ML17158A084

Forwards Meeting Rept Between Util & NRC Mgt,Held on 931109 & 1118 to Discuss Actions Re Fuel Handling Events at Plant During Oct 1993.Meeting Handout Matl from 931118 Meeting Encl

ML17158A084
Person / Time
Site:	Susquehanna
Issue date:	01/06/1994
From:	Wenzinger E NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:	Byram R PENNSYLVANIA POWER & LIGHT CO.
References
NUDOCS 9401240049
Download: ML17158A084 (41)

Text

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)gpss Docket Nos.

50-387 50-388 Mr. Robert G. Byram Senior Vice President - Nuclear Pennsylvania Power &Light Company 2 North Ninth Street Allentown, Pennsylvania 18101

SUBJECT:

NRC REGION I MEETING REPORT This letter documents meetings between PP&L and NRC management, held on November 9, and 18, 1993, to discuss your actions regarding the fuel handling events at Susquehanna Unit 1 during October 1993.

In a drop-in meeting with Mr.

R. Cooper, Director, Division of Reactor Projects, on November 9, you discussed the preliminary findings of PP&L's review of the fuel handling events, as well as an assessment of their interface with the NRC's AIT. In an open management meeting on November 18, you presented your assessment of root causes and corrective actions to support resumption of

'efueling operations.

The information provided at the November 18 meeting is enclosed.

In accordance with 10 CFR 2.790 of the NRC's "Rules of Practice," a copy 'of this letter and its enclosures willbe placed in the NRC Public Document Room.

Your cooperation with us in this matter is appreciated.

Sincerely, 0

IGIscc L SIG D l"I EDWARD C. WEs"lZINGER Edward C. Wenzinger, Chief, Reactor Projects Branch 2

Enclosure:

1. PP&L Handout for Management Meeting, November 18, 1993

'F401240049 940106 PDR ADOCK 05000387 P

PDR Zeus I]a

JAN 6 lgg cc w/encl:

H. G. Stanley, Vice President - Nuclear Operations G. T. Jones, Vice President - Nuclear Engineering J. M. Kenny, Nuclear Licensing M. M. Urioste, Nuclear Services Manager D. F. McGann, Supervisor, Nuclear Compliance H. D. Woodeshick, Special Office of the President J. C. Tilton, III, Allegheny Electric Cooperative, Inc.

Public Document Room (PDR)

Local Public Document Room (LPDR)

Nuclear Safety Information Center (NSIC)

K. Abraham, PAO (2)

NRC Resident Inspector Commonwealth of Pennsylvania

bcc w/encl:

Region I Docket Room (with concurrences)

R. Dean, OEDO R. Clark, NRR Project Manager C. Miller, PDI-2, NRR ite I J//93 Wenzing I /()/9 P

OFFICIALRECORD COPY a;draft.2

A GENDER PPdkL/NRC 1VLMAGEMENTMEETING:

FUEL HANDLINGAIT Noverriber 18, 1993 MANAGEMENTPERSPECTIVE.......

R. G. Byram LESSONS LEARNED/

CORRECTIVE ACTIONS..........

H.G. Stanley

SUMMARY

R G. Byram

I

~

MANAGEMENTPERSPECTIVE The NRC AIT provided a valuable independent perspective.

Recurring problems with fuel handling practices'ave caused us to examine the effectiveness of our assessment and corrective action programs.

We'e completed a

comprehensive review to identify issues and take corrective actions.

Short term corrections, including generic issues, have been implemented.

Intermediate (by March, 1994 Unit 2

RFO) corrections have been identified and are in progress.

A long term evaluation ofthe broader implications is being performed.

We are confident that the results will be effective for the long term, and as a result will strengthen our organization.

MANAGEMENTPERSPECTIVE PPd'cL has a strong record regarding the resolution of issues related to the design and operation of Susquehanna t

We take aggressive measures where safety is challenged.

Our people do high quality work.

Our management is involved.

I

MANAGEMENTPERSPECTA "E

C PPckL recognizes that our actions have been ineffective in resolving long standing problems with fuel handling activities.

The individual events had broader safety implications.

Our actions were inconsistent with our philosophy on shutdown risk.

We did not provide our people with the tools they needed to succeed.

We have not met our values in this area; we are changing 1

our standards.

MANAGEMENTPKRSPKCTA'E The duration ofa refueling outage is defined by tlte tinte it takes to ensure the safe performance of all activities and safe operation for the next cycle.

Questioning attitudes will ensure safety remains our top priority.

Reinforcement of this expectation is a required response to the internally driven pressure of highly motivated people.

Management must lead by example, listen, and be vigilant to ensure that critical path never supersedes safety.

MANAGEMENTPERSPECTIVE PPckL is taking aggressive actions to resolve identified problems, and to continue to assess the broader implications.

We have analyzed the information both specifically and generically.

Short term corrective actions have been implemented that address both the specific events and their commonalities.

Intermediate and longer term actions have been identified.,

Independent, outside insight will be sought and utilized.

R.G. BYRAM Senior VP - Nuclear H.G. STANLEY

'P

- Nuclear Operations A.R. SABOL Manager - Nuclear Quality Assurance G.J. KUCZYNSKI Manager-Nuclear Plant Services J.R. MILTENBERGER Manager - Nuclear Safety Assessment

~ Verification Of Actions

~ NQA Performance

~ Refueling Floor Management

~ Event Commonalities

- ~ Station Culture

~ Department Culture

~ Self Assessment

~ Department Response to NRC AIT

~ NSAG Performance

MANAGEMENTPKRSPKCTIVE LESSONS LEARNED

~ Clearly set forth management expectations.

~ Solve recurrent problems

~ Preserve and enhance strong Susquehanna safety culture.

~

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October 6, 1993 Core'ffload Error October 26, 1993 Unit 1 Refueling Bridge Mast Non-Load Bearing Telescoping Section Dropped October 27, 1993 Double Control Rod Blade Guide Impacted Vessel Wall While Being Moved October 2S, 1993 DifficultyExperienced With Aligning Fuel Bundle In Core Unit 2 Refueling Bridge Mast Non-Load Bearing Telescoping Section Dropped V.P.- Nuclear Operations Stopped AllRefueling Activities (Later, Same Day) AITAnnounced By NRC Region I With Confirmatory Action Letter

EVVESTIGATIONAl'G)ANALFSIS

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Seven Event Reviews

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Station Management Review Of Each Event t

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NSAG Assessments During Event Reviews

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Management Review Teams Management Of Refuel Floor Look For Commonalifies With Other Station Operating Events Station Culture

'epartment Culture Effectiveness Of Self-Assessment

0

REFUELING OPERATIONS HISTORICAL PERSPECTIVE

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Several Previous Occurrences Of Bent Mast Assemblies At Susquehanna

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Higher Frequency Of Occurrences At Susquehanna Compared To Industry

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Each Event By Itself Was Not Judged To Be Significant Incomplete Determination Of Root Causes Did Not Identify Adverse Trends Generic Implications Not Assessed

BASICROOT CAUSES

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Management Oversight Command and Control Structured Monitoring Of Fuel Handling Activities.

Followup On Corrective Actions Communication Of Management Expectations Self Assessment

~

Procedures Design Limitations/Operating Constraints OffNormal Procedure Comprehensiveness (Operations And Maintenance)

User Friendliness

BASIC ROOT CAUSES (continued)

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Training Consistency With Management Direction And Expectations Monitoring Significance Of Refueling Activities

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Culture Threshold For Taking Management Action Acceptance Of Human Error As Root Cause Without Further Inquiry Perception Of Expectations For Critical Path Activities Integrated Management Structure For Refuel Floor Activities Follow-Up On Implementation Of Corrective Actions

~

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CORRECTIjVEACTIONS

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Near Term (Prior To Commencing Unit 1 Core Reload)

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Intermediate Term (Prior To Unit 2 6th Refueling Outage - March '94)

~

Long Term

NEAR TERiM COERECTIjVEACTIONS MANAGEMENT

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Establish Refueling Floor Manager SRO Certified Recognized Leader Technically Competent Reinforces Chain of Command

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Strengthen Engineering Support For Refueling Floor Activities

'ystem Engineer Assigned Implement Short Term Recommendations

~

'eadership K

Listening Communication Teamwork "

Resolution of Concerns

NEAR TERM CORRECT'."ACTIONS PROCEDURES

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Upgrade Maintenance Procedures For Maintaining The Refueling Bridge

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Develop Integrated Single Procedure For Conducting The Unit 1 7th Refuel Outage Core Reload

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Develop Specific Procedure For Off Normal Refueling Bridge Operations

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Revise And Perform Specific Surveillance Procedures

'or Refueling Bridge Operability

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Institute Refueling Floor Management Administrative Procedure/Program

NEAR TERiVCORRECTIVE~ ACTIONS.

TRAINING

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Complete Training For Operations On Refueling Bridge Operation And Procedure For Unit 1 7th Refuel Outage Core Reload

1VEAR TERM COWMCTEVEACTIONS CULTURE

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Communicate Expectations To Station Personnel High Standards Zero Defect Goals, Supervisory Follow-Up And Monitoring Teamwork Listening And Acting On Issues Management Visibility Schedule Pressure

~

Instifutionalize The Concept That Root Causes Attributed To Human Error WillBe Probed Deeper To Determine Why Human Error Occurred

INTERMEDIATETERM CORtK'CTEVE ACTIONS RIOR TO UNIT2 6TH REFUEL OUTAGE MANAGEMENT

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Critique Unit I 7th Refuel Outage Core Reload With Refueling Floor Manager Concept/Adjust Program For Unit 2

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Select/Train Permanent Personnel For Refueling Floor Management

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Assess Operation Support Staff Performance, Training, Qualifications And Organization

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Evaluate Actions Required On The List Of Other Equipment/System Issues For Unit 2 6th Refuel Outage Work

/

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. Implement Short-Term Engin'eering Recommendations On The Unit 2 Refueling Bridge

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Communicate Lessons Learned To Industry,

INTERMEDIATETERM CORRECTIPF. ACTIONS RIOR TO DUVET2 6TH REFUEL OUTAGE PROCEDURES

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Review Fuel And Core/Fuel Pool Handling Procedures To Be Used For Unit 2 6th Refuel Outage and Revise Accordingly

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Enhance Refueling Bridge Test Weight Issues Tech Spec Changes Procedures/Work Controls For Weights

INTERMEDIATETENlfCORRECTIjVE ACTIONS RIOR TO UMT2 6TH REFUEL OUTAGE TRAINING

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Identify Specific Training Needs For Fuel Handling/Core Component Handling Activities And Adjust/Conduct Training Accordingly

INTERMEDIATETERM COWMCTEVEACTIONS RIOR TO UlVIT2 6TH REFUEL OUTAGE CULTURE

~.

Per form A 'DACUM'rocess For Supervisory Training In Areas Of:

Listening Follow-Up Monitoring High Standards (Include In Employee Concerns Module)

INTERMEDIATETERM CORRECTIVE ACTIONS (PRIOR TO UNIT 2 6TH REFUEL OUTAGE)

Culture (Cont.d)

Communicate Expectations To Department Personnel High Standards Zero Defect Goals Supervisory Follow-Up And Monitoring Teamwork I.isfening And Acting On Issues Management Visibility Schedule Pressure

INTERMEDIATETERM CORRECTIVE ACTIONS (PRIOR TO UNIT 2 6TH REFUEL OUTAGE)

Culture (Cont.d)

Lower The Threshold For Writing SOORs and Improve Corrective Action For-Repeat Events '

Lower The Threshold For Conducting NSAG

. Investigations

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Revise Scheduling 'Terminology' Conduct Thorough Human Factors Review Of SSES Refueling Platforms

LONG TERiVCOEtK'CTIVE~ACTIONS MANAl"KMENT

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Benchmark The Industry For The Best Refueling Floor Management

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Conduct/Host An INFO Assist Visit On Refueling Floor, Management

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Institutionalize Refueling Floor Assessment And Monitoring

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Strengthen The Operations Staff Support Function

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Implement The Results Of Evaluation Performed For List Of Other Equipment/System Issues

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Implement The Long Term Engineering Recommendations On The Refueling. Bridges

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Review Root Cause/Corrective Action Process and Recommend Changes

LONG TERM CORtWCTEVEACTIONS PROCEDURES

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Perform A Review Of Related Refueling Floor Procedures And Upgrade Accordingly

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Perform A Review Of Work Controls (Preventive And Corrective) For Refueling Floor Work And Upgrade Accordingly

LONG TEEM CO&K'CTEVEACTIONS TRAINING

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Review And Upgrade Training Programs For Personnel Who Perform Work Activities On The Refuel Floor

LONG TERiVCO&K'CTEVEACTIONS CULTURE

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Conduct Re-training For All Personnel On Nuclear Department Supervisory Training Matrix On The Expectations Of:

Listening Follow-Up Monitoring High Standards Employee Concerns

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Institutionalize A More Stringent Corrective Action Program For Dealing With Repeat Events t

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Implement Human Factors Review Recommendations On Both Refueling Platforms

WLMT HAVE SX LEARlVZD?

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Clearly Set Forth Management Expectations Communicate Individual Performance Objective Of Zero Defects Conduct Verifications With Questioning Attitude Provide Checks And Balances Through Effective Oversight Reinforce Teamwork Lead By Example

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Solve Recurrent Problems Lower Threshold To Initiate Action Identify True Root Causes - Particularly For Human Performance St'rengthen AbilityTo Detect Recurring Problems Generic Implications Status Control

WHAT HAVE WE LEARNED? (continued)

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Preserve And Enhance Strong Susquehanna Safety Culture Reconfirm Commitment That Safety Is Not Compromised By Schedule Better'Utilize Assessment Resources And Listen 4

To Their Messages Strengthen Elements Of Defense-In-Depth (Training, Procedures, Design) Commensurate With Expectations

MANAGEMENTPERSPECTP'E PPckL is committed to learning from these issues and strengthening our organization for the long term.

We are taking a comprehensive, aggressive look at ourselves.

We will listen, and face the facts openly as they unfold.

We are setting new standards, and will take steps to ensure behavioral changes occur.

The results will be effective for the long term,

~

and ensure an e'nvironment of cooperation, communication, and teamwork.