., . _. , ._,. _ . L_____ , , _ =: $, z ,, ..........................................................................................
X _,, . 5 _ ...........
NRCREP - Ensuring Safe Cultures Draft 11-11 -2004.ppt . : Page 53ffi. ,>
w
. =va.
s.
w
=,
it.
.,,,=E=.
.,,,1
! lI ' "' ' ;.'
ll _ 1 E i l _
__l l l l I l ' '-;
11:: .
':-'",: 01; j 00, ,..,- .,.,.,,
-. . - - -- !E il ! !I!!_
- ,,,,, ,,.,q, l Ii I l S- g_I - Sl l l10-.-! . ! 0..-
- .
E_ IlltA5!111 It:lEl@t:IllE: [:J@E1[;1__ !8 il i !
- , : \ I -f:
- - --- S i1 g :- - 1
- :- ---. - B1 l l l ED _ S l ! ! : -: 1 f;S ' ," ,; f l l l l ' , "--' " 00 ff--0\L6E 111 1X l fl0
- - ' ' : . -'.0:: '.. l l l oSiS-A; " - l l 1: : :'- ::; - ' ' 'DX
,t$,, l L 0 ff i l li-t;;l l l ] l l St S - D :
t t--'; ' l il l il:'-00 '-'0 i0' ' 0 0 0 ' 's:,i'7; ILM l i
NRCREP - Ensuring Safe Cultures Draft 11-11-2004.rrDt ' ' 541 Pacie-- Z-mm
1111204ppt.._
INRCREP - Ensuring Safe Cultures Draftll _-Pg PEFO 1-IeN i- . HIl M .-
NRCREP - Ensurina Safe Cultures Draft 1i 2004.Dpt Paae 5611 NRCREP: Ensuring Safe Cultures Draft 11-11-2004.ppt Page 57 NRCREP - Ensuring Safe Cultures Draft 11-11-2004.ppt Page 581 7 a..t
...... t=r.............................-
.............. _ .,=.,=,,_...
.-..... ."=..,.
. ................ vA,===... A _X 9 .ev. _:.
_Wii _ ii" In } _ - S AD 1 E
^Ha s _ Il El S l R l - li lli[l a q 11 A N ffi 5z . WE l l 1 - b l l i i idol S.m*Xa ffi . X 1 a S
NRCREP - Ensurina Safe Cultures Draft 11 2004.P~rt Pane 59I NRCREP Ensurina Safe Cultures Draft 11-11-2004.ont Pane 59K V
INFhhEP --Ensuring Safe Cultures Draft i11-1--200 .p bid"' bP I
-4,
NRCREP:,Ensurirng SafeC'ultures Draift11-11 -2004.ppt P ii-ag'I NRCREP - Ensuring Safe Cultures Draft ll-11-2004.ppIt -Pag6
- ' ;;'- \
- - v-I 1
=-2!m';ZMl.-=.'7' KIP(lPFP - Fneiirinn Rnfp Ci iltuirpfnrnft 11-1-2004 nnt Page b63
- Saf C NRCREP Esrn -rf 1-2004.-pt I1- page64Uj l , _ l i i I iBm 1.11 TfI "1 -
4'
NRCREP- Ensuring Safe Cultures Draft11-11-2004.ppt APageGSI 1i__
!3tI 91m Im Rols3 1!E!]
.E~~~~II 7,, '7 it'7.
INRCREP - Ensurina Safe Cultures Draft 11-11-2004.ppt Pace 6611 I I- -l
Draft 11-11-2004.ppt Page 67Fl NRCREP - Ensuring Safe Cultures
- '., ;;S
_ __l1i i I_l l i -: e00--0-:--- :-
.- ',, ., -1 '.E'.. .f= ;' '.
' ' -,z'tS
- --,0 1!l ll 1-_
9 _ __-l l _-
. .: E 11 S
- 0 ---:-- 0-- SI i l ! S i l ^ _E X
X,
...I 1l1 1t St
- 03. .. - i W Z W iS XllaG l W WR R W E -- -
ff- :
0f ,' V; it rL l l l l . t ' {0 ' ' '
.0, f3 .-. ., S i l =S E l . t-.--.- 0 4 000 l -- f.) ., .; S
@@tE -
i f1N1"lk,1eStI 00d--\
- .
- '-':: t-:.
X-l l i-NEEl0 f f f l l .. 0...- t.-f
-;-.0 t ;
.............. ...... -. f S _l M 3 .........................................................................
- 0gi X;:
NRCREP - Ensuring Safe Cultures Draft 11-11-2004.ppt I 7 2 Page 68 1
- . .eI -
'v'
- *-t' '"
NRCREP -Ensuring Safe Cultures Draft 1 -1i-2004.ppt_- Pge 69
- fl't
,- _--- - - I - . __ _ - - ._1. I - I - - - - - - I __ - - - - --- I-- 1. -- - - - - -I r i, __ I 11. .__ - - I -. - I - - .- -1.- I 1. -1 I I - __
IN RCREP -Ensuring Safe Cultures Draft1i1-11-2004.ppt _ace Pae7b70 ii NRCREP - Ensuring Safe Cultures Draft 11-11-2004.ppt
',,--*x '
NRCREP:- Ensuring Safe Cultures Draft 11-11:2004.ppt - - --- -Page 71
, . . , -. Q 0..... - . -; a-S
. o .- Qs -; .z.7.f.g.
--d:--
-o.-
~~~~~~~~. E2nrl1 1
- b3 i l 1-i 1____4,.
Pae71
-- - Lnulgst NHUKLP . -- Uutue L -at 1-11.-20-4-p-Ensuring bate C~ultures Draft 1 1-1 1-2U04.PPt ~Paae'i29 NHRCREP a.
NRCREP- Ensuring Safe Cuirures Draft 11-11-2004.ppt Page 731
- A' t'
.s:.-i
NRCREP - Ensuring Safe Cultures Draft 11-11-2004.ppt - - Page 74
.(d.. %.
t -t :.-.--. .
i NRCREP - :Ensuring Safe Cultures Draft 11-11-2004.ppt --- Pae 75
- g m gEM P
.Th
NROREP- Ensuring Safe Cultures Draft 11-11 -2004.ppt Page 76 i.'
NRCREP - Ensuring Safe Cultures Daft 11-11-2004.ppt Page 77
.NRCREP- Ensuring Safe Cultures Draft -i:11.2004.ppt- . - -Page 78
. r-j I I I iej e.S~~~~f P~IlE :
FNRCREPR-Ensuring Safe Cultures Draft 11-11-2004.ppt Page 7 I..
'its-
80i NRCREP - Ensuring Safe Cultures Draft 11-11-2004.ppt .
- s ,_ ,, .,
" -zD ' .- :"
turing S. C sD age 81 K:
fl
iN RCREP - Ensurinci Safe Cultures Draftl1li-11 -2004.ppt I NRCREP - EnsurinQ Safe Cultures Draft 11-11 -2004.ppt
- Paae 82 i Paae 82l 31
-1,I, rt-4,
iNRCREP- EnsunqSafeCulturesDraft 11-11-2004.ppt2 ;age dl p.-
4 v,
'lv
nsuring Sa~fe Cultures Draft 11-1 1 -2004.ppt--
fRCEP- !Page 84
-i
.. e ~~~~ .. ,' .j<Si N, EUTRA .L '0M -OR ;* t
- =lIg!~--,~ FO US____*__
00 1l1 19 5 ; 13i ~~NEEDEaRin1l1l 1 ;
- jz ! -s_ _ 1E- 1 llll1
' NRCREP -Ensuring Safe Cultures Draft 1 2004 t Pe 85 S I. I
__ I
q rCRP_:.Ensuring Safe Culturs Draft 11-1 . .204p
. G._4 ... Page A
-T
- -. . :7 N, MM iW_
- e. el 'JI M 4b. F. - exce l -1 50:- '
- 50 - 0 - .lggii EI,--
IRR Ensuring K- Safe Cultures Draft 11-11-2004.ppt Pag
'NRCREP nsuring-afe-ul-uresDraft 11- 1-2004.pp p- Pa-e 8 NR CREP -Ensuring Safe Cultures Draft i1-1i-2004.ppt _Page 8 I_
I3
INRCREP -Ensuring Safe Cultures Draft 11-11-2004.ppt
!'-t~CLk~o--Esuf I 0 - .-- -_~
- Page 90 44 4
- v 4 -
NRCREP- Ensu.ring Sf Cultures Draft i.i-i __ppt . - _ Page A t .'
4
) _ .' t_,_ . w_::X ......................... _ Mot...... .. 7'_ ': :K^............ C't*.' .s._;-'_!:.__'V '.' '. g:Jw .' ': w.g._& & .................................................................................................. u s m ................. __./5_ [.S .......... #54X.&.g,_.>,_w_;,_._,s,,%,,_.^
ts ,5, j _ _
t NRCREP - Ensuring Safe Cultures Draft 11-11-2004.ppt - . : Page 92
, ' ' ' ' f ' ., , ? ' , . ';; - ';
- 0ll le NN l- l_ 3
':; U l l _ 0', .
l l ll -0 a-X X0 w0S 0 i b x l l l l l R l l - I I l l 1 l -" - 0n f >
X i X fit t - - - 'ts. ' I!-i iS 1:1!1U SE l _E1 lii __ _ __ _ i ____ 1N _ lld _ K tU0-X-f?o0- i ll l ll l _ _ l_ l f:;-'-'.S .- :.:--;.. l l l I I
- l l l ;'.==...--; f- -..
- - f--. .,,<,, l l l l l l l
- l - f .
L'. \e'- l IIl l ll 1 _l l l lR f;-
00S :SSv 'II111 l IEl i Il S - i :0d 4l ll lE llll
... ... S l l l S . C; .
ll -$f;; --0 i.
-i00 f0;0,-.E ll I 1l l E X'-00 f
- ,k,..e; ll IDllI ll aD f
P-
-E Da
- - -Cr 11-11 -2004pptPage 9 1;NRCREP - Ensurinqg fieju tres Drft1-1 RL T_ _PLL9
-- , - r- , , -, -- , r-,,
-. z I I,
-. I -,. - -; , - 1, l
.NRC ( P suring§Safe Cultures Drafti1-11-2004.PPt - Pg I - !_ ' _ _ _
w-, : -, a -
'. .1 1
.4:.- 1
. ! 1, "; ,;".
d, . .
NRCREP - Ensuring Safe Cultures Draft 11-11-2004.pp ly . . Page 9
NRCREP - Ensuring Safe Cultures Draft 11-1i1-2004.ppt Page 96 iiA_ ill SHE1 B~~~~~ I__ Xs *i
- t I
NRCREP -Ensuring Safe Cultures Draft 1i-1i-2004.ppt : - Page 97
- C
'3/4,
.NRCREP- Ensuring Safe Cuitures Draft 11 i 2004 p_i . Page 98 r_11 alum i fl l 9st][Qig^s1 8 g l_ l E ER_S .R 1-le _ > l e-l s 3l ll l l l
_ _ 3 . " ! i! §.§ Its ii S E _l (QiilU'.'JllE5 ! !
r NRCREP -Ensuring Safe Cultures Draft 1i-11-2004.ppt L -- ^ ^ I Page 99 NRCREP - Ensuring Safe Cultures Draft 11-11-2004.ppt --- -- . . Page 100 ltNCEP - En~suring Safe Cultures Draft 11-1-20.p ._Page 101
_f ~~
~
'- 'ere'nS~~ ' ;-' t , , i ES ' ;
g l- udd rt ff
.I -- -.-- -, -. 1- -- -q- . :,- I - .7-3 IM .FlPPP
. .=
- Pnqiirinn Rfp C'liiltiirps frnft 11-11-2004-nDt
--.- - - - - --- "I--
Paae I 0z .1 t -
NRCREP - Ensurinq Safe Cultures Draft 11-11-2004.ppt Page 1031 f : , : A: -J ,
, ; ,;S-, C, * -
tYEs -- S .,. i ad,: ,;
'_.',ssf" A, ."
- < . r ,. .
't-.,h ... o. i-. * >e
- 1 :WS
NRCREP - Ensuring Safe Cultures Draft 11-11-2004.ppt ; Page 104 I
~~ _
.................. nuigSfeClue rf511 204pt n in
_NCE SafexC-uiwtuire'ibf 11-1-00 . -..
. . . . _9M . . ...... Pg 0 1 a.............................
.eta ~ e~ei"n,
hNRCREP - Ensuring Safe Cultures Draft 11-11 -2004.ppt . -- - Page 106 "
" .f;3s31 S E _ ..
R .: f ilSIEl _R __a m __1 l l: l! _E i1_ ;f.- i.
- - i i l _ ___ !- _i_ l _ __ .-
- - -'v-: -- "'- l l l I IR l . l
- at.0.:
, .,,-:: l l _ R a
-. S- iD; ;- R l l i -
l l l l-_11 l 0
- 0'_'V's-S-r S' l _l l l l il l " l -0- - '
0 .- .- . l aiil_ l l l l :i- -- ;-:
- . -.ft . -X., ... -_ - l ,11S1 E i i 'rf . --f.
-+: l l >ma aslir-,-,ara lil a l-_
- - -- ff.0 - . l l _ g l l --
- . -;-.-, -: .
- , .
- 1-d. l _ 1 E w _. .,;;.
,,,.E
- f ffS , I l t-=l W liEll=0-;'S,-
t'.'V5.:f-S' .'-L w
---. 0 Eg,lll SE:l_S liER:B= =__ .S> _ E_ ' n,, 0 0 N f-.
- i 1!1 ul S1RtSX
NRCREP - Ensuring Safe Cultures Draft 11-11-2004.ppt . - ,. r,,,,,Page 107,"
- - z S r E- - > w f - +] -- ;
- : . r , . . . _; . : _ f = < , , , i ' :: :
l I l
3 i lI U l _l -l _
- F i l E E C E l
... m l i S , l _, _ _ l , --.
- 0. d.t ; F , , l l ! ....... I . l . l
- - - -; 1f! I N S ...... i l l
.- t - - < i:.- >! E E I l fi 2 _
- _ g _ _ __ ff
.0 . --= m i l g i _ ___ _ _ _ __ i . . -,.
- ; -: , ' '<: ';M l l l l _ l E _ 11 ' - :: ;,
, 1 ll l _ -E _ l!l_ 11 -:
000 dS-- 111 f 11l1 Fii 11 lFlli l 11 t0 .-
11E--;,--- .
0 V
-f,-.,h,/2111 liSI l al
.; t.-. l t l ____ ;
. ! 111 l iBll
- .::,.-.,:-.-Y-> il 111 1__
z
- taV$0Xf 111 111 Ii !!!q ff)0 0 W0ffaf N !g1n-00
- :
- I- I 1 II II . I - . I .- . -- - - ,- .- -- ,- . - - - =. - - . -R-, -- , - - -. 11 klNRCREP - Ensuring
.x.
Safe Cultures Draft w._-.
11-11-2004.ppt - AdSA, A=Page S08
NRCREP I1n -.......................
Ensuring C............Etxz.
................. Safe
.=H.......... §.. .... Cultures Draft f..........................-...
.................... 1i-1 -2004.ppt Page 109 11-. I t
'NRCREP Im- - -, --I__ - - - Ensuring Safe Cultures Draft 11-11-2004.DDt Paae 11011
- ,- i :-, t, ,