ML062680259

Event Investigation Report

ML062680259
Person / Time
Site:	Point Beach
Issue date:	03/22/2005
From:	NRC/OI
To:
References
FOIA/PA-2006-0113
Download: ML062680259 (15)

Text

Event Investigation Report Complete the evaluation of the hurnan perfonnance event using the following, as applicable:

I. Date and Time of the event: 03/22/05 12:20 p.m.

3. Department/Group Involved: Maint. Installation Services Group / DZNPS.

Program/Work Process/Activity Involved:

Scaffold Erection W0#0401229 SI

5. Unit:

PBNP Unit 0 PBNP Unit I PBNP Unit 2

6. Mode/Power Level:

100% / Mode I

7. Describe the inappropriate action and conditions that led up to the event. Consider the following in this description:

a.

Was a conscious decision made or not made by the individual(s) involved?

Yes (lanyard unavailable); (tool pouches not available). Decision was made to continue work without fabricating a restraining device.

b.

Was the event a result of rule non-compliance, misapplication of a rule, or applying an incorrect rule?

Individual chose the desire to keep the job going and complete task over the lanyarding of any of his construction tools.

c.

Was the individual fully trained/knowledgeable of the task? Yes

d.

Did the individual make an error in judgment? Yes

e.

Was an intended action not performed due to shortcuts taken or inadequate tracking?

f.

Was the individual overconfident or was their mental/physical state a factor?

Yes

g.

Did the supervisor not identify error likely situations and error precursors?

No - Issue was discussed in the pie-job brief (the tools the individual had previously used (apron) were not available).

h.

Was there a process or organizational failure that led to this error (see table on next page)?

Information In this record was deleted in accordance with the Freedom of Information Act, exemptions

42.

FOIA-________/_

8. Summarize the inappropriate action in one sentence as follows:

craftsman erection instea(

the job.

(WHO) did use an un-lanyarded tool during scaffold I of waiting for proper tools (lanyards) to be utilized on (WHAT)

(THE REQUIREMENT) as found in Pre-job briefing discussion because individual felt time / schedule pressure (did not want to impact work performance by delaying job to wait for a lanyard).

(Where the Requirement is found)

(WHY if known)

9. Based on what you have learned, describe the error likely situations that were present at the time of the event.

a. What Error Reduction Tools were not used or not used effectively? What Error Reduction Tools could have been used to prevent this event? Clearly state which is the one tool, which if used, would have had the greatest chance of being successful.

Stop when unsure; Are You Ready Checklist; Peer Checking

b. Are these Error Reduction Tools going to provide the barriers to prevent recurrence? Where else should these barriers be applied?

Yes Human Performance Failure Modes (From the NMC Trend Code Manual) 0 S

S S

0 S

0 0

S S

S S

Inattention Distracted & Interrupted Time & Schedule Pressure Spatial Disorientation Inadequate Motivation Unfamiliar or Infrequent Task Inadequate Knowledge of Standards Inadequate Knowledge of Fundamentals Inadequate Verification Inadequate Tracking (Place Keeping)

Habit/Reflex Imprecise Communication S

S 0

S S

0 0

S 0

S S

S Bored Multi-Tasking Fear of Failure Mindset/Preconceived Idea Shortcuts Taken Misdiagnosis Flawed Analytical Process or Model Over Confident Cognitive Overload Tired & Fatigued Lapse of Memory Wrong Assumptions

Work Around

• Tunnel Vision Process Failure Modes (From the NMC Trend Code Manual)

Critical Actions Not Verified a

Person Specified Not Able to Perform Task.

• Excessive Verifications 0 More Than One Person Specified to Perform Task

• No Process Monitoring a No One Specified to Perform Task

• Only Monitoring Problems

• No Acceptance Criteria Organizational Failure Modes (From the NMC Trend Code Manual)

" Inadequate Prioritization Inadequate Communication among Organizations

" Inadequate Trust 0 Inadequate Communication within an Organization

" Inadequate Self Assessment Lack of Commitment

• Inadequate Planning

• Inadequate Knowledge

" Inadequate Teamwork

" Inadequate Emerging Issues Management

" Inadequate Program Insufficient Staffing Management

" Inadequate Span of Control e

Inadequate Levels in Organization

Event Investization Personnel Statement Name:

Position:

Event Date:

Handwritten statements are acceptable. Include the plant conditions prior to the event, your indications that a problem existed, your action as a result of those indications, noted equipment malfunctions or inadequacies, and any identified procedure deficiencies.

Also, include any information you consider important to the review of this event and actions that may prevent recurrence. Use additional paper as necessary.

POINT BEACH NUCLEAR PLANT NP T.n.9A PROCEDURES MANUAL Revision 5 February 2, 2005 QC&

HUMAN PERFORMANCE PROGRAM ATTACHMENT D HUMAN PERFORMANCE EVENT INVESTIGATION TOOL EVENT INVESTIGATION REPORT Complete the evaluation of the human performance event using the following, as applicable:

i. Date and Time of thlent:

5 0 :f

2. Personnel Involved:

3. Department/Group Involve.

4. Urganit:

k Process/Activity Involve t-f AZ

5.

U nit: PBNP U nitI Pf-P q U nit 2,

6. Mode/Power Level:'/rY

//1 ' /'

7. Describe the inappropriate action and conditions that ied up to tfie event. Consider the following in this description:

a.

Was a conscious decision md n md byhe inividual( involyet/

" /

b.

Was the evnt a result of rule non-comr hnce, 4nisapplication of a rule, or d'pplying an incorrect rule?

9W~~

~

'6,ai f

Ai 4 ~

?ArAk

c.

Was the individual fully trained/knowledgeable of the tas

)

d.

Did the individual make an error in judgment? 7 V

e.

Was an i en

&?actionno performed due toshortcuts.tak rn rJnadeuate tracking?

f.

Was the individual over onfiden't or was menta /p y ical state a factor? /Ji)

g.

Did the supervisor not i4pe1ify/e orl1kegy Auaaions anj error preur orsp

h.

Was there a process/br cogani kionafailurd that led to thig error 'see tableon ndxt page)?

8. Summarize lhe inappropriate action in one sentence.s I

Cdid

(~A~

01 P-instead of /7Ti/-/

,/5

-'IA (THE REQUIREMENT)/

its found in _______________because vfer

/

/

L (Where the Requiremcnt is found)

(WHY if known)^//

Page 39 of 58 AT N USE itvr I

POINT BEACH NUCLEAR PLANT PROCEDURES MANUAL HUMAN PERFORMANCE PROGRAM NP 11.10 Revision 5 February 2, 2005 ATTACHMENT D HUMAN PERFORMANCE EVENT INVESTIGATION TOOL

9. Based on what you have learned, describe the error likely situations that were present at the time of the event.

a. What Error Reduction Tools were not used or not used effectively? What Error Reduction Tools could have been used to prevent this event? Clearly state which is the one tool, which if u Lad the greatest ch:nce of ein su essful.

b...Ar T

gin i

t bi t

b. Are these Error Reduction Tools going to provide the barriers to prevent recurrence? Where el.q should these barriers be applied?

Human Performance Failure Modes (From the NMC Trend Code Manual)

Inattention Distracted'&

Interrupted tf Time & Schedule 4

Pressulre Bored Multi-Tasking Fear of Failure Habit/Reflex Lapse of Memory Imprecise Communication Tired & Fatigued Inadequate Tracking (Place Keeping)

Cognitive Overload

&W 7

Page 40 of 58 INFORMATION USE

POINT BEACH NUCLEAR PLANT NP 1..I 0 PROCEDURES MANUAL Revision 5 February 2, 2005 HUMAN PERFORMANCE PROGRAM ATTACHMENT D HUMAN PERFORMANCE EVENT INVESTIGATION TOOL Process Failure Modes (From the NMC Trend Code Manual)

Critical Actions Not Verified Excessive Verifications No Process Monitoring Only Monitoring Problems No Acceptance Criteria No One Specified to Perform Task More Than One Person Specified to Perform Task Person Specified Not Able to Perform Task.

Organizational Failure Modes (From the NMC Trend Code Manual)

Inadequate Communication within an Organization Inadequate Communication among Organizations Inadequate Prioritization Inadequate Planning (.co.(t4 Inadequate Emerging Issues Management Inadequate Program Management Inadequate Span of Control Inadequate Levels in Organization Insufficient Staffing Inadequate Teamwork Inadequate Knowledge Lack of Commitment Inadequate Self Assessment Inadequate Trust Page 41 of 58 INFORMATION USE

(

Event Investigation Personnel Statement Name Position:.4Z4.M Event Date:

o Handwritten statements are acceptable. Include the plant conditions prior to the event, your indications that a problem existed, your action as a result of those indications, noted equipment malfunctions or inadequacies, and any identified procedure deficiencies. Also, include any information you consider important to the review of this event and actions that may prevent recurrence. Use additional paper as necessary.

"1'2

(

(

Event Investigation Personnel Statement ME1" Name:

Positiol.

Event Date:

'9 "0,,Y5 Handwritten statements are acceptable. Include the plant conditions prior to the event, your indications that a problem existed, your action as a result of those indications, noted equipment malfunctions or inadequacies, and any identified procedure deficiencies. Also, include any information you consider important to the review of this event and actions that may prevent-recurrence. Use additional paper as necessary.

0 "t" A*14ý e, vz/ý 14ý4e

,07.S PPe.'-,,.

£~iI~

PdAA

~~

4 At Azk4"-

'P/

%~

lox.,(

(V C,

XL c.. e Z AL?

WJ.L)

., 0

-, /A

(

(

PB:

Maitennc Deatnn The following information is to be used at Maintenance Dept. shift briefs to present timely OE on an event that reset the Maintenance Human Performance Clock.

Clock Reset Based On: Personal Safety Issue / Near Miss CAP Number:

Background:

Event Outline:

Page 1 of 2 J:'\\ShareDala\\mmt\\FORMS\\Mainl. Dept Event Clock Reset Forms

Corrective Action Taken: The workers stopped, placed their work area in a safe condition and notified their Supervisor. The Supervisor then contacted the following personnel:

NMC Contractor Manager Operations Department Manager Maintenance Department Manager Industrial Health and Safety Manager Corrective Action Taken: (cont.) An Operations representative performed a walk down of the area to ensure that no equipment had been damaged during this incident.

The Contractor Site Manager and Responsible Contractor Liaison then held a Briefing I Safety Stand down with all Craft Scaffolding personnel. A lessons learned briefing was also held with all Supervisors.

A Human Performance Investigation was performed.

Operating Experience: N/A

References:

N/A Error Reduction Tools that may have helped In this event: STAR (Worker adjusting the decking), Challenging Information (How am I verifying the loose plate is not being allowed to fall), Communications Human Performance Failure Modes: (Al) - Inattention, (A5) - Distracted, (A6)

- Multi-Tasking, (AS) - Inadequate Tracking, (J5) - Inadequate Verification ACEMAN Barrier Not Met: Worker Practices, Job Planning/Preparation, Verification/Validation, Peer Checking

Attachment:

N/A

Attachment:

/A Page 2 of 2 J.\\ShareDataVnt\\FORMS\\Maint. Dept Event Clock Reset Forms

Event Investigation Personnel Statement Name:

Position:

Event Date:

Handwritten statements are acceptable. Include the plant conditions prior to the event, your indications that a problem existed, your action as a result of those indications, rioted equipment malfunctions or inadequacies, and any identified procedure deficiencies. Also, include any information you consider important to the review of this event and actions that may prevent recurrence. Use additional paper as necessary.

(

Event Investigation Personnel Statement

.Nan{

Position:"

px Event Date: 0

-O* -0 S Handwritten.statements are acceptable. Include the plant conditions prior to the event, your indications that a problem existed, your action as a result of those indications, noted equipment malfunctions or inadequacies, and any identified procedure.deficiencies. Also, include any information you consider important to the review of this event and actions that vent recurrence. Use additional paper as necessary.

',;0 4]C Of oe CA X,

,,0,Jo

+

(

Event Investigation Personnel Statement Nam"""PIP Position:

IF Event Date: $ Z

-5:5 Handwritten statements are acceptable. Include the plant conditions prior to the event, your indications that a problem existed, your action as a result of those indications, noted equipment malfunctions or inadequacies, and any identified procedure deficiencies. Also, include any information you consider important to the review of this event and actions that may prevent recurrence. Use additional paper as necessary.

A116-6'QreS lA

ý 6e Z KeY

-5'e 0

/' /a -,

e"eny

/,/l ki,-

JFý Z/ iv--e i*-~&7Z

--- iC/

a'Yv/APW Z,<74 5

4/c~i4 ce'Pe9LCt4ve

ý/C ZQO 4/e-ro.c./j

/1 0 C? tI'i'1~' ~

-oo~Z

~*

.AIAAC..

1-U,"'-,

4;; j~L~Q

(

(Uo 12 1 H c~

b.o.L.

sý.

a&.4, CA, et'f ZC) rZ~

--tu VZ(ý AUG 2 5 SO*