ML050840498

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Industrial Safety Issues and Poor Work Practices During Nozzle Dam Installation
ML050840498
Person / Time
Site: Point Beach  NextEra Energy icon.png
Issue date: 04/09/2004
From:
Nuclear Management Co
To:
Office of Nuclear Reactor Regulation
References
FOIA/PA-2004-0282 RCE 253
Download: ML050840498 (44)
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0 NMCuStasis Comanined ro tudear Excellence Poilt Beach Nuclear Plant Industrial Safety Issues and Poor Work Practices During Nozzle Dam Installation RCE 253 CAPS5527 Event Date: 04/09/04 Principle Investigators:

Team Leader Team Member Immediate Actions Immediate Actions Immediate Actions Immediate Actions Immediate Actions Immediate Actions Immediate Actions Kristin Zastrow, Kewaunee John Peterson, Monticello Paul Harden, Palisades Kari DenHerder, Prairie Island Joe Hager, Palisades Don Schuelke, Prairie Island Dan Craft, Hudson Aldo Capristo, Hudson Tom Taylor, Prairie Island Approvals:

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Industrial Safety Issues & Poor Work Practices During Nozzle Dam Installation - RCE253 Table of Contents I.

Executive Summary....................................

3-4 1I.

Event Narrative.....................................

5-7 III.

Extent of Condition Assessment....................................

7-8 IV.

Nuclear Safety Significance...........................

.......... 8 V.

Reports to External Agencies & the NMC Sites...................... 9 VI.

Data Analysis.

Information & Fact Sources....................

................. 9-10 Evaluation Methodology & Analysis Techniques...........

.... 10-11 Data Analysis Summary..............

...................... 11-12 Failure Mode Summary....................................

12-14 VII.

Root Causes and Contributing Factors :....................................

15-17 VIII.

Corrective Actions....................................

17-21 IX.

References.......................................................................................22-23 X.

Attachments....................................

24-42 2

Executive Summary

Purpose:

This Root Cause Evaluation will determine the at-risk behaviors that did not meet Point Beach and Nuclear Management Company Expectations, and identify where personnel performed tasks outside of procedures and training to accomplish completion of work related to steam generator nozzle dam installation during the U1R28 Refueling Outage. This Evaluation will additionally identify the underlying causes of those behaviors and actions and recommend actions to correct those causes.

Event Synopsis:

On Friday, April 09, 2004, the Point Beach Nuclear Plant experienced four (4) separate incidents of personnel breathing air issues during steam generator nozzle dam installation evolutions. Two (2) incidents involved air line disconnections at the Snap-tite connection to the "bubble hood",

one (1) worker experienced low air pressure for unknown reasons, and one (1) air supply line was damaged during access to the manway. No personnel injuries occurred, however the incidents did lead to personnel contamination issues.

==

Conclusions:==

Through personnel interviews conducted by an immediate action team and the root cause evaluation team, various Task and Barrier Analyses, Event & Causal Factor Charting, Failure Analysis and Conclusions, Operating Experience review, Training records and Procedure reviews, facts detailed more than 20 inappropriate actions during Point Beach U1R28 Steam Generator Nozzlc Dam Installation. Error-likely situations were not identified through adequate training, walkthroughs, and briefings, while procedures and proper communications were not used or did not provide the information for the team to be successful. In addition, Supervision throughout the event allowed development and approval of an inadequate work plan, and did not provide the necessary leadership to avoid tunnel vision and prevent incident.

Nuclear Safety Significance:

The nuclear safety significance of this event (provided by Plant Licensing) is minimal because Unit 1 was in the refueling shutdown condition (Mode 6) and the steam generators were open to atmosphere. However, the radiological significance of the event was elevated from an ALARA perspective due to three entries into Steam Generator B being required.

Additionally, the industrial safety aspects of this event were more than minor due to the confined space of the task and the necessity to utilize a supplied air breathing system.

Root Cause & Significant Contributing Factors:

  • Root Cause: Oversight by Supervisors/Managers during work planning development and task execution didn't assure compliance with procedures and processes, resulting in an inadequate work plan being developed and approved for use.
  • Significant Contributing Factor #1: Work Order Processing per NP 10.2.4 and Outage Management Planning per NP 10.2.1 does not include logic ties (IF this, THEN that) to drive use of appropriate procedures during work plan development.
  • Significant Contributing Factor #2:

Program Engineering personnel and Radiation Protection personnel did not use and/or follow Work Order Processing, Risk Assessment, Briefing, or Radiation Protection procedures in preparing for and during execution of the steam generator nozzle dam project.

3

  • Significant Contributing Factor #3: Training for steam generator nozzle dam installation was not adequate to identify the error-likely situations that existed upon the start of work.
  • Significant Contributing Factor #4: Communications to the OCC of safety significant events was not delivered and Nuclear Oversight identification of an inadequate briefing was not delivered in a timely or effective manner.
  • Significant Contributing Factor #5: Previous External Operating Experience on failures of quick-disconnect fittings was not adequately used to correct the similar failure mechanisms that existed on the equipment utilized at Point Beach.

Corrective Action Synopsis:

Interim: 1) Plant Stand-down or "Time Out" conducted on 04/09/04 (Excellence through Error Prevention). 2) Nozzle dam Lessons Learned meeting conducted the week of 04/26/04, prior to nozzle dam removal. 3) Following the incident, Radiation Protection brought in an independent team of NMC personnel to review procedures and processes for use of supplied air as breathing air and used their input to: update procedures, change out and replace nitrogen bottle back-up with certified Grade D breathing air, replace all bubble hoods, airlines and Snap-tite fittings to new CEJN type fittings. 4) Radiation Protection developed a Just in Time information sharing package which was used prior to restart of work with bubble hoods. 5) Mock-up training for nozzle dam removal included a review of procedure requirements, bubble hood issuance requirements, and manifold pressure requirements.

Corrective Actions to Restore (broke-fix):

1, 2, & 7) Perform a documented brief for Programs Engineering, Radiation Protection and Nuclear Oversight (separately) on the safety anomalies and poor work practices associated with this event - inappropriate actions taken on the part of their group, and their responsibility for assuring that their actions are corrected.

3)

Complete Lesson Plan HPC-04-LP203, Nozzle Dam Just-in-time Training, and implement Supervisory oversight corrective actions established by nozzle dam removal project plan. 4)

Develop Communications Protocol and include in work plan for nozzle dam removal.

5)

Prepare Expectations and Brief personnel on the adequate use and action to be taken for External Operating Experience that is assessed by Radiation Protection personnel.

6) Programs Engineering CRC perform a Task Analysis to determine personnel knowledge and training required to successfully lead and plan major projects.

Corrective Actions to Prevent Recurrence: 1) Develop a nozzle darn removal work plan in accordance with NP 10.2.1, Outage Management and NP 10.2.6, Work Order Processing, which also includes Supervisory independent approval.

2) Develop procedures for nozzle dam installation and removal that incorporates lessons learned from this event, supervisory and management requirements and stop work criteria, communications protocol, and external Operating Experience. 3) Develop, within NP 10.2.1, Outage Management, and NP 10.2.6, Work Order Processing, a process to determine when HIT teams or Project Managers should be assigned and include logic ties to drive use of appropriate procedures during work plan development.

Other Corrective Actions: 1) Create an "It Can Happen Here" article for distribution to plant personnel. 2) Develop Industry OE on the event 3) Perform INPO Nuclear Safety Culture Assessment to identify gaps and formulate corrective actions. 4) Develop and issue site-wide communication on the purpose of NP 1.1.7, Managing Work Activity Risk, and when to utilize it. 5) Work Week Coordinator review all existing High Risk work orders scheduled within the next five weeks for compliance with NP 1.1.7 and implement a review of High Risk work orders for compliance with NP 1.1.7 at the appropriate E-meeting. 6) OTH #6 - Take completed CRC Task Analysis results from CA #6 to the TOC to identify impacts on other work groups.

Effectiveness Reviews: 1-3) Complete separate Effectiveness Reviews for each CATPR.

4

Event Narrative On Friday, April 09, 2004, with the Point Beach Nuclear Plant Unit I in Refueling Outage UIR28, steam generator nozzle dam installation was to take place per Work Order 0400042, Safety Related Document # 83A7564 (PBNP Approval date of 03/07/04, however a work order plan per NP 10.2.4, Work Order Processing, and the associatedprocedures andforms, was not completed).29,4249 On 04/08/04, this work was identified as a Critical Path/Near Critical Path Activity due to be completed within the next 24 hours2.777778e-4 days <br />0.00667 hours <br />3.968254e-5 weeks <br />9.132e-6 months <br />, with indication on the Outage Status Report that the schedule was 9 hours1.041667e-4 days <br />0.0025 hours <br />1.488095e-5 weeks <br />3.4245e-6 months <br /> behind.4 ' Work to install the nozzle dams in the generators, began in the early morning hours of the Friday (04/09) of Easter weekend.

(This work commenced at 0417, with approximately eleven hours already into the 12-hour shifi for the work group.)'5 A briefing was held prior to the start of work and resulted in comments on the 04/08/04 Nights, Nuclear Oversight Rapid Trending Assessment Daily Report. This report documented that the "IPTE brief for nozzle dam installation was evaluated as less than adequate due to poor communications, failure to document brief on an approved form, and lack of interaction of personnel at the brief."2' (An IPTE (Infrequently Performed Tests & Evolution) briefing was documented per a "Documentation of Information Sharing Worksheet" (QF-1060-02 Rev. 1 (FP-T-SAT-60) and was signed & dated by participants on 04/09/04, with Preparer and Approval signatures dated 04/1 0/04.29 Nuclear Oversight indicated that this was not the correctform for the evolution.)

Upon start of work, Scientech personnel tasked with performance of the nozzle dam installation, dressed in the Radiation Protection area of the 8' elevation of Containment. Dress requirements per the approved Radiation Work Permit, required the use of "bubble hoods", (which utilizes a constant air flow system from a service air manifold), where an airline would be connected to the suit or "bubble hood" for the necessary breathing air required by the worker.

(Scientech personnel had expressed concerns with the clothing requirements (cloth hood required under the plastic "bubble hood"), stay time requirements being too conservative, or not long enough to complete the work.)27 Issuance of this "bubble hood" fell under HPIP 4.58, "Issuance of Respiratory Equipment"3, and Radiation Protection had a qualification task associated with it.3 5'38 However, the procedure and documentation of issuance was not performed as required.

Personnel were dressed as necessary, (without use of guidance provided within HPIP 4.58) with their hood air line connection connected to an air line regulated on the 8' elevation. (Scientech workers expressed concerns with low air pressure at the 8' level airline connection. Radiation Protection personnel discussed the low air pressure issue at the 8' level with the Scientech workers, and expressed the opinions that there would be more airflow at the platform level. 27 No formal investigation into the air pressure concerns was performed.).

Workers then proceeded to the Steam Generator platforms where nozzle dam installation would commence. At the Steam Generator platforms, workers would disconnect their airline supplied by the 8' level regulator, and reconnect to an airline supplied by a regulator on the platform. First, workers would connect to a 100' hose at the bottom of the platform, climb up, then disconnect and allow the line to lower back to the bottom. After disconnection of the 100' airline, they (with the assistance of the RP Technician stationed on the platform) would then connect to a 50' airline that would be used for work while in the generator. 33 The first Scientech worker arrived at UI Steam Generator B platform to perform cold leg nozzle dam installation. He expressed to the RP Technician that he had an air pressure concern, made a request to be wet down with a liquid previously staged on the platform (staging of this liquid was not performed by the RP Technician assigned to the platform at the time, and he was not aware of its purpose or previous delivery to the area. Who staged the liquid, location of the liquid after 5

the event, etc., could not be found.)2 6, was wet down by the RP Technician as requested, and proceeded to enter the steam generator to install the nozzle dam. During the worker's stay time (1:48)15, communications noted his dissatisfaction with the progress of his work (cursing, etc.),

along with a concern that he had low air pressure12 The worker left the steam generator bowl based on his assessment of low air pressure, and was cut out of his bubble hood. This resulted in a personnel contamination event, and was documented per PBF-4039a.30 (Communication between the RP Technician on the platform, as well as RP on the lower level, and individuals in the communications trailer were available throughout the workers stay time.12 ) When the worker exited the bowl, his bubble suit was stated to be inflated with minor fogging of the hood'2' 26' 27, while the worker stated that he was deflated and "sucking plastic"27. The Snap-tite connection from the bubble hood air hose to the regulator air hose, was found to be connected, with no obvious failure identified. The RP Manager contacted the OCC (Outage Control Center regarding the possible loss of breathing air (which was reported as a loss of breathing air)Ib.

This issue was logged by Operations approximately 16 minutes after the worker left the area.'6 The RP Technician and the RP Supervisor discussed the air pressure issue and supervision approved an increase in the air manifold pressure to support the needs of the workers.15.26 (Whether known at the time or not, the increase in air pressure violated HPIP 4.58, Step 4.5.7 which states, "Adjust air supply pressure so that air flow is between 6 and 15 cubic feet per minute. For an air line length of 50 feet, a pressure range of 20 to 28psig corresponds to a flow rate range of 6 to 15 cfm. " As stated earlier, this procedure (Issuance ofRespirator Equipment) was not performed when issuing the "bubble hoods" to workers, and therefore was violated prior to start of work on nozzle dam installation, and again upon increasing the pressure beyond procedural requirements. Again, no formal investigation was performed to confirm or dispute the concerns of low air pressure.) Upon worker leaving the area, a Personnel Contamination Event Report was filed due to the contamination received during cutout, however nasal smears were not performed as directed by PBF-4039a, and was not captured until a supervisory review one (1) day after the incident.3 0 (This was captured by the supervisor on CAP55565, and it was noted that this was not the only case where smears were not performed.)

Ten (10) minutes after the first Scientech worker lost air, the second Scientech jumper attempted to access the steam generator cold leg and failed to gain access upon two attempts.1 2 '2 6 (Details: The worker had difficulty entering due to his size, and requested the RP Technician to wet him down. This request was acknowledged, and he was wet down, as well as provided with assistance to access the manway (RP Technician and other jumper that was stationed on the platfornn)2'2 6 '2 7 ) The jumper gained access on his third attempt, however, with a total logged jump time of 1:18 seconds, the jumper exited due to loss of air.15 26'27 (The worker details that he remained in the bowl after he realized he had lost air. He believed he had 2 or 3 good breaths, and continued working.27). It was determined that the worker's quick disconnect fitting from the hose on his hood had become disconnected at the Snap-tite fitting, causing the loss of air. Like the first jumper, the worker was cut out of the bubble suit to allow breathing, which resulted in a personnel contamination event that was documented per PBF-4039a, again, however, nasal smears were not performed as directed, and it was not identified until the supervisory review one (1) day after the event. 30 Health Physics and an unnamed NMC Project Leader discussed allowance of the next jumper to complete the cold leg nozzle dam installation, and after air pressure was verified good and the airline connection challenged (five minutes from discussion to the time the worker entered cold leg'), the Scientech worker (with a total jump time of 1:14) completed the installation.

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Two (2) other airline anomalies were unofficially communicated after installation of the nozzle dams was completed, though this was not documented in the Containment or Operations Logs.

One (1) additional air line disconnection occurred during nozzle dam installation on Steam Generator A, when a worker became disconnected and was quickly reconnected, while the other issue was described as an airline being damaged (due to the staging of equipment on the platform that caught the hose and cut 12.96.17,222736 and then taped by Radiation Protection personnel to allow for continued work.

Questions were then raised by site Nuclear Regulatory Commission staff, regarding the breathing air problems and a request for a formal investigation was made, leading to the following root cause evaluation.

Extent of Condition Assessment An Extent of Condition evaluation was conducted to determine how far the problem extended, what else the problem may affect and other programs, processes and equipment that may be vulnerable to the same condition. This was also performed to determine how wide spread the condition or its causes may be.

The condition assessment was limited to air line concerns and air line connection failures or concerns during the use of bubble hoods. The issuance of bubble hoods (according to HPIP 4.58), is for Radiological Use Only, and therefore only applies to tasks involving Radiation Protection's concerns for personnel radiological safety. Issuance of the bubble hoods and airline connection checks are part of Radiation Protection's Training Qualifications, and therefore is limited to Radiation Protection.

Department Management has taken corrective actions to replace all bubble hoods, hoses and Snap-tite fittings to new CEJN type fittings. In addition, the Department created a Just in Time information sharing package to be used during a pre-job briefing for this task. This information included a review of procedure requirements, bubble hood issuance requirements, and manifold pressure requirements.

Similar equipment was also considered for this extent of condition. All supplied air for breathing is from the service air system. The Operations Department has an emergency breathing air system for the control room, which is also used to fill SCBA bottles. This system has a compressor but also has X-connect valves with Service Air. No other systems were identified by the Radiation Protection Department.

System interrelations were considered for this assessment as well, and a possible relationship existed when a nitrogen bottle back-up to the air supply line was identified. This issue is being evaluated under CAP 55751, therefore no further action for this system interrelationship is required under this assessment.

This evaluation was a result of an Action Request that was screened as a Significance Level A issue, which is considered to be a Significant Condition Adverse to Quality (SCAQ). The cause of the event, and the organization effectiveness issues surrounding that, supports the initial assessment of a possible SCAQ. Due to the possibilities of an SCAQ in the organizational areas, Management has committed to performance of INPO Nuclear Safety Culture Assessment to bound the identified conditions. This action is being performed under CA57320.

Previous Operating Experience was identified throughout the INPO database "10, as well as external OE that was responded to internally by Point Beach staff'3 relating to air hose disconnections of the type used at Point Beach, as well as problems associated with nozzle dam installationlremoval.

Further information on Operating Experience can be found under 7

Attachment D, OE Analysis.

This OE was now utilized to effectively replace Point Beach bubble hoods, hoses and CEJN type fittings.

Extent of Cause For the extent of "Cause", any organization or process that performs high-risk activities where personnel safety awareness is required, may be affected and therefore must be addressed for this assessment. Plant Management and the Sponsor for this evaluation has committed to performing INPO Nuclear Safety Culture Assessment to determine the present condition for this extent of cause. This action is being performed under CA57320.

Previous Similar Events The TeamTrack database for the Corrective Action Program was queried and Plant Assessment personnel performed interviews of Radiation Protection personnel to determine previous similar events associated with this Root Cause Evaluation.

Statements gathered from individuals involved with the events, identified that air line disconnections may have occurred in a previous outage27, however, no formal documentation through the CAP process nor separate interviews found confirming information. No corrective actions were generated previously, therefore effectiveness of previous actions cannot be assessed.

Previous issues with HPIP 4.58 as well as requests for JITT topics and Task Analysis for specific Radiation Protection tasks related to this event had been captured in Curriculum Review Committee minutes and CAPs prior to this event

. These identified the need for specific training and development of training for tasks associated with this event. However, the activities were post-poned or cancelled by Management sighting lack of support and time constraints.44 The OE Analysis reveals that Radiation Protection personnel closed CAP actions without implementing changes to breathing air system connections/fittings, and were satisfied with the practices in place at the time of OE review. Prior replacement of the Snap-tite fitting could have prevented two of the failures associated with this event. This finding was addressed by the Corrective Actions taken by Radiation Protection for, replacement of the Snap-tite connections/fittings that were previously used for breathing air at Point Beach (Attachment I). In addition, Corrective Action to Restore CA#5, will prepare/develop department expectations and perform a briefing for Radiation Protection personnel regarding adequate use of Operating Experience in the Radiation Protection department.

Nuclear Safetv Significance The nuclear safety significance of this event (provided by Plant Licensing) is minimal because Unit I was in the refueling shutdown condition (Mode 6) and the steam generators were open to atmosphere. However, the radiological significance of the event was elevated from an ALARA perspective due to three entries into Steam Generator B being required.

Additionally, the industrial safety aspects of this event were more than minor due to the confined space of the task and the necessity to utilize a supplied air breathing system.

8

Reports to External Agencies Supplied by Plant Licensing: This event is not reportable to the NRC in accordance with 10 CFR 20, 10 CFR 50.72 or 10 CFR 50.73. The NRC has indicated that they have referred the circumstances associated with this event to OSHA, therefore there may be additional reporting that may be required in the future.

INPO OE has been generated by Assessment personnel per site procedures and is required as documented in CAP 55527.

Data Analvsis Information & Fact Sources Initial information was gathered by a "Rapid Response Team" that consisted of Point Beach, Hudson, Prairie Island, Palisades, and Monticello personnel. Interviews of personnel involved in the event included Radiation Protection personnel, Scientech personnel, and Program Engineering personnel. These interviews were summarized and captured for use in development of a timeline of events, and served as the initial information source by which further questions by the root cause evaluation team were developed. ' 2,17 19,2 4,26 2736 Questions were developed to gather information relevant to pre-staging, planning, training, concerns/problems with the task, and execution.

These interviews and questions detailed more than 20 inappropriate actions throughout planning and implementation of steam generator nozzle dam installation during the UIR28 Refueling Outage.

Data sources included (but were not limited to) Control Room and Containment Logs, Point Beach procedures that were relevant for work planning through to execution of work, Scientech procedures used for installation/removal of nozzle dams, Point Beach Job Files, Training Lesson Plans and Qualification Matrixes, Corrective Action Process Action Requests and Corrective Action items. These data sources identified that personnel throughout planning and execution of the task, did not utilize the information available that would assist in successful task preparation and completion.

Similar equipment was gathered through the site Safety Department and Program Engineering personnel, who acquired bubble hoods and hoses that were the type used during the events, as well as video which allowed viewing of the type of activities that were taking place at the time of the event. Direct evidence - pictures of the air-line system, staged liquid used to wet-down workers, the equipment (bubble hoods and hoses), or video of the actual event - could not be located and secured.

Previous External Operating Experience (Attachment F): The following is a summary of the analysis performed by John Peterson, Monticello, for recent PBNP evaluations of external Operating Events (OE) regarding loss of supplied breathing air due to separation of supplied air line quick disconnect fittings. OE031454-6/19/2003 -

Subject:

Worker lost air to his bubble-hood when one of the fittings unexpectedly became disconnected. The Point Beach evaluation noted that Point Beach uses quick disconnect fittings of a different manufacturer, and that the fittings are taped as further safe guard. Although the quick disconnect fittings made by the two different manufacturer's employed similar mechanisms and action for connecting/disconnecting the fittings, the evaluation was closed with no further action. Action should have been taken to challenge the connections used at Point Beach, to further justify closure without action.

OE048685-8/25/2003 -

Subject:

Fittings became separated and an air line hose was accidentally cut by a co-worker. The Point Beach evaluation of this OE addressed the accidental 9

cutting of the hose but did not address the separation of the quick disconnect fittings. The OE was closed by the activity performer with no further action other than stating that Point Beach RP technicians are trained to cut a person out of a bubble hood if they experience air loss.

Review and Approval by Supervision or Quality Check of this activity should have identified that all issues were not addressed in the Activity Completed section. OE010321-10/10/2003 -

Subject:

Worker experienced a loss of air supply to an air hood because the quick disconnect fittings separated. The Point Beach evaluation of this OE "determined that the procedures and controls at Point Beach are adequate to minimize susceptibility to this event". A statement that "HPIP 4.51.3 have controls in place to address this issue" was used as justification to close the evaluation. Unfortunately, however, in this event, the controls that were in place were not used.

In summary, previous External Operating Experience identified a condition that existed at the site, however, no actions were taken to challenge site equipment and further safeguard against incidence.

Evaluation Methodology & Analysis Techniques An Event & Causal Factor Chart (E&CF) (Attachment A) was used to initially construct a timeline of events that occurred on April 9th, 2004, during steam generator nozzle dam installation. The timeline was usedlto determine actions that were considered inappropriate for the tasks being performed, which then required further analysis to determine a root and contributing causes. This timeline of events, or Event and Causal Factor Chart, identified more than 20 inappropriate actions during installation of steam generator nozzle dams.

Those inappropriate actions were then used as problem statements and analyzed for cause using Tap Root methodology.

A Failure Analysis (Attachment B) was used to identify the underlying cause of the inappropriate actions that were identified on the E&CF Chart. Six common themes were identified for the inappropriate actions, with charting identifying the most common theme throughout the events.

Supervisory Oversight had the highest number of "inputs" and was identified as the cause of at least nine (9) of the inappropriate actions that occurred. Supervisions policies, administrative controls, and the use of corrective action were consistently not strict enough, not utilized, or not accountable for inappropriate actions that led to poor work practices and safety anomalies during a high-risk evolution. When asked "Why", management response was that they were focused on other elements such as the Radiological aspects of the job (Radiation Protection Management),

while Program Engineering Management stated that they did not recognize the task as being high-risk and therefore did not apply the necessary oversight.

Considered to be Significant Contributors to the events was Work Direction and Procedures. Supporting those facts were:

Inadequate scheduling of training, poor worker selection, and inadequacies in pre-job briefings and walkthroughs. Also, procedures were not used, not followed or situations were not covered, and therefore significantly contributed to the unacceptable events that took place during planning and execution of nozzle dam installation.

A Barrier Analysis was performed (Attachment C) to determine what barriers were in place at the time of the event, and determine any failures that may have occurred in those established barriers. Six barriers were identified that, if utilized, would have prevented the inappropriate actions that took place during the steam generator nozzle dam installation. Barriers included:

Work Planning and Associated Outage Management Procedures, Training for nozzle dam installation/removal, Nuclear Oversight observations, Operating Experience, Radiation Protection Procedures, and Human Error Reduction Tools. Each failed barrier, independently, would have impacted performance, however, when all six in combination failed, it led to the 10

safety anomalies and inadequate work practices that were experienced during nozzle dam installation. The Analysis concludes that organizational effectiveness issues exist, as all barriers that were put in place for successful task performance, failed to be utilized to the extent necessary to prevent incident. This analysis then led to a Task Analysis of the process in place to plan this project, that should have included all barriers in it's performance.

The Task Analysis of the Outage Project Plan for this task (Attachment D) identified that a work plan (as directed to be developed by a planner) per NP 10.2.1, Outage Management and NP 10.2.6, Work Order Processing, was not appropriately developed and was subsequently accepted as adequate for performance. A Previous Action Request (CAP 31950) from a Benchmarking Trip in April of 2003, and its associated activities determined that Point Beach would need to develop a change management plan (CEl 1434) for ensuring personnel are prepared to properly install nozzle dams, however a project plan based on the needs of the contractor procedure was developed and approved instead (OTH 29264,29265).

The Analysis further identified that the Outage Management document did not define a process for determining adequacy and acceptability of a work plan, methods or processes to accomplish the responsibilities detailed in the document, or references to perform procedures to assist in work plan development.

Task Analysis of HPIP 4.58 - Issuance of Respiratory Equipment (Attachment E) was also performed to identify the tasks associated with the use of bubble hoods, as was used during the events on April 9th, 2004, during nozzle dam installation. This Analysis identified that Radiation Protection personnel did not perform the steps outlined in the procedure, thereby bringing into question whether or not personnel were appropriated dressed and prepared for work in a bubble suit. This procedure directed verification of air line testing, setup, and on/off requirements (which would have confirmed or disputed worker concerns of "not enough air"), bubble hood and equipment condition, issuance and signature of the person dressed in the bubble suit (which would/could have confirmed or disputed workers acceptance of conditions), contamination cautions, taping of connections (which was not performed initially, or on the quick disconnect/reconnect issue), and air pressure requirements which were violated when pressure was increased beyond 28psig up to 60. This procedure is part of RP Training, and is considered a qualified task, however, the procedure was not used as required.

Data Analysis Summary In summary, data analyses performed for this root cause evaluation identified more than 20 inappropriate actions throughout the planning and execution of a high-risk outage task. Those inappropriate actions, once identified, then required a separate causal analysis. This causal analysis identified six common areas of concern. Those areas were Training, Work Direction, Supervisory Oversight, Procedures, Communications, and Human Engineering. Of those six areas of concern, the most inputs of the inappropriate actions directed cause to Supervision that ultimately approved an inadequate, narrowly focused work plan that wasn't appropriately overseen. Further process analysis identified weaknesses within work planning that contributed to the inadequately prepared outage work plan, however barriers in procedures, training, Nuclear Oversight, previous Operating Experience, and Human Performance tools were in place throughout planning and execution, but were not utilized.

The major contributors to the events were identified to be poor work direction and planning, and the non-use or not following of procedures for a high-risk evolution. Human engineering was a major contributor to the event, however, due to the nature of the evolution, much of the contributors must be considered in the planning, and cannot be changed (cramped and high 11

radiation environment, etc.). Training and Communications contributed on two (2) occasions each, but were not considered major contributors to the event.

Data Analyses through Task Analysis of Radiation Protection and Work Planning and Outage Management procedures further identified that procedures were not followed or did not include checks and balances to promote success.

Failure Mode Identification The likelihood of Failure Modes occurs in a typical order. For the issues evaluated for this root cause, Organization & Management Failures occurred in two (2) Functional areas (F2 & F6) first, and were followed by two (2) Cultural Failures (C2 &C3).

In addition, Human Performance Failures started in Attention (A9), followed by Judgment (J7), and then Knowledge Failures (K2 & K4). Supporting evidence is as follows:

F2 lOrganizational &Management I2FUNCTIONAL - Inadequate Communication among Organizations

  • Throughout the planning and execution of steam generator nozzle dam installation activities, there was a lack of defined interface requirements, expectations and responsibilities. Nuclear Oversight had identified weaknesses in briefings - neither they nor Radiation Protection followed up with concerns.21 In addition, upon identification of several breathing air issues, proper notification was not made, and notification that was made, was informal.15"6 2'36 Included in the improper notification was the fact that the project leader was not formally made aware of contamination events of the Scientech workers other than by an e-mail notification, and had previously not been personally involved with the breathing air issues of those same workers.30 12 F6 Organizational & Management I FUNCTIONAL - Inadequate Program Management
  • Line Management was unfamiliar with the process that drove the requirements associated with breathing air pressures26, as well as the requirements associated with work planning, risk assessment, prejob briefings, and Radiation Protection procedures2 ' 3' 21'- 6' 9' 30' 36'40 In addition, RP Outage JITT for air line testing, as well as Task Analysis for the air line system had been post-poned or cancelled citing time constraints, and therefore impacted successful performance of breathing air use in this event.43'44 This ultimately led to an inadequate oversight of critical work processes to ensure they functioned smoothly and effectively. This results in program degradation over time or increased problems within those processes.

C2 Organizational & Management I CULTURAL - Inadequate Teamwork

  • Interactions and information was informal and, at times, not tracked.

Not all occurrences of breathing air problems were captured and identified in a formal manner, nor were activities stopped or communicated effectively to determine causes and preclude further incident.

"55,I62' In addition, interviews determined that the 12

separate groups involved in the project were each focused on their own specific aspects of nozzle dam installation/removal, without consideration of the impacts each one would have on the other.'2'27 C3 l Organizational&Management CULTURAL -Inadequate Knowledge

  • Line Management and personnel were unfamiliar with the process that drove the requirements associated with breathing air pressures26, as well as the requirements associated with work planning risk assessment, prejob briefings, and Radiation Protection proceduresl 23 9'2I2 62

.30.3640 This lead to a work force that proceeded in a Knowledge Based performance mode.

A9 Human Performance IATTENTIONAL - Time & Schedule Pressure

  • The nozzle dam installation evolution was identified as a Critical Path/Near Critical Path Activity due to be completed that day, with indication on the Outage Status Report that the schedule was 9 hours1.041667e-4 days <br />0.0025 hours <br />1.488095e-5 weeks <br />3.4245e-6 months <br /> behind.

Work on nozzle dam installation began in the early morning hours of the Friday (04/09) of Easter weekend, with work commencing at 0417, with approximately eleven hours already into the 12-hour shift for the work group.'5 Workers had also expressed the fact that they held tickets for weekend travel home for the holiday, and they anticipated completion of the assigned task that shift.12'26,27 No actions were taken to heighten the level of awareness necessary for success, due to the time and schedule pressure that was evident, though not admitted as a contributor.

J7 Human Performance I JUDGMENT - Shortcuts Taken

1) Task analysis identified that a work plan was not developed in accordance with NP 10.2.6, Work Order Processing, or NP 10.2.1, Outage Management. This detailed plan was necessary to promote teamwork among the various work groups involved with the task, identify the consequences associated with an IPTE task, and ultimately identify the critical actions necessary to successful implement the task. 2) HPIP 4.58, Issuance of Respiratory Equipment, would have identified breathing air pressure requirements, air line connection requirements, and verification of issues relevant to the problems that occurred during nozzle dam installation.3 This procedure was not referred to or used in preparation and execution of the task, even though it is in a training lesson plan with a qualification associated with it.37 Line Management stated that there are many procedures and that they couldn't know all of them, and that they 26 never read that one.
3) RP Outage JITT for air line testing, as well as Task Analysis for the air line system had been post-poned citing time constraints, and therefore impacted successful performance of breathing air use in this event.43 '"

13

lK2 Human Performance KNOWLEDGE - Unfamiliar or Infrequent Task

  • The nozzle dam installation evolution is identified as a Critical Path/Near Critical Path Activity that is only performed during Refueling activities. At the most, it would be performed every 18 months on one unit, or twice every 18 months for a two-unit facility such as Point Beach. It was successfully performed on the Unit 2 steam generators in the Outage previously, but had not been performed by the site for years prior to that, making this an infrequently performed task. This work was not appropriately planned or prepared for as an unfamiliar or infrequent task, and awareness was therefore not elevated to a level necessary to avoid incident.

l K4 Human Performance I I KNOWLEDGE - Tunnel Vision

  • Decisions were made without considering all the available information needed to adequately assess the situation. Radiation Protection was focused on Radiological impacts and did not consider the personal safety consequences associated with the task. Programs Engineering personnel were also focused on the task of installing the nozzle dams, and did not consider the personal safety consequences of the task.

There was a loss of the "big picture", which allowed individuals to make decisions without assessing the entire situation.',6,1012,13,21,26,27,2936,37,40,43,44,47 14

Root Causes & Contributing Factors Oversight by Supervisors/1M1anagers during work planning development and task execution didn't assure compliance with procedures and processes, resulting in an inadequate work plan being developed and approved for use.

Supporting details for Supervisory oversight issues: A Failure Analysis (Attachment B) identified six (6) underlying causes of the inappropriate actions that were taken during the steam generator nozzle dam installation evolution. Supervisory Oversight had the highest number of "inputs" and was identified as the cause of at least nine (9) of the inappropriate actions that occurred. Adequate oversight by supervision could have identified an unacceptable work plan, inadequate briefing, and additionally could have investigated identified low air pressure issues, prevented procedure violations or non-use, and could have prevented closure of inadequately assessed OE CAP actions.

Supporting details for inadequate work plan:

A work order to perform nozzle dam installation/removal was generated in December of 2003. This work order was written as a Priority 5, Type "Z" - Elective Maintenance activity, and categorized with a risk of "H - MU Multiple Risks".

According to Planning personnel at Point Beach, this "H-MU"Y would have generated PBF-9812, Categorization and Mitigation of Risk (associated with NP 1.1.7, Managing Work Activity Risk). This form details that a risk category of High, as was the case for this work order, would have had to consider 12 different compensatory actions which included, but were not limited to, a complete look-ahead plan, utilization of high risk pre-job briefing process, FLS and Manager attendance and conduct of pre-job briefing to ensure adequacy, critical step identification, etc. This form, along with the associated PBF forms that would have been generated upon initiation, were not located and the evaluation did not identify that any mitigation or assessment of risk was performed. This detailed plan was necessary to promote teamwork among the various work groups involved with the task, identify the consequences associated with an IPTE task, and ultimately identify the critical actions necessary to successful implement the task.

Significant Contributing Factor #1: Work Order Processing per NP 10.2.4 and Outage Management Planning per NP 10.2. does not include logic ties (IF this, THEN that) to drive use of appropriate procedures during work plan development.

Supporting details: In accordance with Point Beach Nuclear Procedure NP 10.2.4, Work Order Processing and AM-3-15, Work Control Manual and Pont Beach forms associated with work planning, a work plan by a planner is required for all Type "C" work orders (4.15.6). This would include an identification of the support requirements, activity risk, RWP, tools, testing, safety precautions, equipment ventilation, safety evaluation, and Operating Experience, to name a few.

This work order, however, was labeled a type "Z" work order, and no project plan with inclusion or considerations of all elements was performed. This led to the evaluation questioning the process links associated with work order activity type in CHAMPS. This evaluation identified that the work order process does not identify procedures or references that need to be performed or referred to when planning a work package.

Further, a Task Analysis (Attachment D) identified that the Outage Management document did not define a process for determining adequacy and acceptability of a work plan, methods or processes to accomplish the responsibilities detailed in the document, or references to perform procedures to assist in work plan development.

15

Significant Contributing Factor #2:

Program Engineering personnel and Radiation Protection personnel did not use and/or follow Work Planning, Risk Assessment, Briefing, or Radiation Protection procedures in preparing for and during execution of the steam generator nozzle dam project.

Supporting details: During documentation and procedure reviews for the evaluation, the work plan from inception to completion did not include nor reveal that a risk assessment per NP 1.1.7, and its associated PBF documents were utilized.2' I2942 This Risk Assessment would have developed the heightened awareness that was necessary for this infrequently performed, high risk task. In following the risk assessment, a briefing would have resulted in accordance with the assessment procedure, however, a briefing in accordance with the proper procedures was not performed, and was deemed as inadequate by Nuclear Oversight during a Rapid Assessment.2 1 29"4 Radiation Protection procedures were not completed or were violated when bubble hoods were not issued in accordance with HPIP 4.58 and its associated PBF forms, regulator pressure was increased beyond procedural limits without a temporary procedure change performed, and nasal smears were not conducted as directed by the Personnel Contamination Event Report form PBF-4039a.2,15,2 630,38 Significant Contributing Factor #3: Training for steam generator nozzle dam installation was not adequate to identify the error-likely situations that existed upon the start of work.

Supporting details:

Interviews and documentation reveals that training for steam generator nozzle dam installation and removal was limited due to scheduling conflicts and monetary constraints. 27 Training limitations included the fact that Scientech jumpers practiced nozzle dam installation in street clothes. 27 This practice did not 1) address dress requirement issues that Scientech workers expressed once dressed for the evolution by Radiation Protection, 2) identify air pressure issues that were experienced by workers once full dress-out was complete, 3) identify the air line connection failure possibility that was experienced by two (2) workers on the platform, nor did it 4) identify the issues surrounding two individuals requiring to be "wet down" to assist them in gaining access to the steam generator bowl - one specifically who was too large to easily fit in the manway hole. 1,12,15,16.26.27 Significant Contributing Factor #4:

Communications to the OCC of safety significant events was not delivered and Nuclear Oversight identification of an inadequate briefing was not delivered in a timely or effective manner.

Supporting details: Nuclear Oversight detailed in a Rapid Assessment Report, the fact that the IPTE briefing for nozzle dam installation was inadequate for various reasons.2 1 Included, was the fact that the briefing was not in accordance with procedural requirements. This information was not recorded in an Action Request, nor was it brought to the attention of Management for action beyond the discussions that took place between the Assessor and the individual performing the brief.21 Communications break-downs also existed between Radiation Protection, the nozzle dam project leaders, and the Outage Control Center, as evidenced by the fact that the OCC was only made aware of the first breathing air line issue, and that notification was logged after the second air line issue had already been experienced. No notification was made after first communication with the OCC.812.15162I Additionally, project leaders attention was focused on the nozzle dam installation process itself, not the air line problems experienced by the workers, and therefore were not directly made aware of issues concerning the events.122 7 16

Significant Contributing Factor #5: Previous External Operating Experience on failures of quick-disconnect fittings was not adequately used to correct the similar failure mechanisms that existed on the equipment utilized at Point Beach.

Supporting details:

Several PBNP evaluations of external Operating Events (OE) were performed regarding loss of supplied breathing air due to separation of supplied air line quick disconnect fittings. OE031454-6/19/2003 -

Subject:

Worker lost air to his bubble-hood when one of the fittings unexpectedly became disconnected. The Point Beach evaluation noted that Point Beach uses quick disconnect fittings of a different manufacturer, and that the fittings are taped as further safe guard. Although the quick disconnect fittings made by the two different manufacturer's employed similar mechanisms and action for connecting/disconnecting the fittings, the evaluation was closed with no further action.

Action should have been taken to challenge the connections used at Point Beach, to further justify closure without action.

OE048685-8/25/2003 -

Subject:

Fittings became separated and an air line hose was accidentally cut by a co-worker. The Point Beach evaluation of this OE addressed the accidental cutting of the hose but did not address the separation of the quick disconnect fittings. The OE was closed by the activity performer with no further action other than stating that Point Beach RP technicians are trained to cut a person out of a bubble hood if they experience air loss.

Review and Approval by Supervision or Quality Check of this activity should have identified that all issues were not addressed in the Activity Completed section. OE010321-10/10/2003 -

Subject:

Worker experienced a loss of air supply to an air hood because the quick disconnect fittings separated. The Point Beach evaluation of this OE "determined that the procedures and controls at Point Beach are adequate to minimize susceptibility to this event". A statement that "HPIP 4.51.3 have controls in place to address this issue" was used as justification to close the evaluation. Unfortunately, however, in this event, the controls that were in place were not used.

In summary, previous External Operating Experience identified a condition that existed at the site, however, no actions were taken to challenge site equipment and further safeguard against incidence.

Corrective Actions Corrective Actions to Restore (broke - fix)

  • CA #1 Conduct a documented briefing for Engineering on safety anomalies and poor work practices associated with this event - inappropriate actions taken on the part of their group, and their responsibility for assuring that their actions are corrected.

(This will address the immediate needs associated with the Root Cause and Significant Contributing Factors 1-4, and Failure Mode F2)

(Responsible Group: Programs Engineering - Gary Sherwood, Priority 2, 60-day due date)

  • CA #2 Conduct a documented Briefing for Radiation Protection on the safety anomalies and poor work practices associated with this event - inappropriate actions taken on the part of their group, and their responsibility for assuring that their actions are corrected. (This wvill address the immediate needs of the Root Cause, Significant Contributing Factors 1-4, and Failure Mode F2) 17

(Responsible Group: Radiation Protection - Stu Thomas, Priority 2, 60-day due date) o CA #3 Develop Lesson Plan HPC-04-LP203, Nozzle Dam Just-in-time Training, and implement Supervisory oversight corrective actions established by nozzle dam removal project plan (See Attachment I, second halo. (This will address Significant Contributing Factor #2, 3, & Failure Mode C2 as well as the immediate needs associated with the Root Cause and Failure Modes F6 and C3)

(COMPLETE - Approved 05/11/04)

  • CA #4 Develop Communications Protocol and include in the work plan for nozzle dam removal. (This will address Significant Contributing Factor #4 and Failure Mode F2)

(COMPLETE: Programs Engineering - 05/22/04)

  • CA #5 Prepare Expectations and Brief personnel on the adequate use and action to be taken for External Operating Experience that is assessed by Radiation Protection personnel. (This will address Significant Contributing Factor #5)

(Responsible Group: Radiation Protection - Stu Thomas, Priority 2, 60-day due date) o CA #6 Programs Engineering CRC perform a Task Analysis to determine personnel knowledge and training required to successfully lead and plan major projects.

(This will address the long-term needs associated with the Root Cause and Failure Modes C3 and J7)

(Responsible Group:

Programs Engineering - Gary Sherwood, Priority 2, 60-day due date)

  • CA #7 Conduct a documented briefing of Nuclear Oversight personnel on the safety anomalies and poor work practices associated with this event -

inappropriate actions taken on the part of their group (a pre-job briefing was conducted, and was determined by NOS to be inadequate, however, no other action other than a Rapid Assessment Report was documented - no CAP, etc.).

(This will address Significant Contributing Factor #5, and Failure Mode F2)

(Responsible Group: Nuclear Oversight - Mike Holzmann, Priority 2, 15-day due date) 18

Interim Corrective Actions (mitigation)

  • CA #8 Plant Stand-down or "Time Out" conducted on 04/09/04 (Excellence through Error Prevention). (This was to address the immediate site needs at the time of the event.)

(COMPLETE - Conducted 04/09/04)

  • CA #9 Programs Engineering conduct Nozzle dam Lessons Learned meeting prior to nozzle dam removal. (This was to address the immediate Program Engineering Department needs prior to planning the nozzle dam removal evolution.)

(COMPLETE - Conducted week of 04/26/04 by Gary Sherwood)

  • CA #10 Radiation Protection brought in an independent team of NMC personnel to review procedures and processes for use of supplied air as breathing air and used their input to: update procedures, change out and replace nitrogen bottle back-up with certified Grade D breathing air, replace all bubble hoods, airlines and Snap-tite fittings to new CEJN type fittings.

(This addressed Significant Contributing Factor #5 and Failure Mode F6)

(COMPLETE - Conducted the month of April, 2004)

  • CA #11 Radiation Protection conducted Just in Time information sharing before restart of the use of bubble hoods. (This partly addressed the Root Cause, Significant Contributing Factor #3, and Failure Mode F6 and C3.)

(COMPLETE - Radiation Protection - 04/23/04)

  • CA #12 - Mock-up training for nozzle dam removal included a review of procedure requirements, bubble hood issuance requirements, and manifold pressure requirements. (This partly addressed the Root Cause, Significant Contributing Factor #3, and Failure Mode F6 and C3)

(COMPLETE - During mock-up training sessions during 05/20-21/2004)

Corrective Actions to Prevent Recurrence (CATPRs) o CATPR #1 Develop a nozzle dam removal work plan in accordance with NP 10.2.1, Outage Management and NP 10.2.6, Work Order Processing, which also includes Supervisory independent approval.

(This will address the immediate needs associated with the Root Cause, and Failure Modes A9, J7, K2, andK4)

(COMPLETE: ProgramsEngineering- 05/18/04) 19

o CATPR #2 Develop a procedure for nozzle dam installation and removal that incorporates lessons learned from this event, supervisory and management oversight requirements and stop work criteria, communications protocol, and external Operating Experience.

(This will address the long-term needs associated with the Root Cause, Significant Contributing Factors #2, 4, 5 and Failure Modes F6 and K2.)

(Responsible Group - Programs Engineering - Gary Sherwood, Priority 2, Due date 11/15/04)

  • CATPR #3 Develop, within NP 10.2.1, Outage Management, and NP 10.2.6, Work Order Processing, a process to determine when HIT teams or Project Managers should be assigned, and include logic ties (IF this, THEN that) to drive use of appropriate procedures during work plan development.

(This will address the long-term needs of the Root Cause and Significant Contributing Factor.#1)

(Responsible Group: Production Planning -

Ron Davenport, Priority 2, 120-day due date)

Other Corrective Actions o OTH #1 Create an "It Can Happen Here" article for distribution to plant personnel. (This is an additional action for site personnel information.)

(Responsible Group: Assessment - Pat Russell, Priority 2, 90-day due date) o OTH #2 Develop Industry OE on the event. (Required Action associated with an event of this type.)

(Responsible Group: Assessment - Pat Russell, Priority 2, 50-day due date (from the time of the event) o OTH #3 - CA057320 Perform INPO Nuclear Safety Culture Assessment to identify gaps and formulate corrective actions to improve PBNP performance.

(This will address the Extent of Condition issues identified in the evaluation.)

(Responsible Group:

Assessment - Pat Russell, Priority 3, Due date 09/01/04) o OTH #4 - Develop and issue a site wide communication on the purpose of NP 1.1.7, Managing Work Activity Risk, and when to utilize it.

(This will address the site 's needs associated with performance of NP 1.1.7 during work planning.)

(Responsible Group - PPG - Ron Davenport, Priority 2, 7-day due date) o OTH #5 - Work Week Coordinator review all existing High Risk work orders scheduled within the next five weeks for compliance with NP 1.1.7 and implement a review of High Risk work orders for compliance with NP 1.1.7 at 20

i the appropriate E-meeting. (This will address the short-term needs to ensure compliance with NP 1.1. 7.)

(Responsible Group - PPG - Ron Davenport, Priority 2, 14-day due date) o OTH #6 - Take completed CRC Task Analysis results from CA #6 to the TOC to identify impacts on other work groups.

(This will address the long-term needs associated with personnel work planning issues.)

(Responsible Group: Training - Chuck Sizemore, Priority 3, 120-day due date)

Effectiveness Reviews

  • EFR #1 Perform an Effectiveness Review of CATPR #1 per Nuclear Management Company Root Cause Evaluation Guidelines immediately following U1R28 Refueling Outage.

(Responsible Group:

Programs Engineering, Priority 3, Completion Due Date: 90-days)

  • EFR #2 Perform an Effectiveness Review of CATPR #2 per Nuclear Management Company Root Cause Evaluation Guidelines.

(Responsible Group:

Programs Engineering, Priority 3, Completion Due Date: 90-days after completion of CATPR #2)

  • EFR #3 Perform an Effectiveness Review of CATPR #3 per Nuclear Management Company Root Cause Evaluation Guidelines.

(Responsible Group: Production Planning, Priority 3, Completion Due Date:

6-months after completion of CATPR #3) 21

References

1. Breathing Air Supply Issues (Kari DenHerder)
2. HPIP 4.51.3 - Airline Respiratory Equipment PBF-4077d - Respiratory Protection Filter/Manifold Inspection & Maintenance Record
3. HPIP 4.58 - Issuance of Respiratory Equipment & PBF-2234 - Respirator Issue Record
4. Recommended Actions (Immediate Action Team Recommendations)
5. OE - Steam Gen Nozzle dam and cover installation & removal - INPO OE
6. Evaluation of Point Beach Nuclear Plant Safety Conscious Work Environment (Aldo Capristo)
7. IRMP 9391 - Connection of Unit/Nozzle Dam Control Console Remote Alarms to lC20
8. PBNP Vent Path Timeline (from Vent Path RCE)
9. CAPs: 55527-U1R28 Nozzle Dam Installation Supplied Breathing Air Problems 55565 - Facial Contamination Events without Nasal Swabs Being Taken 55587 - S/G Nozzle Dam Installation Dose Exceeded Estimate 55595 - Air supply to Bubble Hoods not within procedure limits 55645 - Bubble hoods not issued LAW HPIP 4.58
10. 0E13365 - Two Separate Incidents where Loss of Breathing Air to Air-supplied Respirators (bubble hoods) occurred.

OE16239 - Separation of Air Line Coupling on Supplied Air Hood OE16908 - Separation of Air Line Coupling on Supplied Air Hood - related to OE16239 OE16368 - Airline Breathing Hood Fitting Disconnects Unexpectedly

11. Radiation Protection Outage Scope (U2R26) and Contractor Current Events Lesson Plans
12. Interviews (Aldo Capristo, Kristin Zastrow, Tom Klesper)
13. Point Beach OE Assessments of External OE CAP 46245 (1999)- OE10197 - Loss of Breathing Air During Steam Generator Nozzle Dam Removal OE10321 (2003) - Separation of Air Line Coupling on Supplied Air Hood OE31454 (2003) - Airline Breathing Hood Fitting Disconnects Unexpectedly OE48685 (2002) - Two Separate Incidents where Loss of Breathing Air to Air-supplied Respirators
14. Supplied Air Respirators - Technical Information from Nuclear Power Outfitters
15. Containment Log
16. Operations Log
17. Supporting Details (from Vent Path RCE)
18. Radiation Work Permit 04-141 - Nozzle Dam Install/Remove
19. E-mail correspondence (Aldo Capristo & Kristin Zastrow)
20. PBF-9157 - FME Material Control Log
21. Nuclear Oversight Rapid Trending Assessment Daily Report for 04/08/04 & Follow-up questions from Dennis Hettick to Brad Cole (Assessor)
22. Timetable from Vent Path RCE
23. NP 8.4.9 - Hose Control, Attachment A
24. List of involved individuals (Tom Klesper, Aldo Capristo, Mark PeroutkaO)
25. Site Communication effective 04/11 (Immediate actions)
26. Interviews (Dan Craft)
27. Interviews (Kari DenHerder)
28. PBF-4077d - Respiratory Protection Filter/Manifold Inspection & Maintenance Record PBF-4107 - Testing to Ensure Breathing Air Standards
29. PBF-4195a - Level 3 Pre-job ALARA review 22

QF-1060-02 (FP-T-SAT-60) -

Documentation of Information Sharing (This was considered the IPTE Brief)

30. PBF-4039a - Personnel Contamination Event Reports
31. PBF-8013, Test Gauge Calibration
32. 83A7564 - Steam Generator Nozzle Dam Installation and Removal, Test, Operation and Maintenance Manual - Scientech Procedure
33. Personal drawings of air supply hook-ups (Al Reiff & Pete VanLaarhoven)
34. NP 1.9.4 - Confined Spaces Procedure
35. Radiation Protection Qualification Matrix
36. Event "Apparent Cause Evaluation" performed by Immediate Action Team (Kari VanDenherder)
37. HPI-02-LP003, Respiratory Protection, Lesson Plan Requirements
38. PBF-4021, Radiological Surveys
39. Time Out, April 9, 2004 - Point Beach Excellence Through Error Prevention
40. NP 1.1.7-Managing work Activity Risk NP 1.2.5 - Special Test Procedures NP 1.2.6 - Infrequently Performed Tests or Evolutions (IPTEs)

NP 1.6.10 - Pre-and Post-Job Briefs PBF-4194a - Pre-Job Briefing Checklist PBF-9175 - Job Walkdown Checklist PBF-9175a - Job Walkdown Facilities Checklist PBF-9205 - High Risk Work Pre-Job Briefing Checklist PBF-9217& 9218 - Pre-Job Brief Checklist PBF-9811 - Look Ahead Process Planning Form

41. Outage Status Reports and U1R28 Today Articles
42. PBF-0039 - Confined Space Entry Permits
43. Internal Correspondence - Minutes for RP CRC Minutes
44. CAP 35015 - RP Outage JITT in jeopardy (too late to begin development of a lesson plan to support Airline training CAP 52203 - Implementation of Grade D aero test equipment inadequate OTH 11943 - Identify RPTs that maintain qualification of the Grade D Air Testing RFT 12018 - RP evaluate the post training feedback for topic selection OTH 12017 - RP Evaluate station improvement suggestions from 11/03
45. ANSI Z88.2-1992
46. HPIP 4.56 - Testing Supplied Air for Air-Line Respiratory Equipment
47. Job File 131 - Steam Generator Primary Manway Removal and Installation Job File 132 - Containment Setup for Steam Generator Work Job File 133 - Survey Schedule During Steam Generator Work Job File 134 - Requirements for Steam Generator Work Using Full Face Respirators Job File 135 - Requirements for S/G Work Using Supplied Air Respirator Hood
48. NP 10.2.1, Outage Management NP 10.2.2, Scheduling Planning & Implementing On-Line Work NP 10.2.4, Work Order Processing NP 10.3.6, Outage Safety Review and Safety Assessment AM 3-15, Work Control Manual
49. UIR28 Outage Risk Plan - PPG Outage Management
50. CAP 31950, Nozzle Dam Benchmarking Trip CE 11434 OTH 29264, 29265 23

Attachments A. Event & Limited Causal Factor Chart B. Failure Analysis & Conclusions C. Barrier Analysis D. Task Analysis of Planning Process for this Task E. Task Analysis of HPIP 4.58 - Respirator Issuance F. Operating Experience Analysis G. Quick Response Team "Apparent Cause Evaluation" H. Nozzle Dam Lessons Learned I. RP Immediate Actions & Actions to Address Supervisory Root Cause Issues 24

Root Cause Evaluation Charter CAP# 55527 RCE# 253 Issue Manaeer/Sponsor:

Pat Russell - Manager Performance Assessment Problem Statement:

Installation of Nozzle Dams resulted in several industrial safety anomalies and poor work practices. Problems were noted in, but are not limited to:

  • Radiation Work Practice for Individuals performing Nozzle dam Installation
  • Inadequate Job Briefings
  • Air line connections Investiention Scope:

Determine at-risk behaviors that do not meet Point Beach and Nuclear Management Company Expectations. Identify areas where personnel performed tasks outside of procedures and training to accomplish completion of work.

Recommendations will be made for:

  • Correcting the problem
  • Preventing recurrence of the problem
  • Applicability of the root cause to other areas (extent of condition)
  • Interface with the recovery team
  • Consideration for quarantine for evidence preservation Investiaation Methodology:

The Team will utilize Event & Causal Factor Charting, document and procedure reviews and Task Analysis, Interviews, and other analysis tools that may be applicable upon further investigation (Barrier Analysis, Failure Modes and Effects, Why Staircase, etc.).

Team Members:

Team Leader Kristin Zastrow, Kewaunee Nuclear Team Member John Peterson, Monticello Immediate Actions Paul Harden, Palisades Immediate Actions Kari DenHerder, Prairie Island Immediate Actions Joe Hager, Palisades Immediate Actions Don Schuelke, Prairie Island Immediate Actions Dan Craft, Hudson Immediate Actions Also Capristo, Fleet Immediate Actions Tom Taylor, Prairie Island Milestones:

Date Assigned 04/09/04 Status Update 04/13/04 I

Draft Report Final Report 04/13/04 05/09/04 Communications Plan: (7f determined to be needed)

Initial communication to the station - Plant briefing 04/10/04 Communication to NRC 04/09/04 Follow up to the station Approved:

Date:-

Management Sponsor Reviewed by:

/ CARB on Cl one)

~/, q-V Date

Attachment A - Event & Causal Factor Chart anner id not use NP cenreathing air hose and associated forms to conducts training for and manifolds set assess risk of evolution when zzle dam Installation ula s (1) r planninge h

(

up on platforms (1) 01 00-0200-S cientech requested longer stay times, RP denied request (27)

Ddnot follow, station procedures r

e real monetary lmitations (7 Proceure not followe Scientech complains about low air at staging/

dressing area (27) 0417-S/G Jumpers arrive at U1 EB S/G to perform cold log nozzle dam Installation. (15)

\\

down per Scientech

/

Wetting of plastic suIt not addressed in station or contractor procedures.

0428 -1 st jumper enters 'B S/G'cold leg to install nozzle dam. Jumpers size makes entry difficult.

Jumper requires assistance. (15)

\\leaves bowl. air hood s

preconceived m an se by jumper regarding air supply.

A 25

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