ML083570327
| ML083570327 | |
| Person / Time | |
|---|---|
| Site: | Monticello, Prairie Island  |
| Issue date: | 12/17/2008 |
| From: | Northern States Power Co |
| To: | NRC/RGN-III |
| References | |
| Download: ML083570327 (17) | |
Text
1 Independent Human Performance Focused Self-Assessment Results October 20 - October 31, 2008 - Monticello December 1 - December 5, 2008 - Prairie Island
2 Objectives Compliance Objectives
- 1. Determine the emerging themes in Human Performance from the station CAP data and NRC inspection results.
- 2. Determine the drivers for the human performance themes - (site and/or corporate).
- 3. Evaluate the current site strategy to address Human Performance and identify gaps to address the drivers for the human performance trend.
Excellence Objectives Make recommendations for improvements to the site excellence plan based on industry best practices and guidance documents.
3 Team Composition Management Sponsor:
Mark Reddemann (VP Operations Support - Xcel Energy Nuclear Department)
Team Leader:
Art Rone - Industry Consultant Team Members: Monticello External Peers:
Dick Cooper - Industry Consultant Human Performance Program Owner - Wolf Creek Internal Peers:
Nuclear Oversight Manager - Monticello Nuclear Oversight Manager - Prairie Island Performance Assessment Coordinator - Marquette Plaza
4 Team Composition Team Members: Prairie Island External Peers:
Human Performance Specialist - Hope Creek Internal Peers:
Director, Operations Standards - Marquette Plaza NOS Manager - PI Fleet Manager Maintenance and Work Management - Marquette Plaza NOS Principal Assessor-Monticello Performance Assessment Coordinator - Marquette Plaza
5 Focused Self Assessment (FSA) Approach Observe Work Interview Staff Current HU Behaviors &
Attitudes HU Drivers NRC Conclusions NRC HU Drivers Compare Recommendations Historical HU Behaviors &
Attitudes CAP HU Issues Nuclear Oversight Department Assessments, Department reports, Industry trended Data INPO Evaluation MT Mid-cycle Evaluation PI
6 Industry Standards Industry Performance Objectives for Excellence:
Human Performance
- Station personnel select and apply appropriate human error prevention techniques commensurate with the importance of assigned tasks to minimize the frequency and consequences of events.
Management and Leadership
- Managers, by leadership, commitment, and example, establish and reinforce high standards of performance and align the organization to achieve safe, reliable station operation.
Industry Good Practice Human Performance Tools for Managers and Supervisors
7 Organizational Factors Expectations for use of error prevention tools established and communicated Expectations for use of Procedures Procedures and other work documents are usable Changes in work plans and schedules are critically reviewed Feedback and observations used to improve HU performance HU events evaluated for learning opportunities Station Processes reduce error likely conditions at job site Job Site Conditions Personnel qualified and fit for duty Job-site conditions and risks evaluated for needed behavior to reduce HU errors Goal, Roles and Responsibilities, understood before work starts Work Preps and Pre-Job Brief (PJB) commensurate with risks Job-site conditions are properly established Defense in depth used to minimize errors and mitigate risks Excellence In Human Performance Individual Behaviors Individuals recommend improvements and willingly report problems Individuals follow procedures and correct deficiencies before acting Individuals identify and eliminate conditions that might lead to human error Individuals understand error prevention techniques, and management expectations Individuals demonstrate questioning attitude, consider consequences before acting Individuals are receptive to feedback Station Processes reduce error likely conditions at job site Individuals communicate effectively to complete work Individuals accept responsibility for their shortfalls Industry Performance Objectives for Human Performance Management and Leadership Work prioritized and matched to resources Staffing is sufficient and adequately trained Industry Performance Objectives for Management and Leadership (partial)
8 Field Observations/Interviews/Data Review Monticello Conducted 16 work observations Conducted 13 sets of interviews Evaluated data from CAP, Observations, Operations +/-
log, Site HU initiatives, INPO Evaluation, and NOS reports Prairie Island Conducted 14 work observations Conducted 19 sets of interviews Evaluated data from CAP, Observations, INPO Evaluation, NOS reports, Mid-cycle report and, Industry Trend data
9 Results
10 Organizational Factors Expectations for use of error prevention tools established and communicated Expectations for use of Procedures Procedures and other work documents are usable Changes in work plans and schedules are critically reviewed Feedback and observations used to improve HU performance HU events evaluated for learning opportunities Station Processes reduce error likely conditions at job site Job Site Conditions Personnel qualified and fit for duty Job-site conditions and risks evaluated for needed behavior to reduce HU errors Goal, Roles and Responsibilities, understood before work starts Work Preps and Pre-Job Brief (PJB) commensurate with risks Job-site conditions are properly established Defense in depth used to minimize errors and mitigate risks Excellence In Human Performance Individual Behaviors Individuals recommend improvements and willingly report problems Individuals follow procedures and correct deficiencies before acting Individuals identify and eliminate conditions that might lead to human error Individuals understand error prevention techniques, and management expectations Individuals demonstrate questioning attitude, consider consequences before acting Individuals are receptive to feedback Station Processes reduce error likely conditions at job site Individuals communicate effectively to complete work Individuals accept responsibility for their shortfalls Monticello HU FSA Results Management and Leadership Work prioritized and matched to resources Staffing is sufficient and adequately trained Industry Performance Objectives for Management and Leadership (partial)
Legend Driver Key Driver
11 Organizational Factors Expectations for use of error prevention tools established and communicated Expectations for use of Procedures Procedures and other work documents are usable Changes in work plans and schedules are critically reviewed Feedback and observations used to improve HU performance HU events evaluated for learning opportunities Station Processes reduce error likely conditions at job site Job Site Conditions Personnel qualified and fit for duty Job-site conditions and risks evaluated for needed behavior to reduce HU errors Goal, Roles and Responsibilities, understood before work starts Work Preps and Pre-Job Brief (PJB) commensurate with risks Job-site conditions are properly established Defense in depth used to minimize errors and mitigate risks Excellence In Human Performance Individual Behaviors Individuals recommend improvements and willingly report problems Individuals follow procedures and correct deficiencies before acting Individuals identify and eliminate conditions that might lead to human error Individuals understand error prevention techniques, and management expectations Individuals demonstrate questioning attitude, consider consequences before acting Individuals are receptive to feedback Station Processes reduce error likely conditions at job site Individuals communicate effectively to complete work Individuals accept responsibility for their shortfalls PI HU FSA Results Management and Leadership Work prioritized and matched to resources Staffing is sufficient and adequately trained Industry Performance Objectives for Management and Leadership (partial)
Legend Driver Key Driver
12 Common Drivers - Monticello/PI Organizational Factors
- Quality of coaching of workers by supervisors and managers results in missed opportunities to set and reinforce Human Performance expectations and standards
- Missed learning opportunities from Observation Programs and CAP result in corrective actions that address the symptom not the cause (focus on what happened not why) thus corrective actions may not solve the problem
- HU Improvement plans
- Monticello - HU improvement plans developed (quality varies by department) but not effectively communicated
- Prairie Island - HU improvement plans limited to those linked to work management improvement initiative - HU improvement plans require further development/focus Management and Leadership
- Loss of experienced personnel
- Lack of balance between work load & resources pushes more work through a shrinking pool of experienced staff
13 Common Drivers - Monticello/PI Individual Behaviors
- Personnel have a tolerance for risk, rationalize it away or dont consider it (Key Driver for both Monticello and PI)
R I
S K
TIME Actual Risk Perceived Risk Familiarity and success create a false perception of risk
14 Drivers - PI Job Site Conditions Pre-Job Briefs not well executed as an HU error reduction tool Work instruction deficiencies are being identified during work execution. Issues noted are a lack of detailed information; lack of consistency; generic statements; missing steps.
Individual Behaviors Rationalize and tolerate poor HU behavior Station workers, supervisors, and managers lack a clear picture of Excellence in Human Performance. Workers are knowledgeable in HU tools but unclear on how to apply them
15 Conclusions - Monticello
- The application of HU performance fundamentals at the worker level are generally sound with the exception of risk perception (key driver)
- Weaknesses exist in the areas of:
3/4 Oversight and Coaching 3/4 Missed learning opportunities (trending and data analysis) 3/4 Balancing work load, priorities, and resources 3/4 Integration and communication of HU improvement Plans
- Several of the HU performance shortfalls have in many cases been identified by oversight groups and station corrective actions have not been effective
16 Conclusions - PI
- The Principal shortfalls (key drivers) are in the application of Human Performance Fundamentals to achieve and sustain high levels of Human Performance:
3/4 Risk tolerance and rationalization 3/4 Tolerance and acceptance of weak HU behaviors 3/4 Unclear picture of how to apply HU tools
- Weaknesses exist in the areas of:
3/4 Oversight and Coaching 3/4 Missed learning opportunities (trending and data analysis) 3/4 Balancing work load, priorities, and resources 3/4 Lost focus on the importance of a robust Human Performance Program 3/4 Quality of Pre Job Briefs 3/4 Quality of work controlling documents
- Several of the HU performance shortfalls have in many cases been identified by oversight groups and station corrective actions have not been effective
17 Conclusions - Corporate The FSA Team concluded that the transition from NMC to Xcel was not a causal factor for the downturn in human performance with the exception that the reduction of the Human Resources department staff at the sites created a latent weakness in consuming additional Managers time in the hiring process.