ML102460627
Text
QF-0433. Rev 2. (FG-PA-RCE-O I) RCE Report Template Page 51 of81 XI].
Attachments Attachment I - Task Analysis
- - Barrier Analysis
- - Change Analysis
- - Evaluation of RMSP Procedures
- - Event and Causal Factors Flow Chart
- - Why Staircases
- - Evaluation of Safety Culture lmpacts
- - Glossary of Terms
- - Root Cause Charter Form retained in accordance with record retention schedule identified in FP-G-RM-OI.
QF-0433. Rev 2. (FG-PA-RCE-O I) RCE Report Template PageSlof81 xn.
Attachments Attachment I - Task Analysis
- - Barrier Analysis
- - Change Analysis
- - Evaluation or RMSP Procedures
- - Event and Causal Factors Flow Chart
- - Why Staircases Anachment 7 - Evalualion or Sarety Culture lmpacts
- - Glossary or Terms Anachment 9 - Root Cause Charter Form retained in accordance with record retention schedule identified in FP-G-RM-O I.
NSP000035C
QF-0433. Rev 2. (FG-PA-RCE-O I) RCE Report Template Page 52 of 81 : Task Analysis (1) Steps in Procedure or (2) Walk through by (3) Questions I Conclusions Practice. (Enter step Analyst or trained about how task was I should number and short individual. (State how be performed.
description.)
actual matches procedure.)
Evaluate the material RWSC is to consider RWSC provides little oversight of potential for small sources the packaging process, because
- 011.7, step 6.9, of irradiated material prior items packaged correctly are not instructions for RWSC to packaging the material considered to be susceptible to or designee prior to (wrapping in plastic) changing dose rates. The RWSC packaging material does not consider the evaluation No mention of evaluation of the material a necessary part of of material in RPIP I 122 the RMSP.
- RPIP I 122, hot particle (RCI) program Package the material Material is packaged for The accepted practice at PI is the controlling the spread of same as it has been for the la~t 20
- RPIP I 122, hot particle contamination at PI.
years, and PI has relied on a single program individual for more than 10 years.
Discrete particles need to (RC2) Put equipment in be restrained for shipment, polyethylene, and if it will be both so the particle doesn't handled, put in Herculite.
move and so the equipment Industry standards dictate fixing containing the particle discrete particles and fixing loose doesn' t move.
equipment so it does not move around during shipment.
RPIP 1122 is mute on packaging options and Discrete particles need to be methods for discrete restrained for shipment, both so particles.
the particle doesn't move and so the equipment containing the RPIP does not implement particle doesn't move.
effective methods to detect discrete particles that are Procedures do not describe fixed in materials.
methods (RCI)
Form retained in accordance with record retention schedule identified in FP-G-RM-OI.
QF-0433. Rev 2. (FG-PA-RCE-Ol) RCE Report Template Page 52 of 81 Attachment J: Task Analysis (1) Steps in Procedure or (2) Walk through by (3) Questions I Conclusions Practice. (Enter step Analyst or trained about how task was I should number and short individual. (State how be performed.
description.)
actual matches procedure.)
Evaluate the material RWSC is to consider RWSC provides little oversight of potential for small sources the packaging process, because
- 01 1.7, step 6.9, of irradiated material prior items packaged correctly are not instructions for RWSC to packaging the material considered to be susceptible to or designee prior to (wrapping in plastic) changing dose rates. The RWSC packaging material does not consider the evaluation No mention of evaluation of the material a necessary part of of material in RPlP 1122 the RMSP.
- RPIP 1 122. hot particle (RCI) program Package the material Material is packaged for The accepted practice at PI is the controlling the spread of same as it has been for the last 20
- RPIP 1 122, hot particle contamination at PI.
years, and PI has relied on a single program individual for more than 10 years.
Discrete particles need to (RC2) Put equipment in be restrained for shipment, polyethylene. and if it will be both so the particle doesn't handled, put in Herculite.
move and so the equipment Industry standards dictate fixing containing the particle discrete particles and fixing loose doesn't move.
equipment so it does not move around during shipment.
RPlP 1122 is mute on packaging options and Discrete particles need to be methods for discrete restrained for shipment. both so particles.
the particle doesn't move and so the equipment containing the RPlP does not implement particle doesn't move.
effective methods to detect discrete particles that are Procedures do not describe fixed in materials.
methods (RCt)
Form retained in accordance with record retention schedule identified in FP-G-RM-O I.
QF-0433, Rev 2, (FG-PA-RCE-Ol) RCE Report Template Page 53 of81 : Task Analysis (1) Steps in Procedure or (2) Walk through by (3) Questions I Conclusions Practice. (Enter step Analyst or trained about how task was I should number and short individual. (State how be performed.
description.)
actual matches procedure.)
Place the material in the There must be a This evolution should be observed shipping container requirement that any by a qualified RWSC. The use of materials subject to discrete secondhand infomlalion does not
- 011.7, step 6.9.2 particle contamination is ensure the material is loaded ensures that the adequately maintained from correctly due to differing mindsets materials are packaged the faces of the container.
and experience. (RC2) in such a manner that This will ensure a robust under conditions program. This is a more Even though the container did not normally incident to concrete task than ensuring have permanent shoring for the transportation, the you find all discrete lid, industry best practice is to materials will not hift particles.
ensure that radioactive material is within the package.
packaged such that it does not come in contact with any interior faces of the shipping container.
Survey the material to be Each is a SHALL The requirements to evaluate the shipped statement.
materials, observe the packaging, and observe the loading, all must
- o I 1.7, steps 6.1 0.5, be SHALL statements to have a 6.10.6, and 6.10.7 There was no discussion of robust RMSP. (RCI) ensure that material to packaging of equipment so be shipped is surveyed.
the equipment does not All the appropriate surveys were move.
completed, the results of some
- RPlP 1319 (loading were questioned and some results LSNSea-Iand boxes) were re-surveyed. All of these are requires materials to be appropriate actions. It is loaded so that nothing impossible to survey shifted shifts.
materials.
Complete administrative Adequate but not very well Shipping paperwork was paperwork laid out on these processed correctly with no requirements.
identified deficiency.
- 011.7 Form retained in accordance with record retention schedule identified in FP-G-RM-O I.
QF-0433. Rev 2. (FG-PA-RCE-O I) RCE Repon Template Page 53 of81 : Task Analysis (1) Steps in Procedure or (2) Walk through by (3) Questions I Conclusions PractIce. (Enter step Analyst or trained about how task was I should number and short individual. (State how be performed.
description.)
actual matches procedure.)
Place the material in the There must be a This evolution should be observed shipping container requirement that any by a qualified RWSC. The use of materials subject to discrete secondhand infomlation does not
- OIl.7. step 6.9.2 panicle contamination is ensure the material is loaded ensures that the adequately maintained from correctly due to differing mindsets materials are packaged the faces of the container.
and experience. (RC2) in such a manner that This will ensure a robust under conditions program. This is a more Even though the container did not nOffilally incident to concrete task than ensuring have permanent shoring for the transponation. the you find all discrete lid. industry best practice is to materials will not shift panicles.
ensure that radioacti ve material is within the package.
packaged such that it does not come in contact with any interior faces of the shipping container.
Survey the material to be Each is a SHALL The requirements to evaluate the shipped statement.
materials. observe the packaging.
and observe the loading. all must
- 011.7. steps 6.10.5.
be SHALL statements to have a 6.10.6. and 6.10.7 There was no discu sion of robust RMSP. (RCI) ensure that material to packaging of equipment so be shipped is surveyed.
the equipment does not All the appropriate surveys were move.
completed, the results of some
- RPIP 1319 (loading were questioned and some results LSAlSea-land boxes) were re-surveyed. All of these are requires mmerials to be appropriate actions. It is loaded so that nothing impossible to survey shifted shifts.
materials.
Complete administrative Adequate but not very well Shipping paperwork was paperwork laid out on these processed correctly with no requirements.
identified deficiency.
- DIU FOffil retained in accordance with record retention schedule identified in FP-G-RM-Ol.
QF-0433, Rev 2, (FG-PA-RCE-Ol) RCE Report Template Page 54 of 81 : Barrier Aoalysis Definition - Barriers are devices employed to protect and enhance the safety and performance of the plant.
Energy I Hazard Barrier Assessment Target Detection of discrete Qualjfied A gross survey of the equjpment was completed when the Detailed evaluation of the partkles on Workers sipper was first lifted from the spent fuel pool after the material equipment.
completion of tbe used fuel test for defects. This survey was completed by qualified RP technkians covering the spent fuel pool job. This survey was completed for the purpose of contamination control and determiillng the decon method. Based on the gross survey h was decided that decontamination of the canister would take place underwater.
As the equipment was decontanUnated, a detailed survey was completed by qualified in house and contract RP technicians. The purpose of this survey was for exposure control.
The indjviduals involved in the surveying of the material were qualified to do the job coverage task according to station reqttirements in place at the tjme.
No effective barrier existed to confLrm Subpart H qualifications for individuals involved in shipping related activities.
Thjs barrier was determjned to be in place, although no specific training and qualification requirements for radjoactive srupments could be jdentified. (CC2)
Form retained in accordance with record retention schedule identified in FP-G-RM-O I.
QF-0433. Rev 2. (FG-PA-RCE-Ol) RCE Repon Template Page 54 of81 : Barrier Aoalysis Definition - Barriers are devices emplo}ed to protect and enhance the safety and performance of the plant-Energy I Hazard Barrier Assessment Target Delection of discrete Qualified A gross survey of the equipment was completed when the Detailed evaluation of the particles on Workers sipper was fust lifted from the spent fuel pool after the material equipment.
completion of the used fuel test for defects. This survey was completed by qualified RP technicians covering the spent fuel pool job. This survey was completed for the pUr]JOse of contamination control and determining the decon method. Based on the gross survey it was decided that decontamination of the canister would take place underwater.
As the equipment was decontaminated. a detailed survey was completed by qualified in house and contract RP technicians. The pUr]JOse of this survey was for exposure control.
The individuals involved in the surveying of the matenal were qualified to do the job coverage task according to station requirements in place at the time.
No effective barrier existed to confirm Subpan H qualifications for individuals involved in shipping related activities.
This barrier was determined to be in place, although no specific training and qualification requirements for radioactive shipments could be identified. (CC2)
Form retained in accordance with record retention schedule identified in FP-G-RM-Ol.
QF-D433. Rev 2. (FG-PA-RCE-Ol) RCE Repon Template Page 55 of81 : Barrier Analysis Definition - Barriers are devices employed to protect and enhance the safety and performance of the plant.
Energy I Hazard Barrier Assessment Target Detection of discrete Job Planning I No specific task was included in the work plan for the Risk significant rad particles on Preparation radiological evaluation of the equipment.
shipping evolutions are equipment.
appropriatel y planned via The RP technicians were briefed on the removal of the the work planning process equipment from the refuel pool to include a survey for and have adequate ALARA exposure control. The briefing did not include specific planning.
direction for surveying for shipment.
The task was not planned as an integral part of the work planning process. (RC2)
This barrier was determined to be missing. This was a missed opportunity to have the task clearly defmed and scheduled.
Form retained in accordance with record retention schedule identified in FP-G-RM-Ol.
QF-0433, Rev 2, (FG-PA-RCE-OI) RCE Report Template Page 55 of 81 : Barrier Analysis Defmition - Barriers are devices emplo,ed to protect and enhance the safety and performance of the plant.
Energy I Hazard Barrier Assessment Target Detection of discrete Job PI.anning I o specific task was included in the work plan for the Risk significant rad particles on Preparation radiological evaluation of the equipment.
shipping evolutions are equipment.
appropriatel y planned via The RP technicians were briefed on the removal of the the work planning process equipment from the refuel pool to include a survey for and have adequate ALARA exposure control. The briefing did not include specific planning.
direction for surveying for shipment.
The task was not planned as an integral part of the work planning process. (RC2)
This barrier was determined to be missing. This was a missed opportunity to have the task clearly defmed and scheduled.
Form retained in accordance with record retention schedule identified in FP-G-RM-Ol.
QF-0433. Rev 2. (FG-PA-RCE-OI ) RCE Report Template Page 56 of8 1 : Barrier Analysis Definition - Barriers are devices employed to protect and enhance the safety and performance of the plant.
Energy 1 Hazard Barrier Assessment Target Procedure RPIP 1122 - Hot Particle Program does not Detection of discrete Procedures 1 provide adequate guidance. The procedure does not include particles on Work an applicability statement outlining when the procedure is to equipment Instructions be used. There is no indication that the procedure was to be included in the task of surveying the equipment on 10/23/08. A second example is that step 7.1 requires either a direct frisk of the material to be removed or a large area (Masslin) survey. Large area surveys will not detect particles embedded in the material (such as in small crevasses or plastic coatings etc.). These particles can become dislodged after removal from the particle area.
Direct surveying of the material should be the fInal determining factor for removal of material from an area.
Additionally direct survey of the material must be done if the material is to be shipped offsite in order to ensure that any potential small discrete source of radiation is identifIed.
Another example is the guidance in step 7.3.2 is weak in that it does not direct the contact of shipping personnel for evaluation of appropriate surveying methods and packaging material to ensure their suitability for shipping.
This barrier was determined to be in place but ineffective.
Fonn retained in accordance with record retention schedule identifIed in FP-G-RM-O 1.
QF-0433. Rev 2. (FG-PA-RCE-OI ) RCE Report Template Page 56 of 8 1 : Barrier Analysis Defmition - Barriers are devices emplo}ed to protect and enhance the safety and performance of the plant_
Energy I Hazard Barrier Assessment Target Procedure RPIP I 122 - Hot Particle Program does not Detection of discrete Procedures I provide adequate guidance. The procedure does not include particles on Work an applicability statement outlining when the procedure is to equipment Instructions be used. There is no indication that the procedure was to be included in the task of surveying the equipment on 10/23/08. A second example is that step 7.1 requires either a direct frisk of the material to be removed or a large area (Masslin) survey. Large area surveys will not detect particles embedded in the material (such as in small crevasses or plastic coatings etc.). These particles can become dislodged after removal from the particle area.
Direct surveying of the material should be the final determining factor for removal of material from an area.
Additionally direct survey of the material must be done if the material is to be shipped offsite in order to ensure that any potential small discrete source of radiation is identified.
Another example is the guidance in step 7.3.2 is weak in that it does not direct the contact of shipping personnel for evaluation of appropriate surveying methods and packaging material to ensure their suitability for shipping.
This barrier was determined to be in place but ineffective.
Form retained in accordance with record retention schedule identified in FP-G-RM-Ol.
QF-0433, Rev 2, (FG-PA-RCE-OI) RCE Report Template Page 57 of8 l : Barrier Analysis Defmition - Barriers are devices emploJ ed to protect and enhance the safety and performance of the plant.
Energy I Hazard Barrier Assessment Target Procedure DI!.7, Radioactive Materials - Shipment - LSA Detection of discrete Procedures I I SCO I LTD Qty to a Licensed Facility, step 6.9.1, states:
particles on Work equipment Instructions "6.9 Prior to packaging, the RWSC or designee should:
6.9.1 Consider the potential for small sources of irradiated material to inadvertently remain within the internals of the equipment. The higher radiation levels of the irradiated materials may be masked by the intrinsic shielding of the equipment."
The procedure is inadequate in its guidance on packaging.
(RCI)
PI shipping personnel are Detection of discrete Verification I PI shipping personnel visited the fuel floor during the present to evaluate an y particles on Validation equipment evaluation step in the shipping process.
evolutions that are risk equipment significant.
This barrier was determined to be weak. Procedure guidance does not require verification and validation of the evaluation process. Though the shipper is qualified to conduct the surveys, this task has been typicaUy delegated to RP technicians. (CC2)
The supervisor provides Detection of discrete Supervisor The supervisor was monitoring multiple tasks during the meaningful oversight for particles on Oversight course of the outage. The current and previous supervisors tasks that represent equipment are not qualified in the area of shipping. (CC2) significant risk Form retained in accordance with record retention schedule identified in FP-G-RM-O I.
QF-0433, Rev 2, (FG-PA-RCE-OI) RCE Report Template Page 57 of81 : Barrier Analysis Dermition - Barriers are devices employed to protect and enhance the safety and performance of the plant.
Energy I Hazard Barrier Assessment Target Procedure DII.7, Radioactive Materials - Shipment - LSA Detection of discrete Procedures I I SCO I LTD Qty to a Licensed Facility, step 6.9. 1, state:
particles on Work equipment Instructions "6.9 Prior to packaging, the RWSC or designee should:
6.9.1 Consider the potential for small sources of irradiated material to inadvertently remain within the internals of the equipment. The higher radiation levels of the irradiated materials may be masked by the intrinsic shielding of the equipment."
The procedure is inadequate in its guidance on packaging.
(RCI)
PI shipping personnel are Detection of discrete Verification I PI shipping personnel visited the fuel floor during the present to evaluate any particles on Validation equipment evaluation step in the shipping process.
evolutions that are risk equipment significant.
This barrier was determined to be weak. Procedure guidance does not require verification and validation of the evaluation process. Though the shipper is qualified to conduct the surveys, this task has been typically delegated to RP technicians. (CC2)
The supervisor provides Detection of discrete Supervisor The supervisor was monitoring multiple tasks during the meaningful oversight for particles on Oversight course of the outage. The current and previous supervisors tasks that represent equipment are not qualified in the area of shipping. (CC2) significant risk Form retained in accordance with record retention schedule identified in FP-G-RM-O I.
QF-0433, Rev 2, (FG-PA-RCE-OI) RCE Report Template Page 58 of81 : Barrier Analysis Definition - Barriers are devices employed to protect and enhance the safety and performance of the plant.
Energy I Hazard Barrier Assessment Target All discrete particles that Detection of discrete Worker Practices The personnel assigned to the initial evaluation of the fuel are of dose consequence for particles on sipping equipment completed an adequate assessment of the the planned tasks are equipment equipment for hot particles.
located and adequate radiological controls put in place to keep dose ALARA.
Fonn retained in accordance with record retention schedule identified in FP-G-RM-O I.
QF-0433, Rev 2, (FG-PA-RCE-Ol) RCE Report Template Page 58 of 81 : Barrier Analysis Definition - Barriers are devices employed to protect and enhance the safety and performance of the plant.
Energy I Hazard Barrier Assessment Target All discrete particles that Detection of discrete Worker Practices The personnel assigned to the initial evaluation of the fuel are of dose consequence for particles on sipping equipment completed an adequate assessment of the the planned tasks are equipment equipment for hot particles.
located and adequate radiological controls put in place to keep dose ALARA.
Form retained in accordance with record retention schedule identified in FP-G-RM-O 1.
- Change Analysis Problem Statement - Prairie Island failed to ensure equipment was adequately packaged to prevent excessive radiation levels on the exterior of a container shipped from Prairie Island to Waltz Mill.
Previous Condition Current Condition Change I Difference Impact or Assessment Sipper design - lid is integral Lid detaches from sipper Position of lid is no longer tied Shipping container did not change for to sipper design canister.
to canister change to equipment Sipper lid - lid is used for Lid used for either canister More efficient overall site fuel New design puts lid in path of fuel single canister only.
sipping evolution detritus Sipper Canister - single Two barrels Makes sipping evolution Requires different lid design.
barrel quicker, can load one while testing another bundle Decontamination The lid was decontaminated Past methods had special No noted impacts.
methodology - There was a while suspended over the tools to spray down inside of special tool to 'hose off' the pool sipper canister.
intemals of the sipper; spray The canisters and remaining hoses were used for the rest of the equipment.
sip per equipment was decontaminated underwater with a high pressure spray hose.
Shipping container-New lid design (detached)
Equipment that went in the Error likely situation - equipment design of the sipper was with was not accommodated in SFP was no longer exposed to discrete particles not kept integral lid, permanent the container.
maintained from the face of from faces of box. Additional shoring was used to maintain the box, by design container loading activities were distance from equipment to needed.
faces of container Container loading - no Some items (the lid) were No longer maintain a specific Error likely situation - Additional items immersed in SFP were able to be placed close to location for all items packaging material required to able to be close (by design) the sides of the container immersed in SFP (except for maintain lid away from sides of the to the sides of the container umbilical) container.
Fonn retained in accordance with record retention schedule identified in FP-G-RM-O I. - Change Analysis Problem Statement - Prairie Island failed to ensure equipment was adequately packaged to prevent excessive radiation levels on the exterior of a container shipped from Prairie Island to Waltz Mill.
Previous Condition Current Condition Change I Difference Impact or Assessment Sipper design - lid is integral lid detaches from sipper Position of lid is no longer tied Shipping container did not change for to sipper design canister.
to canister change to equipment Sipper lid - lid is used for lid used for either canister More efficient overall site fuel New design puts lid in path of fuel single canister only.
sipping evolution detritus Sipper Canister - single Two barrels Makes Sipping evolution Requires different lid design.
barrel quicker, can load one while testing another bundle Decontamination The lid was decontaminated Past methods had special No noted impacts.
methodology - There was a while suspended over the tools to spray down inside of special tool to 'hose off' the pool sipper canister.
internals of the sipper; spray The canisters and remaining hoses were used for the rest of the equipment.
sip per equipment was decontaminated underwater with a high pressure spray hose.
Shipping container-New lid design (detached)
Equipment that went in the Error likely situation - equipment design of the sipper was with was not accommodated in SFP was no longer exposed to discrete particles not kept integral lid, permanent the container.
maintained from the face of from faces of box. Additional shoring was used to maintain the box, by design container loading activities were distance from equipment to needed.
faces of container Container loading - no Some items (the lid) were No longer maintain a specific Error likely situation - Additional items immersed in SFP were able to be placed close to location for all items packaging material required to able to be close (by design) the sides of the container immersed in SFP (except for maintain lid away from sides of the to the sides of the container umbilical) container.
Form retained in accordance with record retention schedule identified in FP-G-RM-Ol.
- Change Analysis Problem Statement - Prairie Island failed to ensure equipment was adequately packaged to prevent excessive radiation levels on the exterior of a container shipped from Prairie Island to Waltz Mill.
Previous Condition Current Condition Change I Difference Impact or Assessment Wrapping methodology -
Wrapped to PI standards None.
Changes needed to package shipped wrapped to PI standards which control contamination materials subject to discrete particles.
which control contamination spread. Wrapped Need to fix equipment andlor discrete spread. Packaged as part of separately from sip per.
particles to prevent movement during sipper, not separate.
shipment.
Condition of fuel sipping Material left PI with Immersed in SFP, subjected Change in equipment radiological equipment - Material came significant radiological to discrete particles status changed the packaging and into PI without any hazards shipping reqUirements, but changes radiological controls.
were not assessed properly.
Form retained in accordance with record retention schedule identified in FP-G-RM-O I. - Change Analysis Problem Statement - Prairie Island failed to ensure equipment was adequately packaged to prevent excessive radiation levels on the exterior of a container shipped from Prairie Island to Waltz Mill.
Previous Condition Current Condition Change I Difference Impact or Assessment Wrapping methodology -
Wrapped to PI standards None.
Changes needed to package shipped wrapped to PI standards which control contamination materials subject to discrete particles.
which control contamination spread. Wrapped Need to fix equipment andlor discrete spread. Packaged as part of separately from sip per.
particles to prevent movement during sipper, not separate.
shipment.
Condition of fuel sipping Material left PI with Immersed in SFP, subjected Change in equipment radiological equipment - Material came significant radiological to discrete particles status changed the packaging and into PI without any hazards shipping reqUirements, but changes radiological controls.
were not assessed properly.
Form retained in accordance with record retention schedule identified in FP-G-RM-O l.
- Evaluation of Procedure Page 61 of81 Evaluation of procedure Dll.7: Radioactive materials shipment - LSAISCOfLTD QTY to a licensed facility.
This evaluation is limited to sections of procedure D 11.7 which have specific bearing on RCE 01 [57726 Radioactive Material Shipment Exceeded DOT Limits.
I. Step 6.9, 6.9.1 and 6.9.2 should be part of the radioactive material packaging procedure (RPIP-1319). See evaluation below.
- 2. Step 6.9.1 directs the Radioactive Material Shipping Coordinator (RWSC) or designee to consider the potential impact of small sources of irradiated material (discrete particles) to remain within the internals of the equipment. This requirement needs to have guidance added to enable the RWSC to perform an effective evaluation to ensure that any potential sources have been identified, and measures taken to prevent them from migrating to a position where they could have an effect on shipment parameters. The consequences part of the steps should be converted to a caution statement placed above the action step.
- 3. Step 6.9.2 directs the RWSC or designee to ensure that the materials be packaged in such a manner that under conditions normally incident to transportation the materials will not shift within the package. Add guidance to ensure that an effective evaluation of the methodes) used to prevent movement is adequate. The consequences part of the steps should be converted to a caution statement placed above the action step.
- 4. Consider adding a step in the checklist here that the material was packaged in accordance with RPIP-1319.
Evaluation of procedure RPIP 1319: Loading LSA Boxes/Sea-land Containers.
I. The title should be "Packaging of Radioactive Material for Shipment" and expanded be a comprehensive procedure that controls the packaging of all radioactive materials shipped offsite. The one exception would be items packaged in accordance with an engineering package such as steam generators, reactor head etc.
- 2. A complete rewrite of the procedure needs to be accomplished. Currently the procedure is designed to give guidance for segregating and packaging waste material for shipment. There is no guidance outlining methods to be used for securing material such that it will not move during transport.
- 3. There is no guidance outlining methods to be used for securing material such that it will not move during transport. The only mention of securing material is in the precautions and limitations with no guidance given.
- 4. Discrete particles are not mentioned in the procedure.
Form retained in accordance with record retention schedule identified in FP-G-RM-O I. - Evaluation of Procedure Page 61 of8 1 Evaluation of procedure DU.7: Radioactive materials shipment - LSAJSCOILTD QTY to a licensed facility.
Tbis evaluation is lim.iled to sections of procedure 011.7 which have specific bearing on RCE 01157726 Radioactive Material Shipment Exceeded DOT Limits.
I. Step 6.9, 6.9.1 and 6.9.2 should be part of the radioactive material packaging procedure (RPlP-1319). See evaluation below.
- 2. Step 6.9.1 directs the Radioactive Materia.l Shipping Coordinator (RWSC) or designee to consider the potentia.l impact of mall sources of irradiated material (discrete particles) to remain within the internals of the equipment. This requirement needs to have guidance added to enable the RWSC to perform an effective evaluation to ensure that any potential sources have been identified, and measures taken to prevent them from migrating to a position where they could have an effect on shipment parameters. The consequences pan of the steps should be convened to a caution statement placed above tbe action step.
- 3. Step 6.9.2 directs the RWSC or designee to ensure that the materials be packaged in such a manner that under conditions normally incident to transponation the materials will not shift within the package. Add guidance to ensure that an effective evaluation of the methodes) used to prevent movement is adequate. The consequences pan of the steps should be convened to a caution statement placed above the action step.
- 4. Consider adding a step in the checklist here that the material was packaged in accordance with RPIP-1319.
Evaluation of procedure RPIP 1319: Loading LSA Boxes/Sea-land Containers.
I. The title sbould be "Packaging of Radioactive Material for Shipment" and expanded be a comprehensive procedure that controls the packaging of all radioactive materials shipped offsite. The one exception would be items packaged in accordance with an engineering package such as steam generators, reactor head etc.
- 2. A complete rewrite of the procedure needs to be accomplished. Currently the procedure is designed to give guidance for segregating and packaging waste material for shipment. There is no guidance outlining methods to be used for securing material such that it will not move during transpon.
- 3. There is no guidance outlining methods to be used for securing material such that it will not move during transpon. The only mention of securing material is in the precautions and limitations with no guidance given.
- 4. Discrete panicles are not mentioned In the procedure.
Form retained in accordance with record retention schedule identified in FP-G-RM-OI.
- Event and Causal Factor Chart 09i12i08 (O14) 09/16108 (026) 09/19108 (028) 313108 (066) 0E26M4 receNed as
.-....t.oon only' New WestInghouse 1 leased Fuel Sippel" f--o PlaMing 2R25 refueling compH!te for f----o outage beglrlS eqlJIprTleflt amves at Forwanled as boefing material No"..,.,....
I Change5 made as a result of this OE CC1 RP does nol effectJvery W'ICiOrJl'CX'iIte industJy expenence 10 mprove the RMSP RC2 The pOonbes the lite has glYen 10 RMSP do not align With the JX,rtenbal acNene~
Event and Causal Factor Chart Key OoIe1Tme DodO I lnappiopiate AdIon Tmehne Event (IA)
PI f Add~
IntonnatlOn
~
~
.--J F.... 8ame<
fueI.. ppmg
'N0367253 add<lOSSed (n WO as per FP-RP-JPP-01
~
G!:) ~
10123/08 (017. 023)
Slpper equipment is surveyed underwater
( ConInbubng Cause) ~
(CC)
' Tern""",,",,
E_
(
)
Root Cause
'---./
(RC) 1011-22108 (026)
Used fuel bundles were tested for defects by Slppu"Ig
~0123108 (017, 023)
I ;Ipper lid Is removed i from the Sipper and derontalTllnated Page 62 of81 10l23I08,1100(022) :
SFP area being set*
up for evolution of takmg sipping equipment out c:I pool 10l23I08 (017 023)
Sippef lid and cables are removed from water and
_ed fOr jOb coverag<V The Lid swveyed DC 130 em 11m. readlOgs 120 ISO 110 mRlhr (017) lAS of lid and ca~
Cletected no loose discrete
_(023)
Techruaans were not IJamed in shipping related adMIJes CC2 raining and qualification for tad shippers' and RP tectmK:ians who peffofm shipping related adMtJes do not meet IndUStry standa<ds Fonn retained in accordance with record retention schedule identified in FP-G-RM-O I.
Auachment 5 - Event and Causal Factor Chan 313108 (066)
I OE26644 t'8C*Y8d _ t-
"",m,,".,., oro;
. f Forwanled os bneftngma_
.,"-d-.
I NoptOOOSS
,Ch8.ngeI mIde as I
- resort of thts L
09i12m8 (014)
New Westinghouse loosed Fuel SIllPO' I ~8mYeSat RP does not eIIocb'"'Y """'J>O<lIte _SOy experwa to ttr'IpI"OVe the RMSP Event and Causal Factor Chart Key
[
OoteITome DodO f T IIl"Iehne E.....ant
,~.. )")......
AdJon (tA)
Addi1>ONIi k1famatJcn
~
o
- Failed Barner 09/16108 (020)
P1anning oompIete lor fuel_ I IW36n53 tAl Shopping not speafic:aIy _ressed
., 'NO 11$ per FP-RP*
JPP...()l 09/19108 (028) 2R25 refueling
-begons
-.. IeSIed lor
',Ol,-2mB (02O)j
-.,I Used hJeI buncles
~
--'I I defects by "-
1D123108 (017 023) L 10l23I08 (017. 023) :
Stpper equipment is J Sipper lid is removed suwyed underWater from the Slpper and decontamonated 10/231081100 (022)
SFP area bHIg set-up roc eYOIutIon 01 1akJng~
eqwpment out d pool 10/23108 (017. 023)
SIppel" lid and cab6es are removed from water and
........ yed lor JOb """""'9&
The lid...wyed DC I 30 em 11m. readlllgS 120 150 I 1Q mRnY (017)
LAS of lid and ca~
detected no k)ose discrete
_(023)
(~~cause)
(
)
Root Couse (RC)
Tenn""""",)
E_
CC2 rtWW'Ig and qualif1callOn for rad stvppers:
and RP tec:hnoaans who perform--"
related acbvrtJes do not meet IndustJy SIa>1datds Form retained in accordance with record retention schedule identified in FP-G-RM-O I.
Page 62 of81 To P2
- Event and Causal Factor Chart
_ 10l23I08,1800 (017 023) rl '-"012
--(-0-27-)'
I 10123108 (017. 023) and put off 10 the &de 1
UmbM::al cables era
~
in a leplrate Wf1Ip I--
(017. 027) lAtw'IQ brdt cables are pIac::<<Ioni:JpdIMldand w_ (03) y IA
- _1ueI_
cables 10 prevent
.fhilbng IAWOl1.Z CC2 step69
~~_I
~
The rue! a.pper canlSlIn SIppIng canister Il/"8 su..-..yed for job wu wrapped in 10124108 (023)
Equ!pment bided into aM :shippwIg c:ontaJnef 10124108 (023)
Westtoghouse c::cwrage upon removal Hercurde
-pool peBOnnei shJppIIlg con~
r ean..... u........ at OC J 30 an. Rudlngs.
120 I 20 mRhlr
~
(017)
Qb J
F8.
SIppel' lid and cables are placed in the botDn d the c:ontall'lef wlth no additional support or sep8fl1bon c:onsdered (03, 027)
F8 2 No specific survey was ordered for vllpping U:J FaJed S.mer tAl
~MSC did not vedy that the survey or pac:Ug.ng was
_Ie""
ShIPPIng (014)
(
)
Fonn retained in accordance with record retention schedule identified in FP-G-RM-OJ.
lQf2<41D8 (014, 023)
The shipping c:ontalfler is surveyed by vendor RP techniOan The talepole readlO5iJ was 170 mRItv contad on bottom of shipping container (01.)
ContaIner tagged with 170 nvlhr reading DOT limillS 200 mRlhr (016) r-__
-'P-=;~ge 63 of 81 10124108 (014)
Transport vetlide
"""'"Y os Highest reading on transport vehicle Is 80 mRIIv 80 mRlhr IS 40% d DOT shipping flfmts (MN DeplalH....
notificatiOf'l not reqUired) - Event and Causal Factor Chart IAl
~fuelSCIt*
cabtes to prIM!M
.fhifmg lAW 011, Z stap 69
--I
~-----,
10/23108 (027)
_caru....
wuWT-wedin I 1012. 108 (023) I-.
EqutpmeOt toaded into d'Ie ~
container
.,Westing-10J24108 (023) 1012.108 (01., 023),t
'Alestinghouse
-a. The shipping container IS labcntrs do5e SllI'\\Oeyed by wndof RP Hera.(",
"""""neI ahlj)pItIg container I technician F81 Slpper lid and cables are placed In the bottDm 01 the container wlth no additloNl support or separlltlon c:onsJdered (03. 027)
F82 No specific 5UfYe)' was.
ordered 101 shipping UU Faied a.mer IA2 RMSC did not verty that the 5UM!Ij or packagWlg was _
(01.)
,........:.l....... m~
u ::...........
(
RCl ~C2 )
C§D t--The teiepole reading was 170 mRn\\t contact 01'1 boHom of shipping contaner (01.)
'c.n __ _
170 mrlhr reading rooT limit IS 200 mR/hf (016)
Fonn retained in accordance with record retention schedule identified in FP-G-RM-Ol.
Page 63 of81 10124108 (01.)
Transport whIde
- Event and Causal Factor Chart Page 64 of 81 1(125108 Ptaire 1$Iand shippen dIscuu contKI dose ratef from II'\\lbIII survey due tc resUtI being dose to DOl
+m4 and decide to 11!......-ve)'
No.c8on reqUll'lld by pt'OC*1ure 101*
( Re. )
r 1~~5108 101. U
........... n'IO\\Ied., the...
......... RC'O
. J lCI3OJ08~12"5,De:
1(I30I08 1305 (023; C/29108 090( ID14Dl!t' 1(129108-1020101",
lCIJOJ08 065E 102.'
Initil!l.,1ftMVatwattzMJI Trailer moved to Weltz
~.
The truck is reieased
, -' -1 Containef 1'I:~&UI'Ve)'ec - f---.. from PI.,
., VYattz -II1TrudI: amves at Waltz -..
determenes 80 mRhu Mil RCA and OOtlanef
_ readlOQ Waf IS( mRltv Mil F~ity Mil hlghest contact reading ramoved from tr.iler and on boaom at traier surveyec:
~ -
Sheppers ~
to use 17C R;;dilgl suniar to readings mRnv OC reading ~use taken for vehide survey It was fTIOI'lI conservative before trudt left P COl
- 014; L---
The in,,* s.urvey perfonnec
(
RC 2 )
at W8Itz Mill did not meet..
1(131108 10" Vendor measured I 2000 mRlhr hot spot
\\ on bottom surface of stllPPAg oontalt1ef
~
cntena for 17:! <<11" : cA 4SCFR and did not mimIC the transport survey performed at PI priof to the' L-trailer Iea~
1[131108 102' 1, 0103108-1"'4108(03:
Wesmghouse notif)es PI PI personnel travellD ENe possible exceedaoce of DOT I
'w'\\Wtz loti for pretim.na.r) r regwation for con.. dose InYeSbga1X::w PI Plant Mal'\\8gef Issuef atop wcwk order on RAIl
~I01 '(
Rad_",
procedures quaranbneC Form retained in accordance with record retention schedule identified in FP-G-RM-Ol.
Anachment 5 - Event and Causal Factor Chart lCJ25.1Oa (0 1<4, I
The IrIIkw
- 1--' mcM!Id., the..
"'"""" R.".
lC129I08 090C 1014 01~ ;
-.. Contalner /'I. ~surveyec - --
new reading W&! 15C mRltv b...._.. usem mR/tv OC reachng because It was ITIOI'e oonset'Y8M 101-0'111
~
( RC' )
Page 64 of81 1C/29108"'1021] 101 ';.11CJ3M)8 065f 102-4' lCJ3OI()8-.124S coe:
IC/3OI06 1305,023: I tniba! t.UIY8)' at wattz Mil Trailer moved to Waltz The tnJck is -'sodl f->
-....... 80 mRnl' J Mil RCA and oon\\lllner from PlIO go II:) 1Nattz Trudt amves at Waltz Mil F dity
"",heat oomact reacmg removed from IrUer and on bockIm 01 traJer swveyo<
~ings S/miar to readings taken ror Yf!hide survey before ~
left P n;..... swvey_
at w.Itz Mill did not mee1..
c::ntM\\8 fof 173...., I'. of 49CFR and did not rnirlUc the transpon survey peIfofmed at PI pOor to the traierlea~
I 1(131108 CD'.
Vend<< measured I
1(I3M'. '0' L I 1'/03108 - " 11111108(03:
l 2000 mRlhrhDI &pOI on bottom surface 01 shipping oontamet Wesbnghouse notifies PI possible exceedance 01 DOT regu1atJOn for contact dose PI Plant Manager fssuet Slop WOI'k order on RAIl
~I014.
R&d shlPP'~
procedures qullranbnec:
PI persoMel tnMIIlD v.ttz M. for pretunnar, InYeStJgalior Form retained in accordance with record retention schedule identified in FP-G-RM-O 1.
Allachlllcnt 6 Why StaircJsc Analysis Page 65 of 8 1 Why 1.0 Rad shipping container from PI exceeded 49CFRl 73.441 limits for contact radiation levels over 200 mrem/hr (01, 016)
Why 1.1 Contact reading on boHom of box @ Waltz Mill Westinghouse facility read 2000 mRlhr (01 )
Why 1.1.1 A discrete particle was close to bottom of container (03)
Why A The discrete particle shifted during transport or unloading (01 5, 01)
Why a. Was not packaged to prevent shifting lAW 011.7 step 6.9.2 (011)
~ IAl - See WS2 Why B A discrete particle was contained in the shipment Why a. Equipment was immersed in SFP Why b. Particle was not removed prior to packaging
~ Particle was not detected during job coverage survey to remove sipper from SFP (017)
Why c. See WS3 Why 2.0 Workers did not package the fuel sipper to prevent shifting (cables not fixed to lid, lid not separated from bottom of the box) lAW 011.7 (IA1).
Why 2.1 No perceived need to package for discrete particles Why 2.1.1 No survey indicated significant discrete particles (017)
Why A Refer to WS3 Why 2.1.2 PI relied on vendor to package the package (014)
Why A The vendor personnel were experienced and had been used for this task in Ihe past Why B It was the vendor's equipment Why C Vendor personnel were the most experienced persons available to perform job (014)
Why a. No in-house qualification for shipping*specific tasks (CC)
Why 2.1.3 Step 6.9.2 of 011.7 is not prescriptive Why A See RC1 Why B The site relies on a single individual to control RMSP evolutions See RC2 Forn1 retained in accordance with record retention schedule identified in FP-G-RM-Ol.
Page 65 o r SI Why 1.0 Rad shipping container from PI exceeded 49CFR173.44 1 limits for contact radiation levels over 200 mremihr (01. 016)
Why 1.1 Contact reading on bottom of box @ Waltz Mill Westinghouse facility read 2000 mRihr (01 )
Why 1.1.1 A discrete particle was close to bottom of container (03)
Why A The discrete particle shifted during transport or unloading (01 5, 01)
Why a. Was not packaged to prevent shifting lAW 011.7 step 6.9.2 (011)
~ IA1 - See WS2 Why B A discrete particle was contained In the shipment Why a. Equipment was immersed in SFP Why b. Particle was not removed prior to packaging
~ Particle was not detected during job coverage survey to remove sipper from SFP (017)
Why c. See WS3 Why 2.0 Workers did not package the fuel sipper to prevent shifting (cables not fixed to lid, lid not separated from bottom of the box) lAW 011.7 (IA1).
Why 2.1 No perceived need to package for discrete particles Why 2.1.1 No survey indicated significant discrete particles (017)
Why A Refer to WS3 Why 2.1.2 PI relied on vendor to package the package (014)
Why A The vendor personnel were experienced and had been used for this task In the past Why B It was the vendor's equipment Why C Vendor personnel were the most experienced persons available to perform job (014)
Why a. No in-house qualification for shipping-specific tasks (CC)
Why 2.1.3 Step 6.9.2 of 011.7 is not prescriptive Why A See RC1 Why B The site relies on a single individual to control RMSP evolutions See RC2 Form retained in accordance with record retention schedule identified in FP-G* RM-O I.
AII;II:hment 6 Why St,me I,~ "'naly,is Page 66 of 81 Why 3.0 Particle was not detected during job coverage survey for removing and wrapping the fuel sipper from the spent fuel pool Why 3.1 Particle was difficult to detect with job coverage survey (04, 05, 017,diagram)
Why 3.1.1 Oose rates measured with RO-2 at 30 cm were 20-30 mA/hr (i.e. not significant to general area dose rates) (023, diagram)
Why 3.1.2 Large Area Smears of equipment and cables detected no particles (023, 017)
Why 3.1.3 All discrete particles found in area were of low dose concern (017, 023)
Why 3.2 Survey conducted for job coverage per RPIP 1135 versus an equipment survey for rad shipment evaluation lAW 011.7 (011, 025)
Why 3.2.1 Person doing job coverage survey was not required to be familiar with 011.7 and 011.7 was not referenced in work documentation (see WS4)
Why A Person was following RPIP 1122 - Hot Particle Program (029)
Why a. RPIP 1122 is not prescriptive with respect to rad shipping concerns (RC1)
Why BRad shipper brief was only about decontamination target levels. not discrete particles (014, 023).
Why C RMSP is outside work management program Why a. See WS4 Why 0 Personnel completing surveys and packaging equipment are not qualified RWSC.
Why a. No training program exists to specifically describe shipping tasks
>> The training and qualification for rad shippers and RP personnel who perlorm shipping related activities does not meet industry standards (CC2, RC2)
Why 3.2.2 RWSC did not verify surveyor packaging was adequate for shipping (1A2) (013)
Why A 011.7, section 6.9 did not require additional, shipping-specific, surveys (013)
Why a. RC1 Why B RWSC relied on RPSs to perlorm rad shipping evolutions (see WS2)
Why C RWSC was focused on documentation and transport survey (014)
Why a. Believed the job coverage survey was adequate to address transport requirements of 011.7 step 6.9.
>> Oid not adequately incorporate industry OE related to similar rad shipment issues (OE23408, OE26644) (CC1)
>> Site relied on single individual to conduct rad shipments Instead of strong process guidance. (RC1)
Why DOose rates seen during the job coverage survey were close to decon targets (reduction from 40000 mRlhr to 120 mRlhr) (011, 014, 017)
Why E Oose rates were not out of line with worker and RWSC expectations for SFP equipment (014)
Why a. Oose rates were close to the target dose rates provided to RPS (011 )
Why b. No other surveys conducted prior to packaging for shipment
>> 0 11.7, step 6.9 did not require additional, shipping-specific, surveys (0 13, RC1)
Form retained in accordance with record retention schedule identified in FP-G-RM-Ol.
Page 66 or81 Why 3.0 Particle was not detected during Job coverage survey for removing and wrapping the fuel sipper from the spent fuel pool Why 3.1 Particle was difficult to detect with job coverage survey (04, OS, 017,diagram)
Why 3.1.1 Oose rates measured with RO*2 at 30 cm were 20*30 mRlhr (i.e. not significant to general area dose rates) (023, diagram)
Why 3.1.2 Large Area Smears of equipment and cables detected no particles (023, 017)
Why 3.1.3 All discrete particles found in area were of low dose concern (017, 023)
Why 3.2 Survey conducted for job coverage per RPIP 1135 versus an equipment survey for rad shipment evaluation lAW 011.7 (011, 025)
Why 3.2.1 Person doing job coverage survey was not required to be familiar with 011.7 and 011.7 was not referenced in work documentation (see WS4)
Why A Person was following RPIP 1122* Hot Particle Program (029)
Why a. RPI P 1122 Is not prescriptive with respect to rad shipping concerns (RC1)
Why BRad shipper brief was only about decontamination target levels, not discrete particles (014,023).
Why C RMSP is outside work management program Why a. See WS4 Why 0 Personnel completing surveys and packaging equipment are not qualified RWSC.
Why a. No training program exists to specifically describe shipping tasks
}> The training and qualification for rad shippers and RP personnel who perform shipping related activities does not meet Industry standards (CC2, RC2)
Why 3.2.2 RWSC did not verify surveyor packaging was adequate for shipping (1A2) (013)
Why A 011.7, section 6.9 did not require additional, shipping* specific, surveys (013)
Why a. RC1 Why B RWSC relied on RPSs to perform rad shipping evolutions (see WS2)
Why C RWSC was focused on documentation and transport survey (014)
Why B. Believed the job coverage survey was adequate to address transport requirements of 011.7 step 6.9.
}> Oid not adequately Incorporate industry OE related to similar rad shipment Issues (OE23408, OE26644) (CC1)
}> Site relied on single individual to conduct rad shipments Instead of strong process guidance. (RC1)
Why DOose rates seen during the job coverage survey were close to decon targets (reduction from 40000 mRlhrto 120 mRlhr) (011, 014, 017)
Why E Oose rates were not out of line with worker and RWSC expectations for SFP equipment (014)
Why B. Oose rates were close to the target dose rates provided to RPS (011)
Why b. No other surveys conducted prior to packaging for shipment
> 0117, step 6.9 did not require additional, shipping*specific, surveys (013. RC1)
Form retained in accordance with record retention schedule identified in FP*G RM-Ol.
Auachl11cnt 6 - Why Staircase Analysis Page 67 of 81 Comparison of fuel sipping lid general area and discrete particle dose rates dose rate distance line 1 meter away from sipping lid = 7 to 10 mRthr ambient work area dose rates =
3 to 20 mRthr
- a.
30 em from particle =
20 to 30 mRlhr General area at 30 em from fuel sipping lid " 50 mRlhr
= dose rate Instrument reading
= discrete radioactive particle (not drawn to scale; actual particle Is microscopic).
= ambient work area dose rates (at 1 meter)
= job coverage dose rates by lid (at 30 cm)
= fuel slpper lid lifting cables (approx 30 feet)
Why 4.0 Shipping not specifically addressed in WO 367253 as required by FP-RP-JPP-O I, step 5.5 (IA3).
Why 4.1 Job wa~ not Passport approved until the beginning of the 2R25 refueling outage. (026)
Why 4.1.1 WO was moved up from post-outage to beginning of outage (023, 026)
Why A Utilize available contractor resources. (014)
Why 4.2 RP Planners consider sipping and shipping to be part of refueling Why 4.2.1 Fuel sipping has always been part of refueling evolution Why 4.2.2 Work Order process does not consider RMSP a discrete task Why A RMSP is outside work management program Why a. RC I and RC2 Form retained in accordance with record retention schedule identified in FP-G-RM-O I.
Attachment h - Why Swirca,c Analysis Page 67 of 81 Comparison of fuel sipping lid general area and discrete particle dose rates dose rate distance line 1 meter away from sipping lid = 7 to 10 mRthr ambient work area dose rates =
3 to 20 mRthr
...... ;,;,'........-__ 30 cm from particle =
20 to 30 mRlhr General area at 30 em from fuel
". sipping lid" 50 mRlhr
= dose rate Instrument reading
= discrete radioactive particle (not drawn to scale; actual particle Is microscopic).
= ambient work area dose rates (all meter)
= Job coverage dose rates by lid (a130 cm) t1!JIi}) = fuel slpper lid lifting cables (approx 30 feel)
Why 4.0 Shjpping not specifically addressed in WO 367253 as required by FP-RP-JPP-Ol. step 5.5 (IA3).
Why 4.1 Job was not Passport approved until the beginning of the 2R25 refueling outage. (026)
Why 4.1.1 WO was moved up from post-outage to beginning of outage (023. 026)
Why A Utilize available contractor resources. (014)
Why 4.2 RP Planners consider sipping and shipping LO be part of refueling Why 4.2.1 Fuel sipping has always been pan of refueling evolution Why 4.2.2 Work Order process does not consider RMSP a discrete task Why A RMSP is outside work management program Why a. RC I,md RC2 Form retained in accordance with record retention schedule identified in FP-G-RM-OI.
- Safety Culture Impact Page 68 of 81 Safety Culture Description of Component Impact Description of Impact:
CAP ref:
Component:
Human Performance (HU)
HU - (H.l)
Decision-Making. - Decisions demonstrate that nuclear safety is Impact The site did not have a CAPR Decision an overriding priority. Spec~ically (as applicable):
IRI Yes method for determining 01157726-06 Making The site makes safety-significant or risk-significant 0
No risk sign~icance of decisions using a systematic process, especially when events related to rad CAPR faced with uncertain or unexpected plant conditions, to shipping.
01157726-07 ensure safety is maintained. This includes formally Assumptions regarding defining the authority and roles for decisions affecting the adequacy of the rad CA nuclear safety, communicating these roles to applicable survey and container 01157726-25 personnel, and implementing these roles and authorities as packing technique were designed and obtaining interdisciplinary input and reviews not conservative. When on safety-significant or risk-significant decisions.
the original equipment The licensee uses conservative assumptions in decision survey indicated 120 making and adopts a requirement to demonstrate that the mremlhr, and the proposed action is safe in order to proceed rather than a subsequent container requirement to demonstrate that it is unsafe in order to survey indicated 170 disapprove the action. The licensee conducts effectiveness mremlhr. the opportunity reviews of safety-significant decisions to verify the validity of the to validate the integrity of undertying assumptions, identify possible unintended that packaging was consequences, and determine how to improve future decisions.
missed. (CC1)
- The licensee communicates decisions and the basis for decisions to personnel who have a need to know the information in order to perform work safely and in a timely manner. H.1 (c)
Form retained in accordance with record retention schedule identified in FP-G-RM-Ol. - Safety Culture Impact Page 68 of81 Safety Culture Description of Component Impact Description of Impact:
CAP ref:
Component:
Human Performance (HU)
HU - (H.1)
Decision-Making. - Decisions demonstrate that nuclear safety is Impact The site did not have a CAPR Decision an overriding priority. Specifically (as applicable):
00 Yes method for determining 01157726-06 Making The site makes safety-significant or risk-significant 0
No risk significance of decisions using a systematic process, especially when events related to rad CAPR faced with uncertain or unexpected plant conditions, to shipping.
01157726*07 ensure safety is maintained. This includes formally Assumptions regarding defining the authority and roles for decisions affecting the adequacy of the rad CA nuclear safety, communicating these roles to applicable survey and container 01157726-25 personnel, and implementing these roles and authorities as packing technique were designed and obtaining interdisciplinary input and reviews not conservative. When on safety-significant or risk-significant decisions.
the original equipment The licensee uses conservative assumptions in decision survey indicated 120 making and adopts a requirement to demonstrate that the mrem/hr, and the proposed action is safe in order to proceed rather than a subsequent container requirement to demonstrate that it is unsafe in order to survey indicated 170 disapprove the action. The licensee conducts effectiveness mrem/hr, the opportunity reviews of safety-significant decisions to verify the validity of the to validate the integrity of underlying assumptions, identify possible unintended that packaging was consequences, and determine how to improve future decisions.
missed. (CC1)
The licensee communicates decisions and the basis for deciSions to personnel who have a need to know the information in order to perform work safely and in a timely manner. H.1 (c)
Fonn retained in accordance with record retention schedule identified in FP-G-RM-Ol.
- Safety Culture Impact Page 69 of 81 Safety Culture Description of Component Impact Description of Impact:
CAP ref:
I Component:
HU - (H.2)
Resources - The licensee ensures that personnel, equipment, Impact Procedures are not CAPR Resources procedures, and other resources are available and adequate to 00 Yes adequate. (CC3) 01157726-07 ensure nuclear safety. Specifically, those necessary for:
0 No Maintaining long term plant safety by maintenance of design Training is required for CA margins, minimization of long-standing equipment issues, RPTs performing RMSP 01157726-20 minimizing preventative maintenance deferrals, and ensuring work. A qualification maintenance and engineering backlogs are low enough to program will be CAPR support safety.
implemented. (CC2) 01157726-13 Sufficient qualified personnel are trained and available to maintain work hours within working hour's guidelines.
CA Complete, accurate and up-to-date design documentation, 01157726-22 procedures, and work packages, and correct labeling of components.
Adequate and available facilities and equipment, including physical improvements, simulator fidelity and emergency facilities and equipment.
Form retained in accordance with record retention schedule identified in FP-G-RM-Ol.
Auacbmem 7 - Safety Culture lmpact Page 69 of 81 Safety Culture Description of Component Impact Description of Impact:
CAP ref:
Component:
HU - (H.2)
Resources - The licensee ensures that personnel, equipment, Impact Procedures are not CAPR Resources procedures, and other resources are available and adequate to 00 Yes adequate. (CC3) 01157726-07 ensure nuclear safety. Specifically, those necessary for:
0 No Maintaining long term plant safety by maintenance of design Training is required for CA margins, minimization of long-standing equipment issues, RPTs performing RMSP 01157726-20 minimizing preventative maintenance deferrals, and ensuring work. A qualification maintenance and engineering backlogs are low enough to program will be CAPR support safety.
implemented. (CC2) 01157726-13
- Sufficient qualified personnel are trained and available to maintain work hours within working hour's guidelines.
CA Complete, accurate and up-to-date design documentation, 01157726-22 procedures, and work packages, and correct labeling of components.
- Adequate and available facilities and equipment, including physical improvements, simulator fidelity and emergency facilities and equipment.
Form retained in accordance with record retentinn schedule identified in FP-G-RM-OI.
- Safety Culture Impact Page 70 of 81 Safety Culture Description of Component Impact Description of Impact:
CAP ref:
Component:
HU - (H.3)
Work Control - The licensee plans and coordinates work Impact RMSP activities are CAPR Work Control activities, consistent with nuclear safety. Specifically (as
!Rl Yes usually completed 01157266-06 applicable):
0 No outside of the work 0
The licensee appropriately plans work activities by management process.
CAPR incorporating:
Shipping tasks and the 01 157726-07 risk insights risks associated with job site conditions, including environmental conditions, shipping are frequently CAPR which may impact human performance; plant not addressed in work 01157726-13 structures, systems, and components; human-system packages. RP interface; or radiological safety technicians providing job CA The need for planned contingencies, compensatory actions, coverage for 011 57726-22 and abort criteria.
decontamination are not aware of rad waste CA 0
The licensee appropriately coordinates work activities by Shipping requirements 01157726-24 incorporating actions to address:
with respect to discrete The impact of changes to the work scope or activity on particle issues.
the plant and human performance.
(CC3)
The impact of the work on different job activities, the need for work groups to maintain interfaces with offsite organizations, and communicate, coordinate, and cooperate with each other during activities in which interdepartmental coordination is necessary to assure plant and human performance.
- The need to keep personnel apprised of work status, the operational impact of work activities, and plant conditions that may affect work activities long-term equipment reliability by limiting temporary modifications, operator work-arounds, safety systems unavailability, and reliance on manual actions. Maintenance scheduling is more preventive than reactive.
Form retained in accordance with record retention schedule identified in FP-G-RM-Ol.
Anachment 7 - Safety Culture Impact Page 70 of 81 Safety Culture Description of Component Impact Description of Impact:
CAP ref:
Component:
HU - (H.3)
Work Control - The licensee plans and coordinates work Impact RMSP activities are CAPR Work Control activities, consistent with nuclear safety. Specifically (as
[RJ Yes usually completed 01157266*06 applicable):
0 No outside of the work 0
The licensee appropriately plans work activities by management process.
CAPR incorporating:
Shipping tasks and the 0115n26-07 risk insights risks associated with job site conditions, including environmental conditions, shipping are frequently CAPR which may impact human performance; plant not addressed in work 0115n26-13 structures, systems, and components; human-system packages. RP interface; or radiological safety technicians providing job CA The need for planned contingencies, compensatory actions, coverage for 0115n26-22 and abort criteria.
decontamination are not aware of rad waste CA 0
The licensee appropriately coordinates work activities by shipping requirements 0115n26-24 incorporating actions to address:
with respect to discrete The impact of changes to the work scope or activity on particie issues.
the plant and human performance.
(CC3)
- The impact of the work on different job activities, the need for work groups to maintain interfaces with ollsite organizations, and communicate, coordinate, and cooperate with each other during activities in which interdepartmental coordination is necessary to assure plant and human performance.
The need to keep personnel apprised of work status, the operational impact of work activities, and plant conditions that may allect work activities Long-term equipment reliability by limiting temporary modifications, operator work-arounds, safety systems unavailability, and reliance on manual actions. Maintenance scheduling is more preventive than reactive.
Form retained in accordance with record retention schedule identified in FP-G-RM-Ol.
- Safety Culture Impact Page 71 of 81 Safety Culture Description of Component Impact Description of CAP ref:
Component:
Impact:
HU - (H.4)
Work Practices - Personnel work practices support human Impact Inadequate CAPR Work performance. Specifically (as applicable):
00 Yes oversight 1157726-07 Practices
- The licensee communicates human error prevention 0
No (RMSP and techniques, such as holding pre-job briefings, self and peer supervisors)
CA checking, and proper documentation of activities. These during 01 157726-techniques are used commensurate with the risk of the packaging, 14 assigned task, such that work activities are performed safely.
surveying Personnel are fit for duty. In addition, personnel do not proceed in and crating the face of uncertainty or unexpected circumstances.
evolutions.
The licensee defines and effectively communicates expectations Some of the regarding procedural compliance. Personnel follow procedures.
behaviors The licensee ensures supervisory and management oversight that of work activities, including contractors, such that nuclear contributed safety is supported.
to this event do not support human performance (CC1)
Fonn retained in accordance with record retention schedule identified in FP-G-RM-Ol. - Safety Culture Impact Page 71 of 81 Safety Culture Descnption of Component Impact Description of CAP ref:
Component:
Impact:
HU - (H.4)
Work Practices - Personnel work practices support human Impact Inadequate CAPR Work performance. Specifically (as applicable):
IRI Yes oversight 1157726-07 Practices The licensee communicates human error prevention 0
No (RMSP and techniques, such as holding pre-job briefings, self and peer supervisors)
CA checking, and proper documentation of activities. These during 01157726-techniques are used commensurate with the risk of the packaging, 14 assigned task, such that work activities are performed safely.
surveying Personnel are fit for duty. In addition, personnel do not proceed in and crating the face of uncertainty or unexpected circumstances.
evolutions.
The licensee defines and effectively communicates expectations Some of the regarding procedural compliance. Personnel follow procedures.
behaviors The licensee ensures supervisory and management oversight that of work activities, including contractors, such that nuclear contributed safety is supported.
to this event do not support human performance
'(CCl)
Fonn retained in accordance with record retention schedule identified in FP-G-RM-Ol.
- Safety Culture Impact Page 72 of 81 Problem Identification and Resolution (PI&R)
Safety Culture Description of Component Impact Description of CAP ref:
Component:
Impact:
PI&R -(P.1)
Corrective Action Program - The licensee ensures that issues Impact None None Corrective potentially impacting nuclear safety are promptly identified, fully DYes Action evaluated, and that actions are taken to address safety issues in a 1&1 No Program timely manner, commensurate with their significance. Specifically (as applicable):
The licensee implements a corrective action program with a low threshold for identifying issues. The licensee identifies such issues completely, accurately, and in a timely manner commensurate with their safety significance.
The licensee periodically trends and assesses information from the CAP and other assessments in the aggregate to identify programmatic and Issue common cause problems. The licensee communicates the results of the trending to applicable personnel.
The licensee thoroughly evaluates problems such that the resolutions address causes and extent of conditions, as necessary.
This includes properly classifying, prioritizing, and evaluating for operability and reportability conditions adverse to quality. This also includes, for significant problems, conducting effectiveness reviews of corrective actions to ensure that the problems are resolved.
The licensee takes appropriate corrective actions to address safety issues and adverse trends in a timely manner, commensurate with their safety significance and complexity.
If an alternative process (i.e., a process for raising concerns that is an alternate to the licensee's corrective action program or line management) for raising safety concerns exists, then it results in appropriate and timely resolutions of identified problems.
Form retained in accordance with record retention schedule identified in FP-G-RM-Ol. - Safety Culture Impact Page 72 of 81 Problem Identification and Resolution (PI&R)
Safety Culture Description of Component Impact Description of CAP ref:
Component:
Impact:
PI&R - (P.1)
Corrective Action Program* The licensee ensures that issues Impact None None Corrective potentially impacting nuclear safety are promptly identified, fully 0
Yes Action evaluated, and that actions are taken to address safety issues in a
[8J No Program timely manner, commensurate with their significance. Specifically (as applicable):
The licensee implements a corrective action program with a low threshold for identifying issues. The licensee identifies such issues completely, accurately, and in a timely manner commensurate with their safety significance.
The licensee periodically trends and assesses information from the CAP and other assessments in the aggregate to identify programmatic and Issue common cause problems. The licensee communicates the results of the trending to applicable personnel.
The licensee thoroughly evaluates problems such that the resolutions address causes and extent of conditions, as necessary.
This includes properly classifying, prioritizing, and evaluating for operability and reportability conditions adverse to quality. This also includes, for Significant problems, conducting effectiveness reviews of corrective actions to ensure that the problems are resolved.
The licensee takes appropriate corrective actions to address safety issues and adverse trends in a timely manner, commensurate with their safety significance and complexity.
If an alternative process (i.e., a process for raising concerns that is an alternate to the licensee's corrective action program or line management) for raising safety concerns exists, then it results in appropriate and timely resolutions of identified problems.
Form retained in accordance with record retention schedule identified in FP-G-RM-Ol.
- Safety Culture Impact Page 73 of81 Safety Culture Description of Component Impact Description of CAP ref:
Component:
Impact:
PI&R -(P.2)
Operating experience* The licensee uses operating experience (OE)
Impact OEis CA Operating information, including vendor recommendations and internally IE] Yes reviewed but 1157726 -12 Experience generated lessons learned, to support plant safety. Specifically (as 0
No some issues applicable) :
identified in CA The licensee systematically collects, evaluates, and communicates to OE are not 1157726 - 16 affected internal stakeholders in a timely manner relevant internal and evaluated external OE.
nor are The licensee implements and institutionalizes OE through corrective changes to station processes, procedures, equipment, and actions training programs.
properly implemented.
Relevant changes to station processes, procedures, eqUipment and training programs are not effectively implemented.
(RC1)
Form retained in accordance with record retention schedule identified in FP-G-RM-OI. - Safety Culture Impact Page 73 of81 Safety Culture Description of Component Impact Description of CAP ref:
Component:
Impact:
PI&R-(P.2}
Operating experience - The licensee uses operating experience (OE)
Impact OEis CA Operating information, including vendor recommendations and internally
[l!J Yes reviewed but 1157726 - 12 Experience generated lessons learned, to support plant safety. Specifically (as 0
No some issues applicable):
identified in CA The licensee systematically collects, evaluates, and communicates to OE are not 1157726 - 16 affected internal stakeholders in a timely manner relevant internal and evaluated externalOE.
nor are The licensee implements and institutionalizes OE through corrective changes to station processes, procedures, equipment, and actions training programs.
properly implemented.
Relevant changes to station processes, procedures, eqUipment and training programs are not effectively implemented.
(ReI)
Fonn retained in accordance with record retention schedule identified in FP-G-RM-Ol.
- Safety Culture Impact Page 74 of81 Safety Culture Description of Component Impact Description of CAP ref:
Component:
Impact:
PI&R -(P.3)
Self-and Independent Assessments - The licensee conducts self-and Impact Assessments CA Self-independent assessments of their activities and practices, as appropriate, IRl Yes are only 1157726-17 Assessment to assess performance and identify areas for improvement. Specifically 0
No included as (as applicable):
part of the
- The licensee conducts self-assessments at an appropriate overall RP frequency; such assessments are of sufficient depth, are program comprehenSive, are appropriately objective, and are se~-critical. The itse~. The licensee periodically assesses the effectiveness of oversight groups RMSP needs and programs such as CAP, and policies.
a separate
- The licensee tracks and trends safety indicators which provide an requirement accurate representation of performance.
for
- The licensee coordinates and communicates results from assessments assessments to affected personnel, and takes corrective actions to
, based on address issues commensurate with their signrricance.
prog ram risk exposure, in order to be more se~-
critical.
(CC1)
Fonn retained in accordance with record retention schedule identified in FP-G-RM -0 I. - Safety Culture Impact Page 740f81 Safety Culture Description of Component Impact Description of CAP ref:
Component:
Impact:
PI&R -(P.3)
Self-and Independent Assessments - The licensee conducts self-and Impact Assessments CA Self-independent assessments of their activities and practices, as appropriate,
!&l Yes are only 1157726-17 Assessment to assess performance and identify areas for improvement. Specifically 0
No included as (as applicable):
part of the
- The licensee conducts self-assessments at an appropriate overall RP frequency; such assessments are of sufficient depth, are program comprehensive, are appropriately objective, and are self-critical. The itself. The licensee periodically assesses the effectiveness of oversight groups RMSP needs and programs such as CAP, and policies.
a separate
- The licensee tracks and trends safety indicators which provide an requirement accurate representation of performance.
for
- The licensee coordinates and communicates results from assessments assessments to affected personnel, and takes corrective actions to
,based on address issues commensurate with their Significance.
prog ram risk exposure, in order to be more self-critical.
(CC1)
Form retained in accordance with record retention scbedule identified in FP-G-RM-O I.
- Safety Culture Impact Page 75 of 8 1 Safety Conscious Work Environment (SCWE)
Safety Culture Description of Component Impact Description of CAP ref:
Component:
Impact:
SCWE-(S.l)
Environment For Raising Concerns - An environment exists in which Impact None None Environment employees feel free to raise concerns both to their management andlor 0
Yes for Raising the NRC without fear of retaliation and employees are encouraged to 00 No Concerns raise such concerns. Specifically (as applicable):
Behaviors and interactions encourage free flow of information related to raising nuclear safety issues, differing professional opinions, and identifying issues in the CAP and through self assessments. Such behaviors include supervisors responding to employee safety concerns in an open, honest, and non*defensive manner and providing complete, accurate, and forthright information to oversight, audit, and regulatory organizations. Past behaviors, actions, or interactions that may reasonably discourage the raising of such issues are actively mitigated. As a result, personnel freely and openly communicate in a clear manner conditions or behaviors, such as fitness for duty issues, which may impact safety; and personnel raise nuclear safety issues without fear of retaliation.
I F alternative processes (i.e., a process for raising concerns or resolving differing professional opinions that are alternates to the licensee's corrective action program or line management) for raising safety concerns or resolving differing professional opinions exists, THEN they are communicated, accessible, have an option to raise issues in confidence, and are independent, in the sense that the program does not report to line management (i.e., those who would in the normal course of activities be responsible for addressing the issue raised).
Form retained in accordance with record retention schedule identified in FP-G-RM-O I. - Safety Culture Impact Page 75 of81 Safety Conscious Work Environment (SCWE)
Safety Culture Description of Component Impact Description of CAP ref:
Component:
Impact:
SCWE-(S.1)
Environment For Raising Concerns - An environment exists in which Impact None None Environment employees feel free to raise concerns both to their management and/or 0
Yes for Raising the NRC without fear of retaliation and employees are encouraged to Il1l No Concerns raise such concerns. Specifically (as applicable):
Behaviors and interactions encourage free flow of information related to raising nuclear safety issues, differing professional opinions, and identifying issues in the CAP and through self assessments. Such behaviors include supervisors responding to employee safety concerns in an open, honest, and non-defensive manner and providing complete, accurate, and forthright information to oversight, audit, and regulatory organizations. Past behaviors, actions, or interactions that may reasonably discourage the raising of such issues are actively mitigated. As a result, personnel freely and openly communicate in a cleB! manner conditions or behaviors, such as fitness for duty issues, which may impact safety; and personnel raise nuclear safety issues without fear of retaliation.
IF alternative processes (Le., a process for raising concerns or resolving differing professional opinions that are alternates to the licensee's corrective action program or line management) for raising safety concerns or resolving differing professional opinions exists, THEN they are communicated, accessible, have an option to raise issues in confidence, and are independent, in the sense that the program does not report to line management (Le., those who would in the normal course of activities be responsible for addressing the issue raised).
Fonn retained in accordance with record retention schedule identi.fied in FP-G-RM-O I.
- Safety Culture lmpact Page 76 of81 Safety Culture Description of Component Impact Description of CAP ref:
Component:
Impact:
SCWE -(S.2)
Preventing, Detecting, and Mitigating Perceptions of Retaliation -
Impact none none Preventing, A policy for prohibiting harassment and retaliation for raising nuclear 0
Yes Detecting, safety concerns exists and is consistently enforced in that:.
IRl No and All personnel are effectively trained that harassment and retaliation Mitigating for raising safety concems is a violation of law and policy and will Perceptions not be tolerated.
of Retaliation Claims of discrimination are investigated consistent with the content of the regulations regarding employee protection and any necessary corrective actions are taken in a timely manner, including actions to mitigate any potential chilling effect on others due to the personnel action under investigation.
The potential chilling effects of disciplinary actions and other potentially adverse personnel actions (e.g., reductions, outsourcing, and reorganizations) are considered and compensatory actions are taken when appropriate.
Form retained in accordance with record retention schedule identified in FP-G-RM-O I. - Safety Culture Jrnpact Page 76 of81 Safety Culture Description of Component Impact Description of CAP ref:
Component:
Impact:
SCWE-(S.2)
Preventing, Detecting, and Mitigating Perceptions of Retaliation -
Impact none none Preventing, A policy for prohibiting harassment and retaliation for raising nuclear 0
Yes Detecting, safety concerns exists and is consistently enforced in that:.
00 No and All personnel are effectively trained that harassment and retaliation Mitigating for raising safety concerns is a violation of law and policy and will Perceptions not be tolerated.
of Retaliation Claims of discrimination are investigated consistent with the content of the regulations regarding employee protection and any necessary corrective actions are taken in a timely manner, including actions to mitigate any potential chilling effect on others due to the personnel action under investigation.
The potential chilling effects of disciplinary actions and other potentially adverse personnel actions (e.g., reductions, outsourcing, and reorganizations) are considered and compensatory actions are taken when appropriate.
Form retained in accordance with record retention schedule identified in FP-G-RM-O 1.
- Safety Culture Impact Page 77 of 81 Other Safety Culture Components (OTH)
This section describes components of safety culture which are not associated with cross-cufting areas. These components, when combined with the cross-cufting area components comprise the safety culture components. Components in this section should be considered if any of the cross cutting areas align to a root or contributing cause.
Safety Culture Description of Component Impact Description of CAP ref:
Component:
Impact:
OTH -(O.l)
Accountability - Management defines the line of authority and Impact none none Accountabilit responsibility for nuclear safety. Specifically (as applicable):
0 Yes y
Accountability is maintained for important safety decisions in that lID No the system of rewards and sanctions is aligned with nuclear safety policies and reinforces behaviors and outcomes which reflect safety as an overriding priority.
Management reinforces safety standards and displays behaviors that reflect safety as an overriding priority.
The workforce demonstrates a proper safety focus and reinforces safety principles among their peers.
Form retained in accordance with record retention schedule identified in FP-G-RM-Ol. - Safety Culture lmpact Page 77 of 81 Other Safety Culture Components (OTH)
This section describes components of safety culture which are not associated with cross-cutting areas. These components, when combined with the cross-cutting area components comprise the safety culture components. Components in this section should be considered if any of the cross cutting areas align to a root or contributing cause.
Safety Culture Description of Component Impact Description of CAP ref:
Component:
Impact:
OTH-(O.l)
Accountability - Management defines Ihe line of authority and Impact none none Accountabilit responsibility for nuclear safety. Specifically (as applicable):
0 Yes y
Accountability is maintained for important safety decisions in that
[R] No the system of rewards and sanctions is aligned with nuclear safety policies and reinforces behaviors and outcomes which reflect safety as an overriding priority.
Management reinforces safety standards and displays behaviors that reflect safety as an overriding priority.
The workforce demonstrates a proper safety focus and reinforces safety principles among their peers.
Fonn retained in accordance with record retention schedule identified in FP-G-RM-O I.
- Safety Culture Impact Page 78 of 81 Safety Culture Description of Component Impact Description CAP ref:
Component:
of Impact:
OTH - (0.2)
Continuous learning environment - The licensee ensures that a Impact Adequate AR Continuous learning environment exists. Specifically (as applicable):
00 Yes training has 01157726 -
Learning The licensee provides adequate training and knowledge o No not been 20 Environment transfer to all personnel on site to ensure technical provided to competency.
ensure Personnel continuously strive to improve their knowledge, skills, personnel and safety performance through activities such as benchmarking, performing being receptive to feedback, and setting performance goals. The RMSP licensee effectively communicates information learned frorn internal duties have and external sources about industry and plant issues.
the required technical competency.
(CC2).
OTH -(0.3)
Organizational change management -Management uses a Impact none none Organizationa systematic process for planning, coordinating, and evaluating the safety 0 Yes I Change impacts of decisions related to major changes in organizational 00 No Management structures and functions, leadership, policies, programs, procedures, and resources. Management effectively communicates such changes to affected personnel.
OTH Safety Safety policies - Safety policies and related training establish and Impact none none Policies reinforce that nuclear safety is an overriding priority in that:
0 Yes These policies require and reinforce that individuals have the right 00 No and responsibility to raise nuclear safety issues through available means, including avenues outside their organizational chain of command and to extemal agencies, and obtain feedback on the resolution of such issues.
Personnel are effectively trained on these policies.
Organizational decisions and actions at all levels of the organization are consistent with the policies. Production, cost and schedule goals are developed, communicated, and implemented in a manner Form retained in accordance with record retention schedule identified in FP-G-RM-O I.
Auachment 7 - Safety Culture Impact Page 78 of 81 Safety Culture Description of Component Impact Description CAP ref:
Component:
of Impact:
OTH -(0.2)
Continuous learning environment - The licensee ensures that a Impact Adequate AR Continuous learning environment exists. Specifically (as applicable):
00 Yes training has 011Sn26 -
Learning The licensee provides adequate training and knowledge 0
No not been 20 Environment transfer to all personnel on site to ensure technical provided to competency.
ensure Personnel continuously strive to improve their knowledge, skills, personnel and safety performance through activities such as benchmarking, performing being receptive to feedback, and setting performance goals. The RMSP licensee effectively communicates information learned from internal duties have and extemal sources about industry and plant issues.
the required technical competency.
(CC2).
OTH-(O.3)
Organizational change management -Management uses a Impact none none Organizationa systematic process for planning, coordinating, and evaluating the safety 0 Yes I Change impacts of decisions related to major changes in organizational 00 No Management structures and functions, leadership, policies, programs, procedures, and resources. Management effectively communicates such changes to affected personnel.
OTH Safety Safety policies - Safety policies and related training establish and Impact none none Policies reinforce that nuclear safety is an overriding priority in that:
0 Yes These policies require and reinforce that individuals have the right 00 No and responsibility to raise nuclear safety issues through available means, including avenues outside their organizational chain of command and to external agencies, and obtain feedback on the resolution of such issues.
Personnel are effectively trained on these policies.
Organizational decisions and actions at all levels of the organization are consistent with the poliCies. Production, cost and schedule goals are developed, communicated, and implemented in a manner Form retained in accordance with record retentjon schedule identified in FP-G-RM-O I.
- Safety Culture Impact Page 79 of 81 that reinforces the importance of nuclear safety.
Senior managers and corporate personnel periodically communicate and reinforce nuclear safety such that personnel understand that safety is of the highest priority.
Conclusions Conclusions and comments from Cross Cutting Element Review:
The evaluation of the safety culture impacts reveals several programmatic flaws that need to be addressed. The issues identified during this assessment have been adequately addressed in the root cause evaluation corrective actions.
Corrective action 1161675 has been written to evaluate the extent of condition of these safety culture issues at the site.
Form retained in accordance with record retention schedule identified in FP-G-RM-O I. - Safety Culture Impact Page 79 of 81 that reinforces the importance of nuclear safety.
Senior managers and corporate personnel periodically communicate and reinforce nuclear safety such that personnel understand that safety is of the highest priority.
Conclusions Conclusions and comments from Cross Cutting Element Review:
The evaluation of the safety culture impacts reveals several programmatic flaws that need to be addressed. The issues identified during this assessment have been adequately addressed in the root cause evaluation corrective actions.
Corrective action 1161 675 has been written to evaluate the extent of condition of these safety culture issues at the site.
Form retained in accordance with record retention scbedule identified in FP-G-RM-O I.
- Safety Culture Impact Page 80 of 81 Glossary of Terms used in this report Acronym Meaning CAP Corrective Action Program CFR Code of Federal Regulations DOT Department of Transportation lAW In Accordance With LAS Large area smear (also, masslin)
LSA Low Specific Activity LTD Limited mRlhr Milliroentgens per hour mremlhr Millirem per hour OC On contact reading OE Operating Experience RAM Radioactive material RMSP Radioactive Material Shipping Program RP Radiation Protection RPIP Radiation Protection Implementing Procedure RPM or Radiation Protection and Chemistry Manager RPCM RPT Radiation Protection Technician RWSC Radioactive Waste Shipping Coordinator SCO Surface Contaminated Object SFP Spent Fuel Pool Form retained in accordance with record retention schedule identified in FP-G-RM-OI. - Safety Culture Impact Page 80 of81 Glossary of Terms used in this report Acronym Meaning CAP Corrective Action Program CFR Code of Federal Regulations DOT Department of Transportation IAW In Accordance With LAS Large area smear (also, masslin)
LSA Low Specific Activity LTD Limited mRlhr Milliroentgens per hour rnremlhr MiJlirem per hour OC On contact reading OE Operating Experience RAM Radioactive material RMSP Radioactive Material Shipping Program RP Radiation Protection RPIP Radiation Protection Implementing Procedure RPM or Radiation Protection and Chemistry Manager RPCM RPT Radiation Protection Technician RWSC Radioactive Waste Shipping Coordinator SCO Surface Contaminated Object SFP Spent Fuel Pool Form retained in accordance with record retention schedule identified in FP-G-RM-OI.
- Safety Culture [mpact Manager Sponsor: Bob Hite Problem Statement:
Root Cause Evaluation Charter CAP AR #01157726 Page 81 of81 On Wednesday. 10/3012008," shipping container was received by the Waltl Mill site that exceeded IOCFR part 71.47 limits for shipping radioactive materials. This was a violation of Prairie Island procedure D 11.7.
section 6.10.6. exceeding 200 mremlhr on contact with the shipping container on an open t",nsport. The container (Box 311677) was shipped from the Prairie Island faci lity and contained fuel sipping equipment.
Investigation Scope:
The evaluation will determine the root cause of exceeding DOT shipping limitations a, required by 10 CFR part 71.47.
The scope of the review will include an investigation of the methods used to determine radiation levels of the components shipped. as well as methods for verifying dose rates on the exterior of the shipping container and the trailer. The investigation will also try to determine the most likely contributor of the changing dose. where the material contributing to the high dose rates came from and why the dose rates changed. Additionally. the RCE will determine any organi7Altionai and industry weaknesses that contribute to the probability of incurring lransport issues relnted to radiation dose limits.
Investigation Methodology:
The team will use interviews. FMEA. cause and effects analysis and why staircases. and other methods listed in FG*PA-RCE*OI. section 5.9. I. to determine the root cause for the failure to adequately control a radioactive Shipment.
Team Members:
Tcam Leader Team Member Team Member Team Member Team Mentor Field Team Field Team Milestones:
Datc Assigned:
11/07/08 Jeff leClair Monti rep Myke Matzitello Jeff Kivi (RCE qual)
Gene Woodhouse SCOII Nelson Clay Sweet Status Update:
///12/08. /1119/08 Draft Report:
11/17/08 Final Report:
//12//08 Communications Plan:
Update< to PARB as per milestones.
Operations Fleet RP RP/Chem Licensing Performance Assessmenl Fleet RPM RP/Chem Initial communication made to station via Clock Reset Red Sheet.
Follow-up to the NRC via established processes.
Approved:
Bob Hlte Management Sponsor Approved by: Screen Team 1 PARB on 11/07/08 Date Date: 11/06108 Form retained in accordance with record retention schedule identified in FP-G-RM *0 I. - Safety Culture Impact AttachmentS Manager Sponsor: Dob Hite Problem Statement:
Root Cause Evaluation Charier CAP AR #0 Il 57726 Page 81 of 81 On Wednesday, 10/30nOOS, a shipping container was received by the Waltl Mill site that exceeded IOCFR part 71.47 limits for shipping radioactive materials. This was u violation of Prairie Island procedure D11.7.
section 6.10.6, exceeding 200 mrcmlhr \\Ht conlact with the shipping container on an open trnnsport. The container (Box 3 11677) was shipped from the Prairie Island facility and conUtined fuel sipping equipment.
Investigation Scope:
The evaluation will determine the root cause of exeeedlOg DOT shipping limitations as required by 10 CFR pan 71.47.
The scope of the review will include an investigation of the methods used to determine radiation levels of the components shipped,.,. well as methods for verlfytng dose rates on the exterior of the shipping container and the trailer. The investigation will also try to determine the most likely contributor of the changing dose, where the material contributing to tbe high dosc rates came from and why lhe dose rates changed. Additionally. the RCE will determine any organi'tional and industry weaknesses thm contribute to the probability of incurring transport issues related to radiation dose limits.
Investigation Methodology:
The team will use interviews. FMEA, cause and effects analysis and why staircases. and other methods listed in FG*PA*RCE*O I, section 5.9.1, to detcrmine the roOl cause for the failure to adequOlely control n radioactive shipmen!.
Team Members:
Team Leader Team Member Team Member Team Member Team Menlor Field Team Field Tcam Milestones:
Date Assigned:
1II07l0S Jeff leClair Monti rep Myke Mal.7.itcllo Jeff Kivi (RCE qual)
Gene Woodhouse SCOII Nelson Clay Swect Status Updatc:
//112/08, /11/9108 Draft Report:
//1/7/08 Final Report; 1112/IOB Communic8tio~ Plan:
Updates to PARB.,. per milestones.
Operations Fleet RP RP/Chem Licensing Perfonnance Assessment Aeet RPM RP/Chem Initial communication made to sUllion via Clock Reset Red Shee\\.
Follow*up to the NRC via established processes.
Approved:
Bob Hlle Management Sponsor Approved by: Screen Team / PARB on Date: 11106108 11107/08 Dzue Foml retained in accordance with record retenlion schedule identified in FP-G-RM-Ol.