ML061090843
| ML061090843 | |
| Person / Time | |
|---|---|
| Site: | Perry  |
| Issue date: | 04/19/2006 |
| From: | Satorius M Division Reactor Projects III |
| To: | Pearce L FirstEnergy Nuclear Operating Co |
| References | |
| CA 03-05-001 IR-06-008 | |
| Download: ML061090843 (55) | |
See also: IR 05000440/2006008
Text
April 19, 2006
CA 03-05-001
Mr. L. William Pearce
Vice President
FirstEnergy Nuclear Operating Company
Perry Nuclear Power Plant
P. O. Box 97, A290
10 Center Road
Perry, OH 44081
SUBJECT: PERRY NUCLEAR POWER PLANT CONFIRMATORY ACTION LETTER (CAL)
FOLLOWUP INSPECTION CORRECTIVE ACTION PROGRAM
EFFECTIVENESS - ACTION ITEM IMPLEMENTATION INSPECTION
NRC INSPECTION REPORT 05000440/2006008
Dear Mr. Pearce:
The purpose of this letter is to provide you with Inspection Report (IR) 05000440/2006008,
detailing the results of our recent review of actions that you completed to address issues
associated with the implementation of your corrective action program. You and other members
of your staff attended the March 14, 2006, public exit meeting, held at the Quail Hollow Resort
in Painesville, Ohio, during which the results of this CAL followup inspection activity were
presented. A summary of the public meeting was documented in a letter to you dated
March 17, 2006.
As a result of poor performance, the Nuclear Regulatory Commission (NRC) designated the
Perry Nuclear Power Plant as a Multiple/Repetitive Degraded Cornerstone column facility in the
NRCs Action Matrix in August 2004. Accordingly, a supplemental inspection was performed in
accordance with Inspection Procedure (IP) 95003, Supplemental Inspection for Repetitive
Degraded Cornerstones, Multiple Degraded Cornerstones, Multiple Yellow Inputs, or One Red
Input. As documented in IP 95003 Supplemental Inspection Report 50-440/2005003, the NRC
determined Perry was being operated safely. The NRC also determined that the programs and
processes to identify, evaluate, and correct problems, as well as other programs and processes
in the Reactor Safety strategic performance area were adequate. Notwithstanding these overall
conclusions, the NRC determined that the performance deficiencies that occurred prior to and
during the inspection were often the result of inadequate implementation of your corrective
action program.
The purpose of this inspection was to review your accomplishment of actions associated with
improving your implementation of the corrective action program. In particular, this inspection
focused on determining whether your commitments associated with the corrective action
program that were identified in your August 8 and 17, 2005, letters that responded to our
L. Pearce -2-
IP 95003 supplemental inspection report, as well as selected completed actions prescribed in
the Perry Phase 1 and Phase 2 Detailed Action and Monitoring Plan (DAMP) to improve the
corrective action program, were adequately implemented. A review of the overall effectiveness
of these actions toward realizing improvements in the corrective action program will be
conducted at a later date.
Based on the results of this inspection, no findings of significance were identified and the team
confirmed that all three of your commitments associated with the corrective action program that
the team reviewed were adequately implemented. In particular, the team observed that during
work meetings to assess and resolve issues entered into the corrective action program,
managers were responding to these issues in a manner consistent with senior management
expectations on an increasingly consistent basis. Similarly, some positive improvement was
reflected in your performance indicators associated with the corrective action program.
However, notwithstanding this overall positive result, the team also identified that 4 of the
31 action items that were reviewed had not been implemented to a level that was considered
adequate by the NRC to allow these items to be considered closed. The reasons for this
varied. In one case, the team identified that one of your completed actions inadvertently
invalidated the qualifications for all of your root cause evaluators, which required that the
corrective action be rescinded. In another case, an action was improperly re-classified as a
temporary measure. In a third case, a section of a procedure was not revised as required by an
action, although other sections were properly revised. And in a final case, a sufficient number
of examples of the accomplishment of an action were not present for the action to be
considered to have been implemented.
In addition, of the actions that were determined to have been adequately implemented, in a
number of cases the implementation of those actions was judged to not be comprehensive.
As a result, it was not clear whether these actions would be lasting and effective. In particular,
some examples were identified in which the lack of a formalized process to ensure the
continuation of actions taken could impact the overall long-term effectiveness of the actions.
Although none of these issues in and of themselves has had a direct impact on the safe
operation of the facility, the fact that the NRC team, and not your staff, identified these issues
causes us to question the quality of your measures to ensure that planned actions are properly
accomplished in a high quality manner, and whether the actions accomplished will have a
lasting and effective impact.
You are requested to respond within 30 days of the date of your receipt of this letter. Your
response should describe the specific actions that you plan to take to address the issues raised
during this inspection. In particular, if you intend to or have revised your planned actions as a
result of the observations in this report, please describe for us the changes you have made or
intend to make and your basis for those changes.
The NRC will continue to provide increased oversight of activities at your Perry Nuclear
Power Plant until you have demonstrated that your corrective actions are lasting and effective.
Consistent with Inspection Manual Chapter (IMC) 0305 guidance regarding the oversight of
plants in the Multiple/Repetitive Degraded Cornerstone column of the NRCs Action Matrix, the
L. Pearce -3-
NRC will continue to assess performance at Perry and will consider at each quarterly
performance assessment review the following options: (1) declaring plant performance to be
unacceptable in accordance with the guidance in IMC 0305; (2) transferring the facility to the
IMC 0350, Oversight of Operating Reactor Facilities in a Shutdown Condition with
Performance Problems process; and (3) taking additional regulatory actions, as appropriate.
Until you have demonstrated lasting and effective corrective actions, Perry will remain in the
Multiple/Repetitive Degraded Cornerstone column of the NRCs Action Matrix.
In accordance with 10 CFR 2.390 of the NRC's "Rules of Practice," a copy of this letter
and its enclosure will be available electronically for public inspection in the NRC Public
Document Room or from the Publicly Available Records (PARS) component of the NRC's
document system (ADAMS), accessible from the NRC Web site at
http://www.nrc.gov/reading-rm/adams.html (the Public Electronic Reading Room).
Sincerely,
/RA/
Mark A. Satorius, Director
Division of Reactor Projects
Docket No. 50-440
License No. NPF-58
Enclosure: Inspection Report 05000440/2006008
cc w/encl: G. Leidich, President - FENOC
J. Hagan, Chief Operating Officer, FENOC
D. Pace, Senior Vice President Engineering and Services, FENOC
Director, Site Operations
Director, Regulatory Affairs
M. Wayland, Director, Maintenance Department
Manager, Regulatory Compliance
T. Lentz, Director, Performance Improvement
J. Shaw, Director, Nuclear Engineering Department
D. Jenkins, Attorney, FirstEnergy
Public Utilities Commission of Ohio
Ohio State Liaison Officer
R. Owen, Ohio Department of Health
L. Pearce -3-
NRC will continue to assess performance at Perry and will consider at each quarterly
performance assessment review the following options: (1) declaring plant performance to be
unacceptable in accordance with the guidance in IMC 0305; (2) transferring the facility to the
IMC 0350, Oversight of Operating Reactor Facilities in a Shutdown Condition with
Performance Problems process; and (3) taking additional regulatory actions, as appropriate.
Until you have demonstrated lasting and effective corrective actions, Perry will remain in the
Multiple/Repetitive Degraded Cornerstone column of the NRCs Action Matrix.
In accordance with 10 CFR 2.390 of the NRC's "Rules of Practice," a copy of this letter
and its enclosure will be available electronically for public inspection in the NRC Public
Document Room or from the Publicly Available Records (PARS) component of the NRC's
document system (ADAMS), accessible from the NRC Web site at
http://www.nrc.gov/reading-rm/adams.html (the Public Electronic Reading Room).
Sincerely,
/RA/
Mark A. Satorius, Director
Division of Reactor Projects
Docket No. 50-440
License No. NPF-58
Enclosure: Inspection Report 05000440/2006008
cc w/encl: G. Leidich, President - FENOC
J. Hagan, Chief Operating Officer, FENOC
D. Pace, Senior Vice President Engineering and Services, FENOC
Director, Site Operations
Director, Regulatory Affairs
M. Wayland, Director, Maintenance Department
Manager, Regulatory Compliance
T. Lentz, Director, Performance Improvement
J. Shaw, Director, Nuclear Engineering Department
D. Jenkins, Attorney, FirstEnergy
Public Utilities Commission of Ohio
Ohio State Liaison Officer
R. Owen, Ohio Department of Health
DOCUMENT NAME: G:\Perr\ML061090843.wpd
- See previous concurrence
To receive a copy of this document, indicate in the box: C" = Copy without attachment/enclosure "E" = Copy with attachment/enclosure "N" = No
copy
OFFICE RIII N RIII N RIII RIII
NAME EDuncan for EDuncan* KOBrien* Satorius
GWright*:dtp
DATE 4/10/06 4/10/06 4/11/06 04/19/06
OFFICIAL RECORD COPY
L. Pearce -4-
ADAMS Distribution:
GYS
KNJ
SJC4
RidsNrrDirsIrib
GEG
KGO
RJP
CAA1
LSL (electronic IRs only)
C. Pederson, DRS (hard copy - IRs only)
DRPIII
DRSIII
PLB1
JRK1
ROPreports@nrc.gov (inspection reports, final SDP letters, any letter with an IR number)
U.S. NUCLEAR REGULATORY COMMISSION
REGION III
Docket No: 50-440
License No: NPF-58
Report No: 05000440/2006008
Licensee: FirstEnergy Nuclear Operating Company (FENOC)
Facility: Perry Nuclear Power Plant
Location: 10 Center Road
Perry, Ohio 44081
Dates: February 6 - March 14, 2006
Inspectors: G. Wright, Lead Inspector, Project Engineer, DRP Branch 6, RIII
R. Morris, Senior Resident Inspector - Fermi Power Plant, RIII
D. Eskins, Resident Inspector - LaSalle County Station, RIII
D. Stearns, Plant Support Branch, DRS, RIV
Approved by: Eric R. Duncan, Chief
Branch 6
Division of Reactor Projects
Enclosure
SUMMARY OF FINDINGS
IR 05000440/2006008; 2/6/2006 - 3/14/2006; Perry Nuclear Power Plant; Confirmatory Action
Letter (CAL) Followup Inspection: Corrective Action Program Effectiveness - Action Item
Implementation Inspection
This report covers a 2-week period of supplemental inspection by resident and region-based
inspectors. No findings of significance were identified during this inspection. The NRCs
program for overseeing the safe operation of commercial nuclear power reactors is described in
NUREG-1649, "Reactor Oversight Process," Revision 3, dated July 2000.
A. NRC-Identified and Self-Revealed Findings
None.
B. Licensee-Identified Violations
None.
1 Enclosure
REPORT DETAILS
1.0 Background
As a result of poor performance, the Nuclear Regulatory Commission (NRC) designated
the Perry Nuclear Power Plant as a Multiple/Repetitive Degraded Cornerstone column
facility in the NRCs Action Matrix in August 2004. A summary of the performance
issues that resulted in this designation is discussed in Attachment 2, Perry
Performance Background, of this report.
In accordance with Inspection Manual Chapter (IMC) 0305, Operating Reactor
Assessment Program, a supplemental inspection was performed in accordance with
Inspection Procedure (IP) 95003, Supplemental Inspection for Repetitive Degraded
Cornerstones, Multiple Degraded Cornerstones, Multiple Yellow Inputs, or One Red
Input. As documented in IP 95003 Supplemental Inspection Report 50-440/2005003,
the NRC determined Perry was being operated safely. The NRC also determined that
the programs and processes to identify, evaluate, and correct problems, as well as other
programs and processes in the Reactor Safety strategic performance area were
adequate.
Notwithstanding these overall conclusions, the NRC determined that the performance
problems that occurred were often the result of inadequate implementation of the
corrective action program. The IP 95003 inspection team identified that a number of
factors contributed to corrective action program problems. A lack of rigor in the
evaluation of problems was a major contributor to the ineffective corrective actions. For
example, when problems were identified, a lack of technical rigor in the evaluation of
those problems, at times, resulted in an incorrect conclusion, which in turn affected the
ability to establish appropriate corrective actions. The IP 95003 inspection team also
determined that corrective actions were often narrowly focused. In many cases a single
barrier was established to prevent a problem from recurring. However, other barriers
were also available that, if identified and implemented, would have provided a defense-
in-depth against the recurrence of problems. The IP 95003 inspection team also
identified that problems were not always appropriately prioritized, which led to the
untimely implementation of corrective actions.
A number of programmatic issues were identified that had resulted in the observed
corrective action program weaknesses. For example, the IP 95003 inspection team
identified a relatively high threshold for classifying deficiencies for root cause analysis.
As a result, few issues were reviewed in detail. In addition, for the problems that were
identified that required a root cause evaluation, the IP 95003 inspection team found that
the qualification requirements for root cause evaluators were limited and
multi-disciplinary assessment teams were not required. The IP 95003 inspection team
also identified that a lack of independence of evaluators existed. This resulted in the
same individuals repeatedly reviewing the same issues without independent and
separate review. In addition, the IP 95003 inspection team identified weaknesses in the
trending of problems, which hindered the ability to correct problems at an early stage
before they became more significant issues. Finally, the IP 95003 inspection team
determined that a lack of adequate effectiveness reviews was a barrier to the
2 Enclosure
identification of problems with corrective actions that had been implemented. A
summary of all of the IP 95003 inspection results is discussed in Attachment 3,
"Perry IP 95003 Inspection Results," of this report.
By letter dated September 30, 2004, and prior to the NRCs IP 95003 inspection
activities, FirstEnergy Nuclear Operating Company (FENOC) advised the NRC that
actions were underway to improve plant performance. To facilitate these performance
improvements, FENOC developed the Perry Performance Improvement Initiative (PII).
As documented in the IP 95003 supplemental inspection report, in the assessment of
the performance improvements planned and implemented through the PII, the NRC
determined that the PII had a broad scope and addressed many important performance
areas. The IP 95003 inspection team also observed that although substantially
completed, the PII had not resulted in a significant improvement in plant performance in
several areas, including the licensees implementation of the corrective action program.
By letters dated August 8, 2005, "Response to NRC Inspection Procedure 95003
Supplemental Inspection, Inspection Report 05000440/2005003," (ML052210512) and
August 17, 2005, "Corrections for Response to NRC Inspection Procedure 95003
Supplemental Inspection, Inspection Report 05000440/2005003," (ML052370357) the
licensee responded to the inspection results documented in the IP 95003 supplemental
inspection report.
As discussed in these letters, the Perry leadership team reviewed the achievements
realized by the PII, the results of the NRC's IP 95003 supplemental inspection activities,
and the conclusions from various additional assessments, and developed updates to the
Perry PII. The Perry leadership team restructured the PII, referred to as the Phase 2
PII, into the following six initiatives that are briefly described in Attachment 4, "Summary
of Phase 2 PII Initiatives," of this report:
- Corrective Action Program Implementation Improvement
- Excellence in Human Performance
- Training to Improve Performance
- Effective Work Management
- Employee Engagement and Job Satisfaction
- Operational Focused Organization
In addition to a discussion of the Phase 2 PII, the licensee's August 8 and August 17
letters also included actions planned to address the NRC's findings and observations
detailed in the IP 95003 supplemental inspection report. Attachment 3, "Actions to
Address Key Issues Identified in the IP 95003 Inspection Report," of these letters
focused on the following areas and summarized the actions that FENOC had taken or
planned to take to address those issues:
- Implementation of the Corrective Action Program
- Human Performance
- Performance Improvement Initiative
- IP 95002 Inspection Follow-Up Issues
- Emergency Planning
3 Enclosure
2.0 Inspection Scope
The purpose of this inspection was to review the licensees accomplishment of actions
associated with improving the implementation of the corrective action program. In
particular, this inspection focused on determining whether the commitments associated
with the corrective action program that were identified in the August 8 and 17, 2005,
letters that responded to the IP 95003 supplemental inspection report, as well as
selected completed actions prescribed in the Perry Phase 1 and Phase 2 Detailed
Action and Monitoring Plan (DAMP) to improve the corrective action program, were
adequately implemented.
To accomplish this objective, commitments and action items grouped in the following
eight areas were reviewed, consistent with Revision 5 of Perry Business Practice
(PYBP) PII-002, Performance Improvement Initiative Detailed Action and Monitoring
Plan (DAMP).
- Improve Ownership and Station Focus
- Focus on Improving the Stations Ability to Self-Identify Problems Using the
Corrective Action Program
- Focus on Prioritization of Problems Identified in the Corrective Action Program
- Improve Quality of Evaluations and Corrective Actions
- Improve Ability to Correct Problems Early Before They Become Significant
Issues
- Focus on Improving Quality of Closure Documentation
- Improve Oversight of the Corrective Action Program
- PII Phase 1 Carry Over Activities
In addition, the team reviewed validated and closed Phase 1 PII Action Items to
determine whether these items had been adequately implemented as well as key
performance indicators (KPIs) associated with the corrective action program to evaluate
the quality of the indicators and to evaluate the licensees use of the corrective action
program when the indicators suggested a decline in performance in a specific area.
3.0 Improve Ownership and Station Focus
The following Commitments and Action Items in the Improve Ownership and Station
Focus area of PYBP-PII-002, Performance Improvement Initiative Detailed Action and
Monitoring Plan (DAMP), Revision 5, were reviewed:
- Commitment 2.a: Develop expectations necessary for successful
implementation of the corrective action program (CAP). Train the site to the
expectations and the accountability methods that will be used to improve
implementation of the CAP.
- Commitment 2.b/DAMP Item I.1.2: Implement management controls to improve
line ownership and accountability at the individual level for successful
implementation of the CAP.
4 Enclosure
- DAMP Item I.1.1: Train all managers and supervisors on the role of a corrective
action program in a learning organization and how it must be used to drive
station performance improvement.
- DAMP Item I.1.5: Establish a periodic meeting for all managers and supervisors
to improve organizational alignment. Periodically brief issues with CAP and
overall performance.
newsletter.
that outlines the initiative purpose, implementation plan and success measures
that demonstrate effective improvement in corrective action program
implementation.
- DAMP Item I.1.9: Perform an interim effectiveness review of the #1 action items
in this table.
To accomplish these reviews, the team reviewed selected documentation such as
condition reports, corrective action program closure documentation, original and revised
procedures, training plans and training attendance records, meeting schedules and
minutes, and FENOC newsletters. In addition, the team conducted interviews of
cognizant licensee personnel to determine whether actions had been accomplished.
For example, in some cases the team interviewed licensee personnel whose names
appeared on training attendance sheets to determine whether these personnel had
received the subject training and to determine whether the personnel were
knowledgeable of the training material.
3.1 Commitment 2.a
a. Inspection Scope
The team reviewed Commitment 2.a: Develop expectations necessary for successful
implementation of the corrective action program (CAP). Train the site to the
expectations and the accountability methods that will be used to improve implementation
of the CAP.
The following DAMP items addressed the areas of CAP expectations development,
training, and accountability. Taken collectively, the accomplishment of these DAMP
items implemented Commitment 2.a:
- DAMP Item l.1.1: Training of supervisors, managers, and directors on CAP
implementation expectations
- DAMP Item l.1.2: CAP implementation accountability
- DAMP Item l.1.8: Communications Plan for CAP implementation
expectations and accountability
- DAMP Item l.2.1: Training of staff on CAP implementation expectations
5 Enclosure
- DAMP Item l.2.2: Development and distribution of CAP implementation
expectations
To determine whether this commitment had been adequately implemented, the team
reviewed condition reports, corrective action program closure documentation, original
and revised procedures, training plans, and training attendance records associated with
each of these DAMP items individually and collectively. In addition, the team
interviewed licensee personnel whose names appeared on training attendance sheets to
determine whether these personnel had received the subject training and to determine
whether the personnel were knowledgeable of the training material. In particular, the
team reviewed PYBP-SITE-0046, Corrective Action Program Implementation
Expectations; Nuclear Operating Business Practice (NOBP) LP-2019, Corrective
Action Program Supplemental Expectations and Guidance; and Nuclear Operating
Procedure (NOP) LP-2001, Condition Report Process, that were developed to
promulgate licensee management expectations for implementation of the corrective
action program.
b. Observations and Findings
No findings of significance were identified and the team concluded that the DAMP items
that collectively addressed Commitment 2.a were adequately implemented.
The individual DAMP items that accomplished Commitment 2.a are also discussed in
this report.
3.2 Commitment 2.b/DAMP Item I.1.2
a. Inspection Scope
The team reviewed Commitment 2.b/DAMP Item I.1.2: Implement management
controls to improve line ownership and accountability at the individual level for
successful implementation of the CAP.
To determine whether this commitment and DAMP item had been adequately
implemented, the team reviewed condition reports, corrective action program closure
documentation, and performance expectations contained in performance appraisals. In
particular, the team reviewed revisions to performance appraisal elements and
determined whether the revised appraisal elements included individual accountability for
successful implementation of the corrective action program. The team also reviewed
documentation that verified that all required appraisals had been revised.
b. Observations and Findings
No findings of significance were identified and the team concluded that the licensees
actions adequately implemented Commitment 2.b.
6 Enclosure
The licensee revised the expectations in the staff performance appraisals to address
this DAMP item. In particular, to reflect the differences in responsibility for implementing
the corrective action program, individual performance appraisal elements were modified
for each department position. Licensee personnel provided specific examples from
recent performance appraisals to demonstrate that the action item had been adequately
addressed on an individual basis.
3.3 DAMP Item I.1.1
a. Inspection Scope
The team reviewed DAMP Item I.1.1: Train all managers and supervisors on the role of
a corrective action program in a learning organization and how it must be used to drive
station performance improvement.
To determine whether this DAMP item had been adequately implemented, the team
reviewed condition reports, corrective action program closure documentation, training
plans, and training attendance records. In addition, the team conducted interviews of
cognizant licensee personnel to determine whether actions had been accomplished. In
particular, the team interviewed licensee personnel whose names appeared on training
attendance sheets to determine whether these personnel had received the subject
training and to determine whether the personnel were knowledgeable of the training
material. In addition, the team reviewed PYBP-SITE-0046, Corrective Action Program
Implementation Expectations; training course CAPC-200501_PY, Corrective Action
Program Implementation Improvement; and Condition Report (CR) 05-08057,
Disposition/Tracking of Personnel Not Trained Per CAPC-200501_PY.
b. Observations and Findings
No findings of significance were identified and the team concluded that the licensees
actions adequately implemented DAMP Item I.1.1.
The team reviewed the training material and concluded that it was adequate.
Specifically, the material addressed the role of a corrective action program in a learning
organization, FENOC and Perry management expectations for the corrective action
program in improving performance, and individual responsibilities in the implementation
of the corrective action program. The training was initially provided to managers and
supervisors, prior to being provided to all site personnel. Typical training sessions were
1 to 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br /> in length. Attendance lists were generated and individuals who were
unable to attend due to extenuating circumstances were identified. Condition
Report 05-08057, Disposition/Tracking of Personnel not Trained per
CAPC-200501_PY, was generated to identify individuals who were initially offsite and
unavailable for the training to ensure that they received the training when they returned
to the site. At the end of the inspection, licensee personnel stated that the list would be
reviewed after about 3 months and 6 months to identify if any individuals still required
the training.
7 Enclosure
The team noted that the licensee combined DAMP Item l.1.1 and DAMP Item l.2.1 and
provided the same training to all required site personnel.
3.4 DAMP Item I.1.2
Refer to Section 3.2 of this report.
3.5 DAMP Item I.1.5
a. Inspection Scope
The team reviewed DAMP Item I.1.5: Establish a periodic meeting for all managers
and supervisors to improve organizational alignment. Periodically brief issues with CAP
and overall performance.
To determine whether this DAMP item had been adequately implemented, the team
reviewed condition reports, corrective action program closure documentation, training
plans, and training attendance records. In particular, the team reviewed training plan
SSC-200502_PY-01, Supervisory Continuing Training, which included corrective action
program elements and was used during periodic manager/supervisor meetings
designed to improve organizational alignment. Team members also attended a
manager/supervisor meeting on February 16, 2006, where corrective action program
implementation expectations were discussed.
b. Observations and Findings
No findings of significance were identified and the team concluded that the licensees
actions adequately implemented DAMP Item I.1.5.
The training material associated with SSC-200502_PY-01 was of appropriate depth and
breadth to establish an adequate understanding of managements expectations for
corrective action program implementation and management/supervisory oversight of
work activities. The observed management meeting included appropriate reinforcement
of corrective action program implementation expectations.
3.6 DAMP Item I.1.6
a. Inspection Scope
The team reviewed DAMP Item I.1.6: Publicize CAP success stories in the FENOC
fleet newsletter.
To determine whether this DAMP item had been adequately implemented, the team
reviewed condition reports, corrective action program closure documentation, and
FENOC fleet newsletters. In particular, the team reviewed FENOC fleet newsletters to
8 Enclosure
identify where corrective action program success stories had been published, corrective
action (CA) 05-07233-03, and PYBP-PII-0006, Process Improvement Initiative
Process.
b. Observations and Findings
No findings of significance were identified; however, the team concluded that the
licensees actions had not adequately implemented DAMP Item D.1.6.
The team identified that the only CAP success story that had been published appeared
in the November 17, 2005, FENOC fleet newsletter. DAMP Item I.1.6 was closed after
that newsletter was published. However, PYBP-PII-0006, Process Improvement
Initiative Process, prescribed DAMP item closure only after several examples of an
action involving periodic activities had been accomplished. Following discussions with
the team, licensee personnel stated that additional stories would be published.
The team also concluded that due to a lack of quality and attention to detail, licensee
personnel failed to identify that this DAMP item had not been adequately implemented
during the DAMP item review and closure process. However, since the inadequate
closure of DAMP Item I.1.6 had no actual impact on the facility, the issue was of only
minor significance.
3.7 DAMP Item I.1.8
a. Inspection Scope
The team reviewed DAMP Item I.1.8: Develop and communicate a CAP PII
Communication Plan that outlines the initiative, purpose, implementation plan and
success measures that demonstrate effective improvement in corrective action program
implementation.
To determine whether this DAMP item had been adequately implemented, the team
reviewed condition reports, corrective action program closure documentation, and
original and revised procedures. In particular, the team reviewed the licensees CAP
Improvement Plan: Communications Roadmap, to determine whether the plan
adequately outlined the elements contained in the DAMP item for the improvement of
the corrective action program. The team also reviewed a summary of the actions taken
to address the individual items in the communications roadmap to determine whether
those actions had been properly implemented.
b. Observations and Findings
No findings of significance were identified and the team concluded that the licensees
actions adequately implemented DAMP Item I.1.8.
The CAP Improvement Plan: Communications Roadmap included the initiative and
purpose prescribed by the DAMP item. Training requirements, necessary management
9 Enclosure
enhancements, Corrective Action Review Board (CARB) improvements, root cause
improvements, and performance monitoring improvements were also included to
address the implementation plan and success measure aspects of the DAMP item. The
team also determined that the actions prescribed by the plan had been adequately
implemented.
3.8 DAMP Item I.1.9
a. Inspection Scope
The team reviewed DAMP Item I.1.9: Perform an interim effectiveness review of the #1
action items in this table.
To determine whether this DAMP item had been adequately implemented, the team
reviewed condition reports, corrective action program closure documentation, and
self-assessment documentation. In particular, the team reviewed Snapshot Assessment
810PII2005, Perry Nuclear Power Plant Performance Improvement Initiative -
Corrective Action Program Implementation Effectiveness, conducted as an interim
effectiveness review, and assessed how well it had been performed; and
CA 05-07223-05, which implemented the DAMP item.
b. Observations and Findings
No findings of significance were identified and the team concluded that the licensees
actions adequately implemented DAMP Item I.1.9.
The team noted that the assessment was thorough and identified a number of issues
that warranted additional licensee attention. Issues identified in the assessment
included incomplete supervisor and worker understanding of corrective action program
implementation expectations, and the untimely completion of root cause and apparent
cause evaluations.
4.0 Focus on Improving the Stations Ability to Self-Identify Problems Using the
Corrective Action Program
The following action items in the Focus on Improving the Stations Ability to Self-Identify
Problems Using the Corrective Action Program area of PYBP-PII-002, Performance
Improvement Initiative Detailed Action and Monitoring Plan (DAMP), Revision 5, were
reviewed:
- DAMP Item I.2.1: Train site personnel to the expectations and accountability
methods that will be used to improve implementation of the CAP.
- DAMP Item I.2.2: Develop and distribute an expectations document to reinforce
the requirements of NOP-LP-2001 and the behaviors necessary for successful
implementation of the CAP. This is similar to DB [Davis-Besse] expectations
document DBBP-PI-2000 CR Process Expectations.
10 Enclosure
- DAMP Item I.2.3: Implement a plan to routinely perform cross-functional
walkdowns of risk-significant systems. These walkdowns should include
management supervision, system engineering and craft performing a joint
walkdown with a focus on improving expectations and standards for identification
of problems. Schedule walkdowns monthly.
To accomplish these reviews, the team reviewed selected documentation such as
condition reports, corrective action program closure documentation, original and revised
procedures, training plans and training attendance records, system walkdown
schedules, and documentation regarding walkdown observations. In addition, the team
conducted interviews of cognizant licensee personnel to determine whether actions had
been accomplished. For example, in some cases the team interviewed licensee
personnel on licensee training attendance sheets to determine whether these personnel
had received the subject training.
4.1 DAMP Item I.2.1
a. Inspection Scope
The team reviewed DAMP Item I.2.1: Train site personnel to the expectations and
accountability methods that will be used to improve implementation of the CAP.
To determine whether this DAMP item had been adequately implemented, the team
reviewed condition reports, corrective action program closure documentation, original
and revised procedures, training plans, and training attendance records. In addition, the
team conducted interviews of cognizant licensee personnel to determine whether
actions had been accomplished. In particular, the team interviewed licensee personnel
whose names appeared on training attendance sheets to determine whether these
personnel had received the subject training and to determine whether the personnel
were knowledgeable of the training material. In addition, the team reviewed
PYBP-SITE-0046, Corrective Action Program Implementation Expectations; training
course CAPC-200501_PY, Corrective Action Program Implementation Improvement;
and Condition Report (CR) 05-08057, Disposition/Tracking of Personnel Not Trained
Per CAPC-200501_PY.
b. Observations and Findings
No findings of significance were identified and the team concluded that the licensees
actions adequately implemented DAMP Item I.2.1.
As was discussed in DAMP Item I.1.1, the team reviewed the training material and
concluded that it was adequate. In particular, the material addressed the role of the
corrective action program in a learning organization, FENOC and Perry management
expectations for the corrective action program in improving performance, and individual
responsibilities in the implementation of the corrective action program. The training was
initially provided to managers and supervisors, prior to being provided to all site
personnel. Typical training sessions were 1 to 2 hours2.314815e-5 days <br />5.555556e-4 hours <br />3.306878e-6 weeks <br />7.61e-7 months <br /> in length. Attendance lists were
11 Enclosure
generated and individuals who were unable to attend due to extenuating circumstances
were identified. Condition Report 05-08057 was generated to identify individuals who
were initially offsite and unavailable for the training to ensure that they received the
training when they returned to the site. At the end of the inspection, licensee personnel
stated that the list would be reviewed after about 3 months and 6 months to identify if
any individuals still required the training.
The team noted that the licensee combined DAMP Item l.1.1 and DAMP Item l.2.1, and
provided the same training to all required site personnel.
4.2 DAMP Item I.2.2
a. Inspection Scope
The team reviewed DAMP Item I.2.2: Develop and distribute an expectations
document to reinforce the requirements of NOP-LP-2001 and the behaviors necessary
for successful implementation of the CAP. This is similar to DB [Davis-Besse]
expectations document DBBP-PI-2000 CR Process Expectations.
To determine whether this DAMP item had been adequately implemented, the team
reviewed condition reports and corrective action program closure documentation. In
particular, the team reviewed CR 05-02725, Substantive Cross-Cutting Issue, Problem
Identification and Resolution; CR 05-03986, Nuclear Oversight Audit PY-C-05-01; and
PYBP-SITE-0046, Corrective Action Program Implementation Expectations. The team
also reviewed handout, FENOC CR Initiation Guidance, that the licensee developed to
provide additional guidance concerning issues that should be documented in a condition
report, specifically identify procedures related to the condition reporting process, and
discuss condition reporting documentation timeliness goals.
b. Observations and Findings
No findings of significance were identified and the team concluded that the licensees
actions adequately implemented DAMP Item I.2.2.
The team determined that the documents reviewed adequately reinforced NOP-LP-2001
and prescribed the behaviors necessary for the successful implementation of the
corrective action program. However, the team determined that due to a lack of quality
and attention to detail, during the DAMP item review and closure process, licensee
personnel failed to address whether PYBP-SITE-0046 and a handout entitled FENOC
CR Initiation Guidance, had been distributed to the staff. The team independently
determined that these documents were appropriately made available to licensee
personnel both electronically and during training. Licensee personnel generated
CR 06-00576, DAMP Item I.2.2. Did Not Provide Complete Closure Documentation, to
enter this issue into the corrective action program.
12 Enclosure
4.3 DAMP Item I.2.3
a. Inspection Scope
The team reviewed DAMP Item I.2.3: Implement a plan to routinely perform
cross-functional walkdowns of risk-significant systems. These walkdowns should
include management supervision, system engineering and craft performing a joint
walkdown with a focus on improving expectations and standards for identification of
problems. Schedule walkdowns monthly.
To determine whether this DAMP item had been adequately implemented, the team
reviewed condition reports, corrective action program closure documentation, and
original and revised procedures. In addition, the team conducted interviews of cognizant
licensee personnel to determine whether actions had been accomplished. Specifically,
the team reviewed procedures and guidance for system walkdowns including refresher
training ESPC-SYS0503_PY, System Walkdown Refresher Training; and Plant
Engineering Section Policy (PESP) 9, System Walkdowns. In addition, to assess the
quality of the walkdowns, the team reviewed a sample of supervisory Observation Cards
completed during system walkdowns and observed a system walkdown of the Main
Generator and Exciter system. The team also reviewed PYBP-POS-1-11, Operations
Section System Ownership.
b. Observations and Findings
No findings of significance were identified and the team concluded that the licensees
actions adequately implemented DAMP Item I.2.3.
Although the team concluded that DAMP Item l.2.3 had been adequately implemented,
the team identified that documents and training that addressed system walkdowns were
inconsistent and prescribed different types and frequencies of walkdowns. For example,
CR 05-02725, Substantive Cross-Cutting Issue, Problem Identification and Resolution,
stated that paired system walkdowns would be conducted once; PESP-09, System
Walkdowns, stated that walkdowns would be performed bi-weekly and quarterly; and
training provided to the system engineers prescribed monthly paired walkdowns. These
inconsistencies were discussed with a system engineer who stated that his instructions
regarding the paired walkdown program were to perform the walkdowns monthly.
Based on the teams observations, licensee personnel planned to revise PESP-09 to
clearly establish the requirements for monthly paired walkdowns.
The team concluded that due to a lack of quality and attention to detail, licensee
personnel failed to identify the inconsistencies described above during the item
resolution and closure process.
The team also noted that the practice of conducting a cross-functional walkdown as
reflected in the DAMP item was not adopted. Discussions with licensee personnel
confirmed that the change to the scope of the DAMP item had been reviewed and
approved in accordance with licensee procedures.
13 Enclosure
The team also identified that although supervisors evaluated system walkdown activities
on an Observation Card, most supervisors did not consistently evaluate all applicable
areas listed on the Observation Card during their observations. For example, most
observations conducted within the radiologically controlled area (RCA) did not include an
evaluation of the use of personal safety equipment, such as eye and hearing protection;
or the implementation of radiation safety practices, such as the obtaining of and use of
radiation dosimetry, although personal safety equipment and dosimetry were required
for entry into the RCA.
In addition to the specific engineering paired walkdowns, the team noted that
PYBP-POS-1-11, Operations Section System Ownership, encouraged operations
personnel to take individual responsibility for equipment operation and reliability.
Non-licensed operators were assigned ownership for individual systems to foster
increased equipment reliability. The operation system owners participated in outage
scope, design change evaluations, system health input, and walkdowns. The team
concluded that this positive initiative had the potential to improve system reliability.
5.0 Focus on Prioritization of Problems Identified in the Corrective Action Program
The following action items in the Focus on Prioritization of Problems Identified in the
Corrective Action Program area of PYBP-PII-002, Performance Improvement Initiative
Detailed Action and Monitoring Plan (DAMP), Revision 5, were reviewed:
- DAMP Item I.3.1: Revise procedure NOP-LP-2001, Corrective Action
Program, to provide guidance for initiation of a significant root cause evaluation
at a lower threshold (i.e. issues that may not be significant but are considered to
be a negative trend, repeat issues, and adverse trend).
- DAMP Item I.3.2: Implement a two-step screening process in accordance with
PYBP-SITE-0045, Initial Screening Committee to improve objectivity,
consistency, and cognitive trending of new condition reports. Also include
assignment of due dates based on the significance of issues.
- DAMP Item I.3.3: Adopt controls to assure proper thresholds are set for human
and organizational performance issues and prevent splitting and relegating these
issues to lower classification.
- DAMP Item I.3.4: Determine the appropriate number and select appropriate
individuals to obtain RCE [root cause evaluation] and/or ACE [apparent cause
evaluation] qualification.
- DAMP Item I.3.5: Revise procedure NOBP-LP-2007, Condition Report Process
Effectiveness Review, to include specific guidance for performing early
effectiveness reviews (i.e. based on negative trends) and to include
requirements for evaluation when actions taken were determined to be
ineffective.
14 Enclosure
To accomplish these reviews, the team reviewed selected documentation such as
condition reports, corrective action program closure documentation, original and revised
procedures, and meeting schedules and minutes. In addition, the team conducted
interviews of cognizant licensee personnel to determine whether actions had been
accomplished.
5.1 DAMP Item I.3.1
a. Inspection Scope
The team reviewed DAMP Item I.3.1: Revise procedure NOP-LP-2001, Corrective
Action Program, to provide guidance for initiation of a significant root cause evaluation
at a lower threshold (i.e. issues that may not be significant but are considered to be a
negative trend, repeat issues, and adverse trend).
To determine whether this DAMP item had been adequately implemented, the team
reviewed condition reports, corrective action program closure documentation, and
original and revised procedures. In particular, the team reviewed NOP-LP-2001,
Corrective Action Program; and NOBP-LP-2019, Corrective Action Program
Supplemental Expectations and Guidance.
b. Observations and Findings
No findings of significance were identified and the team concluded that the licensees
actions adequately implemented DAMP Item I.3.1.
Overall, the procedures contained appropriate guidance and prescribed an adequate,
lower threshold for conducting root cause evaluations. However, during the review the
team identified a discrepancy in NOBP-LP-2019, Corrective Action Program
Supplemental Expectations and Guidance. In the Other category of NOBP-LP-2019,
the identification of organizational-based adverse trends was restricted to those that had
an actual impact on safety, rather than those that had impacted or could impact safety
as specified in other sections of NOBP-LP-2019. Licensee personnel generated
CR 06-00636, DAMP Item I.3.1 Inadvertent Omission from Attachment 1 of
NOBP-LP-2019, to enter this issue into the corrective action program.
The team concluded that due to a lack of quality and attention to detail, licensee
personnel failed to identify this error during the item resolution and closure process.
5.2 DAMP Item I.3.2
a. Inspection Scope
The team reviewed DAMP Item I.3.2: Implement a two-step screening process in
accordance with PYBP-SITE-0045, Initial Screening Committee to improve objectivity,
consistency, and cognitive trending of new condition reports. Also include assignment
of due dates based on the significance of issues.
15 Enclosure
To determine whether this DAMP item had been adequately implemented, the team
reviewed condition reports, corrective action program closure documentation, and
original and revised procedures. In particular, the team reviewed PYBP-SITE-0045,
Initial Screening Committee, and attended an initial screening meeting and a
Management Review Board (MRB) meeting conducted on February 7, 2006.
b. Observations and Findings
No findings of significance were identified and the team concluded that the licensees
actions adequately implemented DAMP Item I.3.2.
By direct observation, the team determined that the licensee had implemented a
two-step screening process that improved the objectivity, consistency, and cognitive
trending of new condition reports; and assigned due dates based on the significance of
issues. Through this process, a condition report was sent to the Initial Screening
Committee (ISC) for review and discussion, and then to the Management Review Board
(MRB) for final approval. Subsequently, the MRB ensured that the condition report was
appropriately screened for Category, Assigned Group, and Due Date. The MRB
also discussed complicated and/or significant condition reports. The ISC was instituted
by procedure, with required training for its members, and was accountable to the MRB.
Although not directly associated with the accomplishment of this DAMP item, the team
noted that the licensee did not compare initial and final Category determinations
between the ISC and MRB. The team concluded that this was a missed opportunity to
monitor the alignment between supervisors and managers. Licensee personnel
generated CR 06-00589, No Indicators to Track Deltas from Condition Report
Categorizations, to enter this issue into the corrective action program.
5.3 DAMP Item I.3.3
a. Inspection Scope
The team reviewed DAMP Item I.3.3: Adopt controls to assure proper thresholds are
set for human and organizational performance issues and prevent splitting and
relegating these issues to lower classification.
To determine whether this DAMP item had been adequately implemented, the team
reviewed condition reports, corrective action program closure documentation, and
original and revised procedures. In particular, the team reviewed NOBP-LP-2011,
FENOC Cause Analysis; and NOBP-LP-2019, Attachment 1, Condition Report
Category and Activity Tracking Descriptions, and Attachment 2, Condition Report
Evaluation Methods.
b. Observations and Findings
No findings of significance were identified and the team concluded that the licensees
actions adequately implemented DAMP Item I.3.3.
16 Enclosure
The team identified that the closure documentation had not credited the revision to
NOBP-LP-2011, which was necessary for closure of the DAMP item. However, through
discussions with licensee personnel, the team determined that Revision 3 to
NOBP-LP-2011, FENOC Cause Analysis, specifically addressed the DAMP item.
Licensee personnel generated CR 06-0604, DAMP Item I.3.3 Did Not Provide
Complete Closure Documentation, to enter this issue into the corrective action
program.
The team concluded that due to a lack of quality and attention to detail, licensee
personnel failed to identify that the item closure documentation associated with this
DAMP item was not adequate to close the item during the item closure process.
5.4 DAMP Item I.3.4
a. Inspection Scope
The team reviewed DAMP Item I.3.4: Determine the appropriate number and select
appropriate individuals to obtain RCE and/or ACE qualification.
To determine whether this DAMP item had been adequately implemented, the team
reviewed condition reports, corrective action program closure documentation, and
original and revised procedures. In particular, the team reviewed CA 05-01043-7, which
prescribed the assessment of resource needs for root cause and apparent cause
evaluators and CR analysts, followed by the assignment of individuals to fill those
positions.
b. Observations and Findings
No findings of significance were identified and the team concluded that the licensees
actions adequately implemented DAMP Item I.3.4.
The subject DAMP item prescribed that for each department, licensee personnel identify
and select the appropriate number of evaluators needed to support root cause and
apparent cause evaluations. Corrective Action 05-01043-7, which implemented this
DAMP item, prescribed that in addition to the identification and selection of root cause
and apparent cause evaluators, that additional necessary personnel to support the
CR Analyst position also be identified and selected.
During the review of CA 05-01043-7, the inspectors determined that the licensees
actions adequately implemented the DAMP item. However, the team also identified that
licensee personnel had not identified or selected the individuals to support the
CR Analyst position, although CA 05-01043-7 had been closed.
To address this issue, licensee personnel generated CR 06-00697, DAMP Item I.3.4
Closed Correctly However, Reference CA Not Complete, to enter this issue into the
corrective action program. Subsequently, licensee personnel identified the number of
CR analysts needed. The team verified that the appropriate number of CR analysts
17 Enclosure
were either trained or scheduled to attend training to meet necessary CR analyst
staffing levels.
The team concluded that the closure of CA 05-01043-7 was premature since all
CR Analyst positions had not been filled as required by CA 05-01043-7. However, since
the issue was associated with the staffing levels of CR analysts, and there had been no
identified impact on the facility during the period the issue existed, the issue was of only
minor significance.
5.5 DAMP Item I.3.5
a. Inspection Scope
The team reviewed DAMP Item I.3.5: Revise procedure NOBP-LP-2007, Condition
Report Process Effectiveness Review, to include specific guidance for performing early
effectiveness reviews (i.e. based on negative trends) and to include requirements for
evaluation when actions taken were determined to be ineffective.
To determine whether this DAMP item had been adequately implemented, the team
reviewed condition reports, corrective action program closure documentation, and
original and revised procedures. In particular, the team reviewed NOBP-LP-2007,
Condition Report Process Effectiveness Review, and CA 05-07233-7.
b. Observations and Findings
No findings of significance were identified; however, the team concluded that the
licensees actions had not adequately implemented DAMP Item I.3.5.
The team reviewed NOBP-LP-2007, Condition Report Process Effectiveness Review,
and confirmed that it eliminated the nominal 6 month guideline for performing
effectiveness reviews and added the evaluation of corrective action effectiveness at the
earliest practical opportunity. In addition, the process incorporated a corrective action
effectiveness review following a challenge to a system, component, or process,
sufficient to evaluate whether the corrective actions were effective.
However, the team identified that the procedure failed to address the performance of
early effectiveness reviews based on, for example, negative trends. Licensee personnel
generated CR 06-0080, DAMP Items I.3.5 and I.8.4 Incomplete, to enter this issue into
the corrective action program.
The team concluded that the licensees actions had not adequately implemented
DAMP Item I.3.5. The team also concluded that due to a lack of quality and attention to
detail, licensee personnel failed to identify that this DAMP item had not been adequately
implemented during the DAMP item review and closure process. However, since the
inadequate closure of DAMP Item I.3.5 had no actual impact on the facility, the issue
was of only minor significance.
18 Enclosure
6.0 Improve Quality of Evaluations and Corrective Actions
The following action items in the Improve Quality of Evaluations and Corrective Actions
area of PYBP-PII-002, Performance Improvement Initiative Detailed Action and
Monitoring Plan (DAMP), Revision 5, were reviewed:
- DAMP Item I.4.2: Strengthen the root cause investigators training plan and
qualification requirements (JFG) [Job Familiarization Guidelines].
- DAMP Item I.4.4: Improve implementation of FENOC NOBP-LP-2007,
Condition Report Effectiveness Review, to improve challenging of the adequacy
of the actions taken. Utilize periodic effectiveness reviews rather than a single
review at the end of completing all CAs.
- DAMP Item I.4.5: Manager pre-job brief all apparent cause evaluations and
establish scope, expected resource investment, analytical techniques and
guidance for evaluation of generic implications. Ensure evaluator(s) have
appropriate skill set. Identify where mentoring is required to improve critical
thinking. The desired outcome is improvement in technical rigor.
To accomplish these reviews, the team reviewed selected documentation such as
condition reports, corrective action program closure documentation, original and revised
procedures, pre-job briefing records, and qualification records. In addition, the team
conducted interviews of cognizant licensee personnel to determine whether actions had
been accomplished.
6.1 DAMP Item I.4.2
a. Inspection Scope
The team reviewed DAMP Item I.4.2: Strengthen the root cause investigators training
plan and qualification requirements (JFG).
To determine whether this DAMP item had been adequately implemented, the team
reviewed condition reports, corrective action program closure documentation, original
and revised procedures, training plans, and training attendance records. In particular,
the team reviewed NOBP-TR-1111-01, Corrective Action Program (CAP) Training
Program; Training Plan 9903, Root Cause Evaluator; Training Plan 9908, Corrective
Action Review Board (CARB) Member; and the training requirements specified in
CAP-RCA_FEN, FENOC Root Cause Evaluation Basic Training; CAP-RCT_FEN,
FENOC Root Cause Evaluation Advanced Training; and CAP-JFGRCE_FEN, Root
Cause Evaluator Job Familiarization Guide. In addition, the team interviewed Perry and
FENOC training management personnel.
19 Enclosure
b. Observations and Findings
No findings of significance were identified; however, the team concluded that the
licensees actions had not adequately implemented DAMP Item I.4.2.
To strengthen the root cause evaluator training plan and qualification requirements,
licensee personnel modified the training and certification program to require a 5 day root
cause methodology-specific training course, removed the previous 2 day training course
as an acceptable method for certification, and added a generic root cause training
course. The generic training course also prescribed that the expectations for performing
root cause evaluations be discussed.
In reviewing these changes, the team determined that the training was managed by
FENOC corporate office personnel. In addition, the team determined that the generic
root cause training course had not been fully developed and that the only action that had
been implemented was to place a non-specific course description in the training plan.
The team also determined that this revised training and certification program had been
approved and implemented in December 2005.
Based on the above information, the team inquired about the controls in place to prevent
the corporate office from inadvertently revising the training requirements or the content
of lesson plans in a manner that would nullify the outcomes prescribed by the DAMP
item. Further, because the training program required a course for which no lesson plan
existed and no waivers had been granted, the team questioned the certification of
individuals currently performing root cause evaluations and the certification of Corrective
Action Review Board (CARB) members for root cause training.
During followup discussions, the team identified that although FENOC corporate office
personnel had issued the proposed training and certification program revision to the site
for review, the training organization, responsible for tracking certifications, had not been
provided a copy for review. Further, no mechanism existed to ensure that the results of
the implementation of DAMP items were not inadvertently nullified through the issuance
of a revised business practice. This team concluded that the licensees coordination
effort did not appropriately ensure that organizations were provided the opportunity to
review the changes prior to their implementation. Licensee personnel generated
CR 06-00630, No Process Exists to Prevent Inadvertent Changes to Closed PII
Actions, to enter this issue into the corrective action program.
While addressing the teams question regarding individual certifications, site and
FENOC corporate training personnel realized they had not adhered to site procedures or
the change management plan when implementing the revised training and certification
program. In an attempt to correct the situation, FENOC corporate office personnel
issued a memorandum dated February 10, 2006, which stated that all individuals
remained certified. However, the team identified that the memorandum was not
consistent with site procedures since the granting of a waiver required the evaluation of
an individuals qualification against the original and revised lesson plans and, as
20 Enclosure
previously stated, no revised lesson plan existed for the generic root cause training
course.
On February 17, 2006, licensee personnel informed the team that they planned to
re-implement the previous training and certification program that existed prior to the
revisions. Licensee personnel also generated CR 06-00784, Issues With
Implementation of Revised CAP Training, to review the condition and review individual
certifications while the revised program was in effect.
The team also noted that DAMP l.4.2 prescribed that the generic root cause training
course would include FENOC specific expectations for conduct of a root cause
evaluation. However, the team identified that the course description did not specify
what would be included in the training course.
The team further noted that although completion of only one of the four 5 day
methodology-specific training course was required for certification as a root cause
evaluator, the root cause evaluator training course description listed all four
methodology-specific 5 day training courses as prerequisites for root cause evaluator
certification.
The team also noted that NOBP-LP-2011, Section 4.5.3, stated, Appropriate
methodologies should be selected by the investigators and used appropriately.
However, the practice did not require that the individual(s) making the determination of
which method to use be qualified in the selected method.
The team concluded that DAMP Item I.4.2 had not been adequately implemented since
the actions taken by licensee personnel had not strengthened the root cause
investigators training plan and qualification requirements. The team also concluded that
due to a lack of quality and attention to detail, licensee personnel failed to identify that
this DAMP item had not been adequately implemented during the DAMP item review
and closure process. However, because the inadequate closure of DAMP Item I.4.2
had no actual impact on the facility, the issue was of only minor significance.
6.2 DAMP Item I.4.4
a. Inspection Scope
The team reviewed DAMP Item I.4.4: Improve implementation of FENOC NOBP-LP-
2007, Condition Report Effectiveness Review, to improve challenging of the adequacy
of the actions taken. Utilize periodic effectiveness reviews rather than a single review at
the end of completing all CAs.
To determine whether this DAMP item had been adequately implemented, the team
reviewed condition reports, corrective action program closure documentation, original
and revised procedures, and attended a CARB meeting. In particular, the team
reviewed CA 05-07223-11 and NOBP-LP-2007, Condition Report Process
Effectiveness Review. In addition, team members attended a February 10, 2006
21 Enclosure
CARB meeting and observed the discussion of effectiveness reviews associated with
CR 05-05260, Closed Cooling Chemistry Out of Admin Specification.
b. Observations and Findings
No findings of significance were identified and the team concluded that the licensees
actions adequately implemented DAMP Item I.4.4.
The team determined that through completion of CA 05-07223-11, NOBP-LP-2007,
Condition Report Process Effectiveness Review, had been revised to prescribe interim
effectiveness reviews to improve the challenging of the adequacy of actions taken. The
effectiveness reviews as described in NOBP-LP-2007 prescribed an appropriate scope
and were required to be completed prior to closing the subject condition report. The
team also noted that condition reports that prescribed apparent cause and root cause
evaluations also received a final effectiveness review. In addition, team members
observed, during the February 10, 2006 CARB meeting, that managers exhibited many
of the behaviors the licensee had described in its expectations for successful
implementation of the corrective action program. The team also noted that the MRB
reviewed the CR list weekly to identify candidates for early effectiveness reviews.
6.3 DAMP Item I.4.5
a. Inspection Scope
The team reviewed DAMP Item I.4.5: Manager pre-job brief all apparent cause
evaluations and establish scope, expected resource investment, analytical techniques
and guidance for evaluation of generic implications. Ensure evaluator(s) have
appropriate skill set. Identify where mentoring is required to improve critical thinking.
The desired outcome is improvement in technical rigor.
To determine whether this DAMP item had been adequately implemented, the team
reviewed condition reports, corrective action program closure documentation, and
original and revised procedures. In addition, the team conducted interviews of cognizant
licensee personnel to determine whether actions had been accomplished. In particular,
the team reviewed PYBP-SITE-0046, Corrective Action Program Implementation
Expectations, and the Apparent Cause Expectation brochure.
b. Observations and Findings
No findings of significance were identified and the team concluded that the licensees
actions adequately implemented DAMP Item I.4.5.
The team noted that the licensee had developed a guidance document for pre-job
briefings. In reviewing the document, the team identified that the licensee had
exceeded the actions prescribed in DAMP l.4.5.
22 Enclosure
During the pre-job briefing process review, the team determined that the guidance
addressed when a pre-job briefing was to be conducted, and how to document the
briefing for root cause evaluations; however, no written guidance existed for pre-job
briefings for apparent cause evaluations. During followup discussions with licensee
personnel, the team verified that pre-job briefings were being conducted for apparent
cause evaluations; however, without written guidance, the long-term ability to sustain the
effort was questionable.
The team also identified a discrepancy in the Closure Documentation Summary for
DAMP Item 4.5. The documentation stated, ...each day at the MRB, the MRB
Chairperson discusses the need for the pre-job brief with each Manager and refers them
to the Apparent Cause Expectation brochure to be used in the Apparent Cause
investigation pre-job brief. During followup discussions, the team was informed that the
actual expectation was that the MRB Chairperson would discuss the need for a pre-job
briefing on Tuesdays and any time a new apparent cause evaluation was brought before
the MRB.
The team also identified that although the DAMP item stated, Identify where mentoring
is required to improve critical thinking, there was no documentation that required this to
be accomplished or evidence that it had been accomplished. The team also identified
that the closure package review did not identify this deficiency.
The team concluded that notwithstanding the omission of actions to address mentoring
to improve critical thinking, the licensees completed actions were sufficient to consider
this DAMP item, overall, to have been adequately implemented.
The team also concluded that due to a lack of quality and attention to detail, licensee
personnel failed to identify that some aspects of this DAMP item had not been
implemented during the DAMP item resolution and closure process.
7.0 Improve Ability to Correct Problems Early Before They Become Significant Issues
The following action items in the Improve Ability to Correct Problems Early Before They
Become Significant Issues area of PYBP-PII-002, Performance Improvement Initiative
Detailed Action and Monitoring Plan (DAMP), Revision 5, were reviewed:
- DAMP Item I.5.1: Perform a focused self-assessment of the results of
Integrated Performance Assessment Trending to provide feedback on quality
and to identify site-wide trends.
- DAMP Item I.5.4: Develop guidance and implement a CAP focus day to identify
and eliminate lower tier CAP open items.
To accomplish these reviews, the team reviewed selected documentation such as
condition reports, corrective action program closure documentation, self-assessment
reports, original and revised procedures, training plans and training attendance records,
23 Enclosure
and meeting schedules and minutes. In addition, the team conducted interviews of
cognizant licensee personnel to determine whether actions had been accomplished.
7.1 DAMP Item I.5.1
a. Inspection Scope
The team reviewed DAMP Item I.5.1: Perform a focused self-assessment of the results
of Integrated Performance Assessment Trending to provide feedback on quality and to
identify site-wide trends.
To determine whether this DAMP item had been adequately implemented, the team
reviewed condition reports, corrective action program closure documentation, and
self-assessment reports. In addition, the team conducted interviews of cognizant
licensee personnel to determine whether actions had been accomplished. In particular,
the team reviewed self-assessment FL-SA-05-05, Self-Assessment of Integrated
Performance Assessment Trending, dated December 14, 2005, and CA 05-07223-13.
b. Observations and Findings
No findings of significance were identified and the team concluded that the licensees
actions adequately implemented DAMP Item I.5.1.
The licensees self-assessment identified that the overall implementation of trending
activities was marginally effective and statistical trending of condition reporting data was
ineffective. The self-assessment appeared to be thorough and comprehensive.
Condition reports were generated to enter the issues identified in the assessment into
the licensees corrective action program.
7.2 DAMP Item I.5.4
a. Inspection Scope
The team reviewed DAMP Item I.5.4: Develop guidance and implement a CAP focus
day to identify and eliminate lower tier CAP open items.
To determine whether this DAMP item had been adequately implemented, the team
reviewed condition reports, corrective action program closure documentation, and
meeting schedules and minutes. In addition, the team conducted interviews of
cognizant licensee personnel to determine whether actions had been accomplished.
Specifically, the team reviewed a document entitled Criteria for CAP Focus Day, and
CARB meeting minutes for a CARB meeting conducted on October 27, 2005. In
addition, team members attended the February 13, 2006 CAP Focus Day meeting.
24 Enclosure
b. Observations and Findings
No findings of significance were identified and the team concluded that the licensees
actions adequately implemented DAMP Item I.5.4.
The CAP Focus Day was developed to review, and evaluate for elimination, any
corrective actions that had not been implemented, or actions that had been assigned for
implementation with a due date of greater than 360 days. The criteria developed for the
CAP Focus Day was implemented at the first CAP Focus Day meeting held on
October 25, 2005. Based upon the observation of the February 13, 2006, CAP Focus
Day meeting, the team concluded that the licensee had established an adequate
method to eliminate lower tier CAP open items through a CAP Focus Day.
8.0 Focus on Improving Quality of Closure Documentation
The following action items in the Focus on Improving Quality of Closure
Documentation area of PYBP-PII-002, Performance Improvement Initiative Detailed
Action and Monitoring Plan (DAMP), Revision 5, were reviewed:
- DAMP Item I.6.1: Establish the Corrective Action Closure Board (CACB) as
having review authority for apparent cause evaluations. Establish a quorum that
requires one CARB member.
- DAMP Item I.6.2: Provide feedback on CACB determinations to CR analysts,
CARB, and managers.
To accomplish these reviews, the team reviewed selected documentation such as
condition reports, corrective action program closure documentation, original and revised
procedures, feedback forms, and meeting schedules and minutes. In addition, the team
conducted interviews of cognizant licensee personnel to determine whether actions had
been accomplished.
8.1 DAMP Item I.6.1
a. Inspection Scope
The team reviewed DAMP Item I.6.1: Establish the Corrective Action Closure Board
(CACB) as having review authority for apparent cause evaluations. Establish a quorum
that requires one CARB member.
To determine whether this DAMP item had been adequately implemented, the team
reviewed condition reports, corrective action program closure documentation, original
and revised procedures, and meeting schedules and minutes. In addition, the team
conducted interviews of cognizant licensee personnel to determine whether actions had
been accomplished. Specifically, the team reviewed PYBP-SITE-0042, Corrective
Action Closure Board Charter; and the October 20, 2005 CACB meeting agenda.
25 Enclosure
b. Observations and Findings
No findings of significance were identified and the team concluded that the licensees
actions adequately implemented DAMP Item I.6.1.
The team identified that the CACB had been established, and had been provided the
authority to review apparent cause evaluations through the implementation of
PYBP-SITE-0042, Corrective Action Closure Board Charter. The CACB had
performed this function through December 2005 when the CACB was suspended due to
the unavailability of resources. Although the licensee planned to reinstate the CACB,
the backlog of CAs and CRs requiring review continued to increase. At the end of the
inspection, there were about 700 CAs and 270 CRs that required CACB review. In
addition, there were a number of apparent cause and root cause evaluations in progress
that would also require CACB review.
Although the team concluded that the DAMP item had been adequately implemented at
the time the DAMP item was closed, the decision to suspend the CACB activities
affected the effectiveness of the actions.
8.2 DAMP Item I.6.2
a. Inspection Scope
The team reviewed DAMP Item I.6.2: Provide feedback on CACB determinations to
CR analysts, CARB, and managers.
To determine whether this DAMP item had been adequately implemented, the team
reviewed condition reports, corrective action program closure documentation, and
meeting schedules and minutes. In addition, the team conducted interviews of
cognizant licensee personnel to determine whether actions had been accomplished. In
particular, the team reviewed CACB meeting minutes and discussed CACB activities
with board members and CR analysts.
b. Observations and Findings
No findings of significance were identified and the team concluded that the licensees
actions adequately implemented DAMP Item I.6.2.
The team reviewed information related to feedback provided by CACB. In
September 2005, feedback from CACB determinations was provided to CR analysts,
CARB, and managers through CACB meeting minutes. Subsequently, CR analyst
meeting minutes were provided as feedback. In November 2005, feedback was
provided both verbally at CR analyst meetings as well as through e-mail
correspondence. Through discussions with CR analysts, the team determined that
written feedback alone frequently did not provide sufficient detail for the CR analysts to
understand the basis for CACB determinations. To improve their understanding of
CACB determinations, CR analysts proactively attended CACB meetings.
26 Enclosure
The team noted that the CACB review and feedback process had not been formalized.
The team concluded that the lack of a formal process to provide feedback on CACB
determinations to CR analysts, CARB, and managers could impact the long-term
effectiveness of the actions.
9.0 Improve Oversight of the Corrective Action Program
The following commitment and action items in the Improve Oversight of the Corrective
Action Program area of PYBP-PII-002, Performance Improvement Initiative Detailed
Action and Monitoring Plan (DAMP), Revision 5, were reviewed:
- Commitment 2.c/DAMP Item I.7.1: Establish a management review process
that routinely monitors the sites and section level CAP performance. Take
action to improve performance when expectations are not met and hold the
organization accountable for overall CAP effectiveness.
- DAMP Item I.7.2: Focus CARB review on rigor of cause analysis and effective
cause/action resolution. Ensure that actions are smart and will fix the problem.
Use the FENOC fleet RCA [Root Cause Analysis] scoring sheet to drive
improved performance.
improve ability to routinely establish quorums and hold CARB meetings as
scheduled.
- DAMP Item I.7.4: Improve the CARB/CACB feedback process to ensure
lessons learned are getting to site personnel to promote continuous
improvement in the CAP area.
- DAMP Item I.7.6: Qualify additional managers in root cause to enable meeting
quorum requirements.
To accomplish these reviews, the team reviewed selected documentation such as
condition reports, corrective action program closure documentation, original and revised
procedures, and qualification records. In addition, the team conducted interviews of
cognizant licensee personnel to determine whether actions had been accomplished.
9.1 Commitment 2.c/DAMP Item I.7.1
a. Inspection Scope
The team reviewed Commitment 2.c/DAMP Item I.7.1: Establish a management review
process that routinely monitors the sites and section level CAP performance. Take
action to improve performance when expectations are not met and hold the organization
accountable for overall CAP effectiveness.
27 Enclosure
To determine whether this commitment and DAMP item had been adequately
implemented, the team reviewed condition reports, corrective action program closure
documentation, original and revised procedures, and meeting schedules and minutes.
In addition, the team conducted interviews of cognizant licensee personnel to determine
whether actions had been accomplished. In particular, the team observed and reviewed
meeting minutes associated with CARB meetings, CACB meetings, Management
Review Committee (MRC) meetings, CR Screening meetings, Senior Leadership Team
(SLT) meetings, and Monthly Performance Review (MPR) meetings. In addition, the
team reviewed the Key Performance Indicators (KPIs) developed to monitor corrective
action program implementation. The team also reviewed NOP-LP-2001, Corrective
Action Program; NOBP-LP-2008, Corrective Action Review Board; and
PYBP-SITE-0046, Corrective Action Program Implementation Expectations.
b. Observations and Findings
No findings of significance were identified and the team concluded that the licensees
actions adequately implemented Commitment 2.c and DAMP Item I.7.1.
The team determined that the licensee had implemented appropriate review processes
to routinely monitor corrective action program performance. In addition, corrective
action program key performance indicators (KPIs) had been developed with color-coded
thresholds to monitor performance. In some cases, condition reports were generated to
document red and yellow KPIs and to track development and implementation of
corrective actions when expectations were not met.
The team determined that some actions had been implemented to improve corrective
action program performance when program performance expectations were not met.
Management feedback to corrective action owners, the appointment of management
sponsors for corrective action program products, and the analysis and development of a
closure plan to address KPI performance gaps were all examples of actions that the
licensee had implemented to address corrective action program performance issues.
However, a formal mechanism to address KPI issues within the licensees corrective
action program did not exist. In particular, licensee personnel had not developed written
guidance that prescribed the generation of a condition report to address declining KPIs,
performance gaps between actual and expected performance, the development of
action plans to reduce the gap between actual and expected performance, or the
tracking of the success of action plans to address identified performance deficiencies.
Although specific guidance did not exist, the team did not identify any declining KPIs for
which appropriate corrective actions had not been implemented.
The team concluded that the lack of a formal process to address KPI issues could
impact the long-term effectiveness of the actions. Licensee personnel generated
CR 06-00787, Inconsistencies With GAP Closure plans for Red/Yellow CAP KPIs, to
enter this issue into the corrective action program.
28 Enclosure
9.2 DAMP Item I.7.2
a. Inspection Scope
The team reviewed DAMP Item I.7.2: Focus CARB review on rigor of cause analysis
and effective cause/action resolution. Ensure that actions are smart and will fix the
problem. Use the FENOC fleet RCA scoring sheet to drive improved performance.
To determine whether this DAMP item had been adequately implemented, the team
reviewed condition reports, corrective action program closure documentation, original
and revised procedures, and meeting schedules and minutes. In addition, the team
conducted interviews of cognizant licensee personnel to determine whether actions had
been accomplished. Specifically, the team reviewed NOBP-LP-2008, FENOC
Corrective Action Review Board, to address this DAMP item including
NOBP-LP-2008-01 that contained the Root Cause Review Summary. Team members
also attended a February 8, 2006, CARB meeting.
b. Observations and Findings
No findings of significance were identified and the team concluded that the licensees
actions adequately implemented DAMP Item I.7.2.
The team noted that NOBP-LP-2008 assigned CARB the responsibility for reviewing all
root cause evaluation reports, selected apparent cause evaluation reports, and the
associated corrective actions. Further, the team noted that the standing CARB agenda
defined that one purpose of CARB was to ensure that causes were coupled to problem
statements. Team members observed that CARB meeting packages used the
FENOC-wide Root Cause Review summary sheets and Apparent Cause Quality sheets,
which aided in the alignment of corrective actions to root causes. In addition, the team
noted that CARB assigned one of its members to interface with the organization
presenting the RCE or ACE to ensure that feedback from CARB was understood.
9.3 DAMP Item I.7.3
a. Inspection Scope
The team reviewed DAMP Item I.7.3: Qualify additional managers in FENOC CARB
JFG to improve ability to routinely establish quorums and hold CARB meetings as
scheduled.
To determine whether this DAMP item had been adequately implemented, the team
reviewed condition reports, corrective action program closure documentation, original
and revised procedures, and qualification records. In addition, the team conducted
interviews of cognizant licensee personnel to determine whether actions had been
accomplished. In particular, the team reviewed the FENOC Integrated Training System
(FITS) Qualification Matrices associated with root cause evaluators and CARB
29 Enclosure
members, for specific individuals who were added to the CARB roster. The team also
reviewed CA 05-07223-18.
b. Observations and Findings
No findings of significance were identified and the team concluded that the licensees
actions adequately implemented DAMP Item I.7.3.
The team verified that two additional managers had been certified as CARB members,
which improved the licensees ability to meet CARB quorum requirements. However,
the team determined that a process had not been established to maintain a specific
number of qualified CARB members after this DAMP item was closed.
The team concluded that the lack of a formal process to maintain a specific number of
qualified CARB members could impact the long-term effectiveness of the actions.
9.4 DAMP Item I.7.4
a. Inspection Scope
The team reviewed DAMP Item I.7.4: Improve the CARB/CACB feedback process to
ensure lessons learned are getting to site personnel to promote continuous
improvement in the CAP area.
To determine whether this DAMP item had been adequately implemented, the team
reviewed condition reports, corrective action program closure documentation, original
and revised procedures, and meeting schedules and minutes. In addition, the team
conducted interviews of cognizant licensee personnel to determine whether actions had
been accomplished. In particular, the team reviewed NOBP-LP-2008, Corrective Action
Review Board; the CARB review package dated November 4, 2005; CACB minutes for
September and October 2005; the CACB and CARB overview from the Supervisor Brief
on October 31, 2005; NOBP-SITE-0046, Corrective Action Program Implementation
Expectations; and the Condition Report Analyst Meeting Agenda for November 3, 2005.
b. Observations and Findings
No findings of significance were identified and the team concluded that the licensees
actions adequately implemented DAMP Item I.7.4.
The team noted that CARB/CACB feedback was routinely provided during monthly
CR analyst meetings and in certain cases, CARB/CACB meeting notes were
electronically distributed to select site personnel. At times, CR analysts personally
attended CARB meetings to receive feedback. The team did not identify a specific
feedback process by which lessons learned were disseminated to general site
personnel so that the corrective action program could be continuously improved.
30 Enclosure
Similar to DAMP l.6.2, the team concluded that the lack of a formal CARB/CACB
feedback process could impact the long-term effectiveness of the actions.
9.5 DAMP Item I.7.6
a. Inspection Scope
The team reviewed DAMP Item I.7.6: Qualify additional managers in root cause to
enable meeting quorum requirements. (Note, this item is similar to, but not the same
as DAMP 7.3)
To determine whether this DAMP item had been adequately implemented, the team
reviewed condition reports, corrective action program closure documentation, original
and revised procedures, and qualification records. In addition, the team conducted
interviews of cognizant licensee personnel to determine whether actions had been
accomplished. Specifically, the team reviewed the FITS Qualification Matrices
associated with the Root Cause Evaluator position for recently certified CARB members,
and CA 05-07223-21.
b. Observations and Findings
No findings of significance were identified and the team concluded that the licensees
actions adequately implemented DAMP Item I.7.6.
The team reviewed information related to the number of root cause qualified CARB
members necessary for the CARB to meet minimum quorum requirements. During the
review, the team noted that three additional managers had been credited for root cause
training, which provided an increased ability to meet CARB quorum requirements. The
team also noted that no process was in place to maintain a specific number of root
cause-trained CARB members after this DAMP item had been closed.
The team concluded that the lack of a formal process to maintain a specific number of
root cause-trained CARB members could impact the long-term effectiveness of the
actions.
10.0 PII Phase 1 Carry Over Activities
The following Action Items in the PII Phase 1 Carry Over Activities area of
PYBP-PII-002, Performance Improvement Initiative Detailed Action and Monitoring Plan
(DAMP), Revision 5, were reviewed:
- DAMP Item D.8.1: Fully Implement the Station Operating Experience (OE)
coordinator and Section OE coordinator role at Perry, as established in
NOP-LP-2100, by ensuring the Job Familiarization Guides (JFGs) are completed
for all sections.
31 Enclosure
- DAMP Item D.8.3: Communication will be provided to PIU/Analysts with the
formality determined by the SAP conversion change management plan to
understand and apply coding.
- DAMP Item D.8.4: A method to improve the timeliness of effectiveness reviews
will be established and implemented.
To accomplish these reviews, the team reviewed selected documentation such as
condition reports, corrective action program closure documentation, original and revised
procedures, and training plans and training attendance records. In addition, the team
conducted interviews of cognizant licensee personnel to determine whether actions had
been accomplished.
10.1 DAMP Item 8.1
a. Inspection Scope
The team reviewed DAMP Item 8.1: Fully Implement the Station Operating Experience
(OE) coordinator and Section OE coordinator role at Perry, as established in
NOP-LP-2100, by ensuring the Job Familiarization Guides (JFGs) are completed for all
sections.
To determine whether this DAMP item had been adequately implemented, the team
reviewed condition reports, corrective action program closure documentation, original
and revised procedures, training plans and training attendance records, and qualification
records. In addition, the team conducted interviews of cognizant licensee personnel to
determine whether actions had been accomplished. In particular, the team reviewed
CA 04-02404-08; the FITS Qualification Matrix for Section OE Coordinators; Job
Familiarization Guide (JFG) GEN_JFGSOEC_FEN-01, Section Operating Experience
Coordinator Job Familiarization Guideline; and NOP-LP-2100, Operating Experience
Program. In addition, the team interviewed selected OE personnel.
b. Observations and Findings
No findings of significance were identified and the team concluded that the licensees
actions adequately implemented DAMP Item I.8.1.
The team noted that although completion of the JFG was not a prerequisite for the
Section OE Coordinator position, it was considered by the licensee as an enhancement
necessary to fully implement the station OE program. The team verified that at the time
the DAMP item was closed, all original Section OE Coordinators had received the JFG
training.
However, the team identified that although three replacement Section OE Coordinators
had been designated since the DAMP item had been closed, these newly assigned
Section OE Coordinators had not completed the JFG training. In addition, the team
32 Enclosure
identified that a process had not been established to ensure newly assigned Section OE
Coordinators completed the JFG training.
The team concluded that the lack of a formal process to qualify Section OE
Coordinators could impact the long-term effectiveness of the licensees actions.
10.2 DAMP Item 8.3
a. Inspection Scope
The team reviewed DAMP Item D.8.3: Communication will be provided to PIU/Analysts
with the formality determined by the SAP conversion change management plan to
understand and apply coding.
b. Observations and Findings
Licensee personnel reviewed and approved the removal of this DAMP item from
PYBP-PII-002, Performance Improvement Initiative Detailed Action and Monitoring Plan
(DAMP), Revision 5 prior to the inspection. As a result, the team was unable to review
corrective actions implemented to address this DAMP item.
The team noted that the closure documentation associated with this DAMP item did not
explicitly include a discussion of the licensees actions to remove this item from
Revision 5 of PYBP-PII-002.
10.3 DAMP Item 8.4
a. Inspection Scope
The team reviewed DAMP Item 8.4: A method to improve the timeliness of
effectiveness reviews will be established and implemented.
To determine whether this DAMP item had been adequately implemented, the team
reviewed condition reports, corrective action program closure documentation, and
original and revised procedures. In addition, the team conducted interviews of cognizant
licensee personnel to determine whether actions had been accomplished. In particular,
the team reviewed NOBP-LP-2007, Condition Report Effectiveness Review, and
CA 05-07233-07.
b. Observations and Findings
No findings of significance were identified and the team concluded that the licensees
actions adequately implemented DAMP Item 8.4.
As discussed in DAMP Item 3.5 of this report, the team noted that NOBP-LP-2007,
Condition Report Process Effectiveness Review, had been revised to evaluate
effectiveness at the earliest opportunity. This revision eliminated a 6 month guideline for
33 Enclosure
performance of effectiveness reviews and provided guidance on when to initiate an
effectiveness review.
11.0 Validated/Closed Perry Phase 1 Action Items
The following validated and closed Perry Phase 1 DAMP Action Items were reviewed:
- DAMP Item D.1.6: Perform an external assessment of the Corrective Action
Program (CAP) (04-02468-46).
- DAMP Item D.9.2: Develop a method to assign clear, single point ownership of
root cause CRs, from CR investigation through CA implementation/effectiveness
review completion for each root cause CR (04-02468-69).
- DAMP Item D.11.1: A two-step screening process is being implemented to
improve timeliness of issue entry into CAP and more accurate prioritization
(04-02468-66).
To accomplish these reviews, the team reviewed selected documentation such as
condition reports, corrective action program closure documentation, original and revised
procedures, and training plans and training attendance records. In addition, the team
conducted interviews of cognizant licensee personnel to determine whether actions had
been accomplished.
11.1 DAMP Item D.1.6
a. Inspection Scope
The team reviewed DAMP Item D.1.6: Perform an external assessment of the
Corrective Action Program (CAP) (04-02468-46).
To determine whether this DAMP item had been adequately implemented, the team
reviewed condition reports, corrective action program closure documentation, and
self-assessment records. In addition, the team conducted interviewed cognizant
licensee personnel to determine whether actions had been accomplished. In particular,
the team reviewed Self-Assessment SA 761 PYRC-2005 Perry Corrective Action
Program Self-Assessment.
b. Observations and Findings
No findings of significance were identified and the team concluded that the licensees
actions adequately implemented DAMP Item D.1.6.
The team reviewed SA 761 PYRC-205, Perry Corrective Action Program
Self-Assessment, and determined that it provided a thorough assessment of the
corrective action program.
34 Enclosure
However, the team could not determine whether the assessment could be considered as
having been performed externally since two of the five self-assessment auditors were
licensee staff members and the licensee had not defined the requirements for a
self-assessment to be considered externally conducted. Licensee personnel generated
CR 06-00613 NRC Definition of External is Different Than What They Observed, to
enter this issue into the corrective action program.
In addition to documentation associated with this DAMP item, the team reviewed the
results of two licensee audits and a Corrective Action Program Summit meeting that
were conducted to identify additional areas for improvement in the corrective action
program. The audit results identified many of the same issues identified by the team. In
some cases, corrective actions were planned, but had not been implemented prior to
this inspection. Although the licensees corrective actions to address the issues had not
been implemented, these actions represented additional licensee efforts to improve the
implementation of the corrective action program.
11.2 DAMP Item D.9.2
a. Inspection Scope
The team reviewed DAMP Item D.9.2: Develop a method to assign clear,
single point ownership of root cause CRs, from CR investigation through
CA implementation/effectiveness review completion for each root cause
CR (04-02468-69).
To determine whether this DAMP item had been adequately implemented, the
team reviewed condition reports and corrective action program closure documentation.
In addition, the team conducted interviews of cognizant licensee personnel to
determine whether actions had been accomplished. In particular, the team reviewed
CA 04-02468-69 and discussed its contents with the Performance Improvement
Unit (PIU) supervisor, and reviewed NOP-LP-2001, Condition Report Process.
b. Observations and Findings
No findings of significance were identified; however, the team concluded that the
licensees actions had not adequately implemented DAMP Item D.9.2.
Corrective Action 04-02468-69 was generated to implement DAMP 9.2 and stated that
the corrective action was to develop a method to assign clear, single point ownership of
root cause CRs... The team determined that CR 04-02468 had been closed as an
intervention action and a method to assign clear, single point ownership had not been
developed.
The PIU supervisor informed the team that the issue of ownership had been discussed
with the CARB and the MRB. The subject condition report assigned the responsibility
for completing the associated corrective action to CARB and identified that this item had
been added to the agenda as a standing item for the 1st Thursday of each month. The
35 Enclosure
PIU supervisor also stated the action was not proceduralized as it was an intervention
action. In addition, the individual who closed CR 04-02468 stated that the issue was
only applicable to a limited number of CRs and was not intended to be a long-term
corrective action.
The team determined that Section 4.7.1 of NOP-LP-2001 required that the MRB validate
or establish a CR condition owner. Further, if a root cause evaluation was determined to
be warranted to review the issue(s) identified in the CR, the MRB was required to
ensure a director level individual was designated as root cause sponsor.
The team identified that although Step 4.4.3.5 of NOP-LP-2001 prescribed the selection
of a Condition Owner, the owners responsibilities were not defined. In addition, the
team was unable to identify in NOP-LP-2001 or other documents where one individual
was identified with the responsibilities as prescribed by the DAMP item. In particular,
the team was unable to identify any documentation that defined an individual as being a
single point owner of root cause CRs, from CR investigation through CA
implementation and effectiveness review completion for each root cause CR. Licensee
personnel generated CR 06-00767, Corrective Action Alternately Closed Without
Proper Approval, to enter this issue into the corrective action program.
The team concluded that due to a lack of quality and attention to detail, licensee
personnel failed to identify that this DAMP item had not been adequately implemented
during the DAMP item review and closure process. However, because the inadequate
closure of DAMP Item D.9.2 had no actual impact on the facility, the issue was of only
minor significance.
11.3 DAMP Item D.11.1
a. Inspection Scope
The team reviewed DAMP Item D.11.1: A two-step screening process is being
implemented to improve timeliness of issue entry into CAP and more accurate
prioritization (04-02468-66).
To determine whether this DAMP item had been adequately implemented, the team
reviewed condition reports, corrective action program closure documentation, original
and revised procedures, and meeting schedules and minutes. In addition, the team
conducted interviews of cognizant licensee personnel to determine whether actions had
been accomplished. In particular, the team reviewed PYBP-SITE-0045, Initial
Screening Committee, and attended a MRB meeting on February 7, 2006.
b. Observations and Findings
No findings of significance were identified and the team concluded that the licensees
actions adequately implemented DAMP Item D.11.1.
36 Enclosure
By direct observation, the team determined that the licensee had implemented a
two-step screening process for condition reports that improved the timeliness of issue
entry and resulted in more accurate prioritization. Through this process, a condition
report was sent to the Initial Screening Committee (ISC) for review and discussion, and
then to the Management Review Board (MRB) for final approval. Subsequently, the
MRB ensured that the condition report was appropriately screened for Category,
Assigned Group, and Due Date. The MRB also discussed complicated and/or
significant condition reports. The ISC was instituted by procedure, with required training
for its members, and was accountable to the MRB.
12.0 Key Performance Indicators (KPIs)
a. Inspection Scope
The team reviewed existing corrective action program performance indicators to
evaluate the quality of the indicators, the licensees use of the corrective action program
when indicators suggested a decline in corrective action program performance, and the
overall performance of the corrective action program based upon the licensees KPI
data.
b. Observations and Findings
No findings of significance were identified.
The team verified that KPIs for the corrective action program had been developed and
were adequately maintained. The KPIs defined thresholds for acceptable performance
for specific corrective action program functions and tracked actual numbers or
percentages against the pre-defined thresholds. The performance level for each KPI
were color-coded (green, white, yellow, red) to facilitate performance monitoring. Based
on a review of the most recently issued KPIs, in general, the KPIs reflected an improving
performance trend.
The licensees expectation for yellow or red KPIs was that a condition report should be
generated and corrective actions should be implemented to address the issue. The
team reviewed a number of condition reports that had been generated to document red
and yellow KPIs. The corrective action program was used to track the development and
implementation of corrective actions to improve performance. The team also noted a
number of actions had been implemented to improve corrective action program
performance when program performance expectations were not met. Management
feedback to corrective action owners, the appointment of management sponsors for
corrective action program products, and the analysis and development of a closure plan
to address KPI performance gaps were all examples of actions implemented to address
corrective action program performance issues. However, a formal mechanism to
address KPI issues within the licensees corrective action program did not exist. In
particular, licensee personnel had not developed written guidance that prescribed the
generation of a condition report to address declining KPIs, performance gaps between
actual and expected performance, the development of action plans to reduce the gap
37 Enclosure
between actual and expected performance, or the tracking of the success of action
plans to address identified performance deficiencies. Although specific guidance did not
exist, the team did not identify any declining KPIs for which appropriate corrective
actions had not been implemented.
The team concluded that the lack of a formal process to address KPI issues could
impact the long-term effectiveness of the actions. Licensee personnel generated
CR 06-00787, Inconsistencies With GAP Closure plans for Red/Yellow CAP KPIs, to
enter this issue into the corrective action program.
13.0 Exit Meeting
On March 14, 2006, the team presented the inspection results to Mr. L. Pearce, Vice
President, and other members of his staff, who acknowledged the findings and
observations.
The team asked the licensee whether any materials examined during the inspection
should be considered proprietary. No proprietary information was identified.
Attachments: 1. Supplemental Information
2. Perry Performance Background
3. Perry IP 95003 Inspection Results
4. Summary of Phase 2 PII Initiatives
38 Enclosure
SUPPLEMENTAL INFORMATION
KEY POINTS OF CONTACT
Licensee
G. Leidich, Chief Nuclear Office, FENOC
D. Pace, Senior Vice President, Fleet Engineering and Services, FENOC
J. Hagan, Chief Operating Officer, FENOC
J. Rinckel, Vice President, Oversight, FENOC
L. Pearce, Vice President, Perry
F. von Ahn, Plant Manager, Perry
F. Cayia, Director, Performance Improvement, Perry
T. Lentz, Director, Performance Improvement Initiative, Perry
J. Shaw, Director, Engineering, Perry
M. Wayland, Director, Maintenance, Perry
K. Howard, Manager, Design, Perry
J. Lausberg, Manager, Regulatory Compliance, Perry
J. Messina, Manager, Operations, Perry
LIST OF ITEMS OPENED, CLOSED, AND DISCUSSED
None.
1 Attachment 1
LIST OF DOCUMENTS REVIEWED
The following is a list of documents reviewed during the inspection. Inclusion on this list does
not imply that the NRC inspectors reviewed the documents in their entirety rather, that selected
sections or portions of the documents were evaluated as part of the overall inspection effort.
Inclusion of a document on this list does not imply NRC acceptance of the document or any part
of it, unless this is stated in the body of the inspection report.
Perry Business Practices:
PYBP-PII-0006, Process Improvement Initiative Process
PYBP-POS-1-11, Operations Section System Ownership
PYBP-SITE-0042, Corrective Action Closure Board Charter
PYBP-SITE-0045, Initial Screening Committee
PYBP-SITE-0046, Corrective Action Program Implementation Expectations
Nuclear Operating Business Practices:
NOBP-LP-2007, Condition Report Process Effectiveness Review
NOBP-LP-2008, Corrective Action Review Board
NOBP-LP-2008-01, Root Cause Review Summary
NOBP-LP-2011, FENOC Cause Analysis
NOBP-LP-2019, Corrective Action Program Supplemental Expectations and Guidance
NOBP-LP-2019, Attachment 1, (Condition Report Category and Activity Tracking Descriptions),
and Attachment 2, (Condition Report Evaluation Methods).
NOBP-TR-1111-01, Corrective Action program (CAP) Training Program
NOBP-SITE-0046, Corrective Action Program Implementation Expectations;
Nuclear Operating Procedures:
NOP-LP-2001, Corrective Action Program
NOP-LP-2100, Operating Experience Program
Condition Reports:
CR 05-02725, Substantive Cross-Cutting Issue, Problem Identification and Resolution
CR 05-03986, Nuclear Oversight Audit PY-C-05-01"
CR 05-08057, Disposition/Tracking of Personnel Not Trained Per CAPC-200501_PY
CR 06-00080, DAMP Items I.3.5 & I.8.4 Incomplete
CR 06-00576, DAMP Item I.2.2 Did Not Provide Complete Closure Documentation
CR 06-00589, No Indicators to Track Deltas From Condition Report Categorizations
CR 06-00604, DAMP Item I.3.3 Did Not Provide Complete Closure Documentation
CR 06-00613, NRCs Definition of External is Different Than What They Observed
CR 06-00630, No Process Exists to Prevent Inadvertent Changes to Closed PII Action
CR 06-00636, DAMP Item I.3.1 Inadvertent Omission from Attachment 1 of NOBP-LP-2019
CR 06-00697, DAMP Item I.3.4 Closed Correctly However, Reference CA Not Complete
CR 06-00767, Corrective Action Alternately Closed Without Proper Approval
CR 06-00784, Issues With Implementation of Revised CAP Training
CR 06-00787, Inconsistencies With GAP Closure Plans for Red/Yellow CAP KPIs
2 Attachment 1
Corrective Actions:
CA 04-02404-08
CA 04-02468-69
CA 05-07223-13
CA 05-07233-07
CA 05-07223-21
Self-Assessments:
Snapshot Assessment 810PII2005, Perry Nuclear Power Plant Performance Improvement
Initiative - Corrective Action Program Implementation Effectiveness,
Self-Assessment FL-SA-05-05, Self-Assessment of Integrated Performance Assessment
Trending, dated December 14, 2005
Self-Assessment SA 761 PYRC-2005 Perry Corrective Action Program Self-Assessment
Training Documents:
SSC-200502_PY-01, Supervisory Continuing Training
Training Plan 9903, Root Cause Evaluator
Training Plan 9908, Corrective Action Review Board (CARB) Member
Training Requirements CAP RCA_FEN, FENOC Root Cause Evaluation Basic Training
Training Requirements CAP-RCT_FEN, FENOC Root Cause Evaluation Advanced Training
Training Requirements CAP-JFGRCE_FEN, Root Cause Evaluator Job Familiarization Guide
ESPC-SYS0503_PY, System Walkdown Refresher Training
FITS Qualification Matrices associated with Root Cause Evaluators and CARB Members
Job Familiarization Guide (JFG) GEN_JFGSOEC_FEN-01, Section Operating Experience
Coordinator Job Familiarization Guideline
Other Documents:
FENOC Performance Appraisal Elements
CAPC-200501-PY, Corrective Action Program Implementation Improvement
CAP Improvement Plan: Communications Roadmap
FENOC CR Initiation Guidance
PESP-9, System Walkdowns
Apparent Cause Expectation brochure
Criteria for CAP Focus Day
CARB meeting minutes, dated September 2005 and October 2005
CACB meeting agenda, dated October 20, 2005
CARB review package, dated November 4, 2005
CACB and CARB overview, dated October 31, 2005
Condition Report Analyst Meeting Agenda, dated November 3, 2005
3 Attachment 1
LIST OF ACRONYMS USED
ACE Apparent Cause Evaluation
CA Corrective Action
CACB Corrective Action Closure Board
CAL Confirmatory Action Letter
CAP Corrective Action Program
CARB Corrective Action Review Board
CFR Code of Federal Regulations
CR Condition Report
DAMP Detailed Action and Monitoring Plan
DB Davis-Besse
ESW Emergency Service Water
FENOC FirstEnergy Nuclear Operating Company
FITS FENOC Integrated Training System
IMC Inspection Manual Chapter
INPO Institute for Nuclear Power Operation
IP Inspection Procedure
IR Inspection Report
ISC Initial Screening Committee
JFG Job Familiarization Guidelines
KPI Key Performance Indicators
LPCS Low Pressure Core Spray
MPR Monthly Performance Review
MRB Management Review Board
MRC Management Review Committee
NOBP Nuclear Operating Business Practice
NOP Nuclear Operating Procedure
NRC Nuclear Regulatory Commission
OE Operating Experience
PARS Publicly Available Records
PESP Plant Engineering Section Policy
PI Performance Indicator
PII Performance Improvement Initiative
PIU Performance Improvement Unit
PNPP Perry Nuclear Power Plant
PYBP Perry Business Practice
RCA Root Cause Analysis
RCE Root Cause Evaluation
SCAQ Significant Condition Adverse to Quality
SLT Senior Leadership Team
TS Technical Specification
4 Attachment 1
PERRY PERFORMANCE BACKGROUND
As discussed in the Perry Annual Assessment Letter dated March 4, 2004, plant performance
was categorized within the Degraded Cornerstone column of the NRCs Action Matrix based on
two White findings in the Mitigating Systems cornerstone. An additional White finding in the
Mitigating Systems cornerstone was subsequently identified and documented by letter dated
March 12, 2004.
The first finding involved the failure of the high pressure core spray (HPCS) pump to start
during routine surveillance testing on October 23, 2002. An apparent violation of Technical Specification (TS) 5.4 for an inadequate breaker maintenance procedure was identified in
IR 05000440/2003008. This performance issue was characterized as White in the NRC's
final significance determination letter dated March 4, 2003. A supplemental inspection was
performed in accordance with IP 95001 for the White finding and significant deficiencies
were identified with regard to the licensee's extent of condition evaluation. Inspection
Procedure 95001 was re-performed and the results of that inspection were documented in
IR 05000440/2003012, which determined that the extent of condition reviews were adequate.
The second finding involved air-binding of the low pressure core spray(LPCS)/residual heat
removal (RHR) 'A' waterleg pump on August 14, 2003. A special inspection was performed for
this issue and the results were documented in IR 05000440/2003009. An apparent violation of
TS 5.4 for an inadequate venting procedure was identified in IR 05000440/2003010. This
performance issue was characterized as White in the NRC's final significance determination
letter dated March 12, 2004.
The third finding involved the failure of the 'A' Emergency Service Water (ESW) pump, caused
by an inadequate maintenance procedure for assembling the pump coupling that contributed to
the failure of the pump on September 1, 2003. An apparent violation of TS 5.4 was
documented in IR 05000440/2003006. This performance issue was characterized as White in
the NRC's final significance determination letter dated January 28, 2004.
As documented in IP 95002 Supplemental Inspection Report 05000440/2004008, dated
August 5, 2004, which reviewed the licensees actions to address these issues, the NRC
concluded that the corrective actions to prevent recurrence of a significant condition adverse to
quality (SCAQ) were inadequate. Specifically, the same ESW pump coupling that failed on
September 1, 2003, failed again on May 21, 2004. This resulted in the ESW pump White
finding remaining open.
As a result, Perry entered the Multiple/Repetitive Degraded Cornerstone column for Mitigating
Systems in the Reactor Safety strategic performance area for having two White inputs for five
consecutive quarters. Specifically, for the third quarter of 2004, the waterleg pump finding
remained open a fourth quarter while the ESW pump finding was carried open into a fifth
quarter as a result of the findings of the IP 95002 supplemental inspection.
Attachment 2
1
PERRY IP 95003 INSPECTION RESULTS
As a result of poor performance, the Nuclear Regulatory Commission (NRC) designated the
Perry Nuclear Power Plant (PNPP), owned and operated by FirstEnergy Nuclear Operating
Company, as a Multiple/Repetitive Degraded Cornerstone Column facility in the NRCs Action
Matrix1 in August 2004. Accordingly, a supplemental inspection was performed in accordance
with the guidance in NRC Inspection Manual Chapter (IMC) 0305 and Inspection Procedure (IP) 95003, Supplemental Inspection for Repetitive Degraded Cornerstones, Multiple Degraded
Cornerstones, Multiple Yellow Inputs, or One Red Input.
In addition, the scope of the IP 95003 inspection included the review of licensee actions to
address deficiencies identified during a previous IP 95002 inspection. In particular, the NRC
reviewed the licensees root cause and corrective actions to address the areas of procedure
adequacy, procedure adherence, and training deficiencies identified in the previous IP 95002
inspection; as well as the problem identification, root cause review, and corrective actions to
address repetitive emergency service water (ESW) pump coupling failures.
By letter dated September 30, 2004, FirstEnergy advised the NRC that actions were underway
to improve plant performance. To facilitate these performance improvements, FirstEnergy
developed the Perry Performance Improvement Initiative (PII). As part of the NRC's IP 95003
inspection, the team conducted a detailed review of the PII.
As documented in IP 95003 Supplemental Inspection Report 50-440/2005003, the NRC
determined Perry was being operated safely. The NRC also determined that the programs and
processes to identify, evaluate, and correct problems, as well as other programs and processes
in the Reactor Safety strategic performance area were adequate. Notwithstanding these overall
conclusions, the NRC determined that the performance deficiencies that occurred prior to and
during the inspection were often the result of inadequate implementation of the corrective action
program (CAP) and human performance errors.
The team identified that a number of factors contributed to CAP problems. A lack of rigor in the
evaluation of problems was a major contributor to the ineffective corrective actions. For
example, in the engineering area, when problems were identified, a lack of technical rigor in the
evaluation of those problems at times resulted in an incorrect conclusion, which in turn affected
the ability to establish appropriate corrective actions. The team also determined that corrective
actions often were narrowly focused. In many cases a single barrier was established to prevent
a problem from recurring. However, other barriers were also available that, if identified and
implemented, would have provided a defense-in-depth against the recurrence of problems. The
team also identified that problems were not always appropriately prioritized, which led to the
untimely implementation of corrective actions. A number of programmatic issues were
identified that have resulted in the observed CAP weaknesses. For example, the team
identified a relatively high threshold for classifying deficiencies for root cause analysis. As a
result, few issues were reviewed in detail. In addition, for the problems that were identified that
Attachment 3
1
The NRCs Action Matrix is described in Inspection Manual Chapter 0305, Operating
Reactor Assessment Program.
1
required a root cause evaluation, the team found that the qualification requirements for root
cause evaluators were limited and multi-disciplinary assessment teams were not required. The
team also identified that a lack of independence of evaluators existed. This resulted in the
same individuals repeatedly reviewing the same issues without independent and separate
review. In addition, the team identified weaknesses in the trending of problems, which has
hindered the ability to correct problems at an early stage before they become more significant
issues. Finally, the team determined that a lack of adequate effectiveness reviews was a
barrier to the identification of problems with corrective actions that had been implemented.
Overall, the NRC concluded that while some limited improvements may have been realized,
there has been no substantial improvement in the licensees implementation of the corrective
action program since Perry entered the Multiple/Repetitive Degraded Cornerstone column of
the NRCs Action Matrix.
In the area of human performance, the team determined that a number of self-revealed
findings relating to procedure adherence occurred that had a strong human performance
contribution. These findings emanated from events that have resulted in an unplanned
engineered safety feature actuation, a loss of shutdown cooling, an unplanned partial drain
down of the suppression pool, inadvertent operation of a control rod (a reactivity event), and
other configuration control errors. The team reviewed the events that occurred during the
inspection and identified that the procedure adherence problems had a number of common
characteristics. In a number of cases, personnel failed to properly focus on the task at hand.
Although pre-job briefings were held prior to many events, and procedures were adequate to
accomplish the intended activity, personnel failed to sufficiently focus on the individual
procedure step being accomplished and performed an action outside of that prescribed by the
procedure. In some cases, the team determined that a lack of a questioning attitude
contributed to the procedure problems that occurred. Although information was available to
personnel that, if fully considered, could have prevented the procedure adherence issues that
occurred, that information was not sought out or was not questioned. The presence of
supervisors with the necessary standards to foster good procedure adherence could have acted
as a significant barrier to prevent some of the problems that occurred. However, adequate
supervisory oversight was not always available or used. Further, the team identified that
available tools for assessing human and organizational performance had not been effectively
used. Overall, the NRC concluded that while some limited improvements may have been
realized, there has been no substantial improvement in human performance since Perry
entered the Multiple/Repetitive Degraded Cornerstone column of the NRCs Action Matrix.
In the area of design, the IP 95003 inspection team concluded that the systems, as designed,
built, and modified, were operable and that the design and licensing basis of the systems were
sufficiently understood. Notwithstanding the overall acceptability of performance in the
engineering area, the team identified common characteristics in a number of problems
identified during the inspection. These characteristics included a lack of technical rigor in
engineering products that resulted in an incorrect conclusion. Also, there appeared to be a lack
of questioning by the licensee staff of some off-normal conditions. Finally, weaknesses in the
communications between engineering and other organizations such as operations and
maintenance sometimes hindered the resolution of problems.
Attachment 3
2
In the area of procedure adequacy, the team determined that the licensees procedures to
safely control the design, maintenance, and operation of the plant were adequate, but
warranted continued management focus and resource support. In particular, process-related
vulnerabilities in areas such as periodic plant procedure reviews, procedure revisions, and use
classifications were identified by the team.
In the area of equipment performance, the team acknowledged that the licensee had completed
numerous recent plant modifications to improve equipment performance. In addition, improved
engineering support and management oversight of equipment performance were noted.
Notwithstanding the above, the team identified numerous examples that indicated that the
resolution of degraded equipment problems and implementation of the CAP continued to be a
challenge to the organization.
In the area of configuration control, the team identified numerous examples that indicated the
resolution of configuration control issues and implementation of the CAP continued to be a
challenge to the organization. The team agreed with the licensees assessment that continuing
configuration control problems were primarily the result of inappropriate implementation of
procedural requirements rather than the result of configuration management procedural
shortcomings. However, given the on-going errors associated with equipment alignment, as
well as multiple errors associated with maintenance configuration control such as scaffolding
erection, the team concluded that adequate evaluations of the root causes of configuration
control errors had not been performed. The team also concluded that the licensee lacked rigor
in its efforts to resolve latent configuration control issues. Several licensee-identified issues
have not been corrected, and contributed to configuration control shortcomings.
In addition, in the area of emergency preparedness, the team determined that there were some
performance deficiencies associated with the licensees implementation of the Emergency Plan.
A number of findings were identified in which changes to the Emergency Plan or Emergency
Action Levels were made without required prior NRC approval. In addition, the results of the
augmentation drill where personnel were called to report to the facility for a simulated
emergency were unsatisfactory.
With regard to the NRC's review of issues associated with the previous IP 95002 inspection, the
NRC determined that actions to address procedure adequacy and ESW pump failures was still
in progress at the end of the IP 95003 inspection. In particular, the team identified that one of
the licensees corrective actions to address the verification of the quality of ESW pump work
was inadequate. In addition, in light of the continuing problems in human performance and the
impact on procedure adherence, the team concluded that actions to address procedure
adherence had not been fully effective. Finally, actions to address training were also still in
progress at the end of the inspection. In this case, the licensees corrective actions to address
this issue had not been timely and at the conclusion of the IP 95003 inspection, had not yet
been implemented. As a result, the NRC concluded that the open White findings associated
with the IP 95002 inspection would continue to remain open pending additional licensee actions
and the NRCs review of those actions.
In the assessment of the licensees performance improvements planned and implemented
through the Perry PII, the team determined that the Perry PII had a broad scope and addressed
Attachment 3
3
many important performance areas. The IP 95003 inspection team also observed that,
although substantially completed, the PII had not resulted in significant improvement in plant
performance in several areas. There were a number of reasons identified as why this occurred,
one being that the PII was largely a discovery activity, and as such, many elements of the PII
did not directly support improving plant performance. Instead, the problems identified through
the PII reviews were entered into the CAP and the proper resolution of these problems
depended upon the proper implementation of the CAP. During the IP 95003 inspection, the
NRC identified that in some cases the CAP had not been implemented adequately to address
the concerns identified during PII reviews. The team identified that although many PII actions
have been completed, some of the more significant assessments, such as in the area of human
performance, were still in progress at the end of the inspection.
Overall, based on the factors discussed above, the NRC was unable to draw any definitive
conclusions regarding the overall effectiveness of the Perry PII. As a result, further reviews
were deemed to be necessary to determine whether the PII was sufficient to address and
resolve the specific issues identified.
Attachment 3
4
SUMMARY OF PHASE 2 PII INITIATIVES
To correct the identified declining trends in performance at Perry, the Perry Phase 2 PII was
structured around the following six key improvement initiatives:
Corrective Action Program Implementation Improvement
As described in the Phase 2 PII, the Corrective Action Program Implementation Improvement
initiative was designed to drive ownership and accountability for the corrective action program
(CAP) deep into the PNPP organization. The initiative was aimed at driving behavior changes
to increase ownership and accountability of the corrective action program to solve plant issues.
Key objectives of this initiative included improvement in the following areas:
- ownership and station focus,
- management and oversight of the corrective action program,
- prioritization of issues and resolution activities,
- trending capability,
- backlog management,
- quality of corrective actions and documentation,
- individual accountability, and
- corrective action work assignment and resource utilization.
Excellence in Human Performance
As described in the Phase 2 PII, the Excellence in Human Performance initiative was designed
to clarify standards and expectations for human performance, establish line ownership,
alignment, and integration of the Institute for Nuclear Power Operation (INPO) Performance
Model, and strengthen line accountability for human performance. Key objectives of this
initiative included improvement in the following areas:
- performance expectations,
- line ownership, alignment, and integration, and
- line accountability of results.
Training to Improve Performance
As described in the Phase 2 PII, the Training to Improve Performance initiative was targeted at
improving both PNPP Skills Training and Operator Training Programs to improve plant and
personnel performance. Key objectives of this initiative included the following:
- establish training as a dominant tool to improve station performance, and
- develop a comprehensive plan to help line and training managers return the
performance of Perry's training programs to a level consistent with current industry
standards.
Attachment 4
1
Effective Work Management
As described in the Phase 2 PII, the Effective Work Management initiative was designed to
provide a site-wide systematic and focused effort to drive improvements in work management.
The initiative was intended to implement improvements in the selection, preparation, and
execution of work to achieve excellence in work management. Key objectives of this initiative
included the following:
- a long range plan for equipment performance,
- contingency planning guidance and execution,
- strong use of operating experience in work packages,
- improvement in outage preparation and execution, and
- control of contract workers.
Employee Engagement and Job Satisfaction
As described in the Phase 2 PII, the Employee Engagement and Job Satisfaction Initiative was
designed to increase employee contribution to PNPP success by creating and environment in
which all employees can make a meaningful contribution and feel pride and a sense of
accomplishment in their work. Key objectives of this initiative included the following:
- employee involvement in Phase 2 PII activities,
- leadership behaviors and performance management,
- leadership assessment and development, and
- use of overtime.
Operational Focused Organization
As described in the Phase 2 PII, the Operational Focused Organization initiative was designed
to improve the operational focus of the PNPP organization to achieve a higher order of safe and
reliable operation. Key objectives of this initiative included the following:
- fundamental skills and behaviors required for safe and reliable operation,
- operations-led organization,
- alignment of goals and priorities,
- strong craft ownership and engineering presence, and
- operations resources replenishment planning.
Attachment 4
2