ML112420068
| ML112420068 | |
| Person / Time | |
|---|---|
| Site: | Robinson  |
| Issue date: | 08/30/2011 |
| From: | NGG Holdings, Progress Energy Carolinas |
| To: | NRC/RGN-II/DRP/RPB4 |
| Shared Package | |
| ML112420049 | List: |
| References | |
| IR-10-006, IR-11-008 | |
| Download: ML112420068 (14) | |
Text
R bi N
l Pl t
Robinson Nuclear Plant August 25, 2011 1
RNP White Finding - Initiating Events (95001)
RNP White Finding Initiating Events (95001)
Event Cause(s)
Status of Corrective Action(s)
Feedwater Regulating Valve Control Circuit Failure Vendor design errors with Hagan power supplies resulted in premature part failure Complete:
- Identified and located all RNP Hagan modules with Rev.
3 Ensign power supplies installed Replaced Ensign Re 5 Po er S pplies ith Ensign 5A
- Replaced Ensign Rev. 5 Power Supplies with Ensign 5A power supplies Plant Trip With 4 KV Fire Inadequate impact review of problem resulted Complete:
- Revised work management process to provide specific 4 KV Fire Inadequate impact review of problem resulted in wrong priority Behaviors identified previously in training and crew assessment were not corrected and followed-up
- Revised work management process to provide specific guidance for impact reviews of new Work Requests
- Operator Fundamentals were fully integrated into the RNP simulator evaluation grading, and students receive immediate feedback for improvement opportunities. The During the installation of design change MOD 851 in 1986 the cable installed was different f
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improvement opportunities are included in the Crew Notebooks
- The Engineering Change process has been modified to include numerous sign-offs and reviews of plant designs from the specification, was inappropriate for the application and was contrary to the manufacturers data sheet to minimize the potential for a similar event to occur under the current process. (Historical) 2
RNP White Finding - Initiating Events (95001)
RNP White Finding Initiating Events (95001)
Event Cause(s)
Status of Corrective Action(s)
Electro-hydraulic Control Circuit Board Pins Circuit board (1A08H) connection in the Electro Hydraulic control cabinet was found to have a degraded connection with the backplane connector The cause of the poor connection Complete:
- Replaced the 1A08H circuit board
- Revised existing PM Model to require testing to validate Pins connector. The cause of the poor connection was due to bent pins on the circuit board, but the cause of the bent pins is unknown.
proper circuit card seating of any EH System circuit cards that are replaced. This PM revision includes checking circuit boards for bent pins prior to installation as well as verifying all installed and surrounding circuit boards are seated properly Reactor Coolant The end-turn insulation in the stator windings Complete:
- Implement a Preventive Maintenance task to rewind Pump Winding Shorted degraded and ultimately failed, resulting in a turn to turn short each of the RCP motors, including the spare, on a 20 year frequency Due 10/01/12:
- Rewind the failed C RCP motor and the motor currently installed on the C RCP using a design that provides for proper securing of all winding end -turns to reduce vibration and improve long-term reliability 3
RNP White Findings - Mitigating Systems (95002)
RNP White Findings Mitigating Systems (95002)
Finding Cause(s)
Status of Corrective Action(s)
Conduct of Operations Senior Management did not implement a formal program or process to continually monitor, evaluate, and improve Operation crew performance Complete:
- Implemented Standards for Operations Shift/Training Crew Performance Improvement to drive consistent operator performance and improve Operation crew performance drive consistent operator performance
- Implemented Organizational Effectiveness Review Committees to assure Senior Management oversight is maintained Training did not identify and remediate operator performance deficiencies Site did not maintain an appropriate level of CAP initiation threshold
- Revised appropriate training processes
- Established appropriate Leadership engagement to initiate a culture shift in NCR initiation GP-004 did not contain an appropriate level of detail
- Revised procedure references and connections to other procedures 4
RNP White Findings - Mitigating Systems (95002)
RNP White Findings Mitigating Systems (95002)
Finding Cause(s)
Status of Corrective Action(s)
Operations Complete:
Operations Systematic Approach to Training Operations, Training, Senior Site Managers, and the Training Advisory Board did not provide the leadership necessary to ensure the integrity of Operations training infrastructure was maintained and monitored Complete:
- Implemented requirements for Organizational Effectiveness Reviews; specifically addressing Staffing, Supervisor Effectiveness, Training and Qualifications, and Self-Evaluation Overview
- Completed Management and Supervisory Leadership Assessments through panel process for all individuals new to positions since August 2010
- Established and reinforced management standards within the training workforce 5
RNP White Findings - Mitigating Systems (95002)
RNP White Findings Mitigating Systems (95002)
Finding Cause(s)
Status of Corrective Action(s)
Failure to Complete:
Failure to Document EDG Output Breaker in Corrective Action Employees did not use a systematic method for problem identification and resolution for a safety significant component failure Complete:
- Training Maintenance personnel for work package documentation Complete:
- Revised conduct of Maintenance to clearly establish Program RNP personnel responded differently to a Diesel Generator breaker failure between outage and online conditions
- Revised conduct of Maintenance to clearly establish expectations for Skill of the Craft Due 06/20/12:
- Establish and implement methods for Site Leadership engagement to initiate a culture shift in order to change engagement to initiate a culture shift in order to change behavior to embrace CAP 6
RNP White Findings - Mitigating Systems (95002)
RNP White Findings Mitigating Systems (95002)
Finding Cause(s)
Status of Corrective Action(s)
White Finding Complete:
White Finding Common Cause Site and Corporate Senior Leadership allowed behavioral standards of performance to deteriorate while focusing on the attainment of other business planning objectives.
Complete:
- Implemented Performance Planning and Monitoring requirements for Organizational Effectiveness Reviews; specifically addressing Staffing, Supervisor Effectiveness, Training and Qualifications, and Self-Evaluation Program Overview j
As a result of declining / poor standards, Leadership did not ensure organizational capacity was sufficient to execute core Overview Complete:
- Develop and implement a Safety Culture Improvement Plan to address behavioral shortfalls processes.
RNP has exhibited behavioral shortfalls in Safety Culture These shortfalls have Complete:
- Complete Supervisor Leadership Assessments and make changes Complete:
Safety Culture. These shortfalls have impacted organizational decisions and actions at all levels.
- Initiate and begin execution of Procedure Upgrade Project Due 11/15/11:
- Revise the annual budget process at RNP and incorporate into Fleet or Site procedures to develop the budget in a risk-informed manner incorporating identification of the gap between resources available and workload requirements and incorporate the revised process into a site or fleet procedure (Continued on next page) 7
RNP White Findings - Mitigating Systems (95002)
RNP White Findings Mitigating Systems (95002)
Finding Cause(s)
Status of Corrective Action(s)
White Finding Common Cause (Continued)
Due 10/05/11:
- Perform a comprehensive organizational capacity review Due 12/15/12:
- Complete a material upgrade project tying a solid task list to p
pg p
j y g objectives in material 8
Procedure Upgrade Project Scope Procedure Upgrade Project Scope Type Number Operations Single Column Procedures 626 Operations Emergency Operating Procedures 43 Operations Abnormal Operating Procedures 72 Operations Abnormal Operating Procedures 72 Maintenance Procedures 858 Chemistry Procedures 133 Radiation Protection Procedures 60 Total
- 1792 9
Procedure Upgrade Project Milestone Schedule Procedure Upgrade Project Milestone Schedule Execution Phase Complete all Path 1/2 EOPs September 2011 C
l t ll R i i EOP A
il 2012 Phase Complete all Remaining EOPs April 2012 Complete all Radiation Protection Procedures October 2013 Complete all Chemistry Procedures July 2014 Complete all Electrical Maintenance Procedures August 2014 Complete all Mechanical Maintenance Procedures July 2015 Complete all AOPs August 2016 Complete all Operations Single Column Procedures August 2016 Complete all I&C Maintenance Procedures November 2016 Closeout Phase Lessons Learned Report September 2016 10
Safety Culture Improvement Action Plan Inputs:
95002 Root Causes/Common Cause 95002 Root Causes/Common Cause USA Safety Culture Assessment Conducted March/April Safety Culture Surveys NRC 95002 Inspection Feedback NRC 95002 Inspection Feedback Key Focus Areas/Actions:
Significantly Enhanced Leadership and Employer-Significantly Enhanced Leadership and Employer-Employee Communications Monthly Organizational Effectiveness Challenge Meetings Corrective Action Program Improvements in identification g
p and quality of investigation Work Management Effectiveness Nuclear Electric Institute 09-07 Implementation - on going S f t C lt t
Safety Culture assessment 11
Strategic Improvement Plan Objectives Strategic Improvement Plan Objectives
- Address Performance and Historical Issues Issues
- Address and Change Behaviors
- Correct Programmatic Deficiencies g
- Establish a Continuous Learning Organization E
C lt f S t i bilit
- Ensure Culture of Sustainability
- Maintain Strong Nuclear Safety Culture
- Serve as a Station Communications Alignment Tool 12
Key Strategic Improvements Key Strategic Improvements Focus on Behaviors Increase Permanent And Supplemental Staffing Accelerate Design And Implementation Of 17 Plant Modifications g
p Backlog Reduction Work Management Procedure Upgrade Project Training Material Upgrade Project F
ilit U
d Facility Upgrades 13
RNP Mission RNP Mission Value Continuous Improvement d
Bi f
th Ri ht A ti and a Bias for the Right Action to Achieve Safe, Predictable, d R li bl Pl t O ti and Reliable Plant Operations 14