ML17291A959

Operations Instructions OI-23,Rev a to, Human Performance Improvement Program

ML17291A959
Person / Time
Site:	Columbia
Issue date:	07/28/1995
From:	WASHINGTON PUBLIC POWER SUPPLY SYSTEM
To:
Shared Package
ML17291A958	List: IR 05000397/1995007 ML17291A959
References
OI-23, NUDOCS 9508180231
Download: ML17291A959 (37)

Text

1NSTRUCrloN NUMBER OI-23 OPERATIONS

%Np-2

'PERATIONS INSTRUCTIONS OPERATlONS MANAGER DATE HUMANPERFORMANCE IMPROVEMENTPROGRAM I-0 RLIERQK

~.o This instruction defines the Human Performance Improvement Program within the Operations Department.

It identifies sources of information on the performance of the department, in total, as well as crew and individual basis.

This instruction also identifies who has responsibility for gathering the information and organizing it'into useful forms to assist management personnel in recognizing excellent performance and improving the performance of the crews and individuals they are responsible to supervise.

Department personnel have a variety of information which identifies individuals, crews or the department's level of human performance.

This information is either direct (individuals performance observed by other individuals, i.e. OI-9 program), or indirect (via overall plant capacity, factor).

This instruction addresses compilation, assessment and actions for direct information..

Direct information comes from the following sources:

a.

PERs which identify human errors by Operations personnel b.

OI-9 Observation Program c.

Gold Card Observation Program d.

Personal Contamination Events (PCE) e.

Radiation Exposure Summaries

f. Training Observations g.

Comments from other Operations department staff Direct information which is documented in a corrective action program, such as PER and PCE, will be assessed during the resolution process on the issue.

Actions to improve human performance will be developed and implemented as part of the process for resolving the issue.

This instruction does not require any additional action for such cases.

9508i80231 9508lh PDR ADQCK 05000397 6

PDR Revision A OI-23 Page l of 6

3.0 N

I R

3.1 Alldirect information will be coded with the following information.

a.

Date of the Event (PER, PCE} or observation (OI-9, Gold Card, Training Observations, Radiation Exposure Summaries, and comments).

b.

Event or observation category (use the OI-9 Topical list).

c.

Crew involved..

d.

Individual involved (ifapplicable).

3.2 The coding willoccur as part of the generation of document involved in reporting human performance, or willbe provided by an individual assigned by Operations management.

3.3 Alldirect information willbe routed to the Operations Administrative Specialist for data compilation.

3.4 The Operations Administrative Specialist willgenerate the data displays listed on, and ensure they are distributed as indicated.

3.5 The responsible shift supervision should maintain a confidential file of direct information, sorted by individual. Alldirect information will be placed in the file for the individual(s) causing the event, or observed.

This file is open to review by the individual, the individual s direct supervisor, the Operations Department Manager and Assistant Operations Manager.

Any other personnel requesting access to these files must be approved by the Operations Department Manager.

Information in this file willbe retained for not more than 24 months.

4.0 W

F 4.1 Shift managers and supervisors are expected to review the direct information from the 01-9s, training observations, PERs and PCEs in a timely manner.

It is expected that most examples of weak performance willbe "corrected" at the time of the observation.

This correction should be in the form of an immediate action(s) to correct the situation, as well as a clear communication with the individual involved addressing the weakness, the management expectation and the way the employee can improve performance of the task.

(See section 5.0 for more detail) 4.2 Shift managers and supervisors are expected to review the information in the file each

.month.

The purpose of this review is to ensure that the human performance of an individual is recognized, and action taken to reinforce good performance, as well as correct/improve weak performance.

The direct information file is expected to be reviewed in conjunction with assessments for individual performance appraisals or salary actions.

This information is not expected to be the sole source for such reviews but is expected to be a large contributor.

Revision A OI-23 Page 2 of 6

4.3 In addition, the Shift managers and supervisors are expected to review the current months data and previous data to determine ifany trends exist which may need additional coaching/action to improve performance.

5.1 Ifthe reviews performed in step 4.0 indicate that additional action is needed to '

improve individual human performance, then that action should be taken using the following guidelines.

a.

Improvement actions should be commensurate with the significance of the weakness observed (See G.I.H. 4.2.6.).

b.

Ifan individual is phced into the Human Performance Improvement Program, he must complete the following:

1)

Be observed per OI-9 by a peer or supervisor for the first activity of the shift for the task involved (hanging clearance orders, etc).

2)

Complete the task under observation for a minimum of two weeks and at least 10 observations.

3)

The OI-9 observations may be tracked using Attachment 2, ifdesired.

At the end of the observation period, the OI-9 observations willbe reviewed by the responsible shift management.

At that time, the shift management provides recommendations to the Operations Manager whether the individual may once again be released to perform the task independently or requires further performance under observation.

c.

Ifminor weaknesses are repetitive, the supervisor must exercise judgement on the need for additional observation, coaching or other actions, to prevent the weaknesses from recurring.

d.

Repetitive weaknesses may result in additional disciplinary action, up to and, including removal from the current position (See G.I.H. 4.2.6).

e.

The need for improvement actions should be based on an assessment of all observations, including both strengths, satisfactory performance and weak performance.

5.2 Improvement actions should be coordinated with the Training Department, so that training experience reinforces the expectations and improvements expected.

Determination of the appropriate actions should involve the Operations Trainers to assure consistent teamwork on improvements in human performance.

6.0 D

MENTATI N F A ONS Revision A OI-23 Page 3 of 6

6.1 Actions taken in response to PER, PCE and Training Observations are captured in

'those documents.

Copies of completed documents should be in the individuals direct information file for information.

6.2 Actions taken during OI-9 or Gold Card Observations should be documented briefly on the respective forms.

The forms are retained in the direct information file.

6.3 Actions taken for OI-9 Human Performance Improvement requirements are to be documented as part of the appraisal process and retained in personnel files.

6.4 Actions taken as a result of observations identifying repeated weaknesses, or based on radiation exposure summaries are to be documented as part of the appraisal process and retained in personnel files.

Revision A OI-23 Page 4 of 6 INFORMATION

" PRESENTATION DISTRIBUTIONMEfHOD PERs a.

b.

C.

d.

PERs per month, assigned to Operations on rolling 12 month look ahead.

PERs per month sorted by Ol-9 topic PERs per month, by crew sorted by OI-9 topic PERs per month, by individual "causing Postings Postings Ops Mgr/SM(crew only)

Ops Mgr/SM(crew only)

OI-9 a.

b.

Co d.

OI-9s performed each month sorted by topic OI-9s performed each month sorted by crew and topic OI-9s performed each month sorted by topic and level of individual performing observation.

OI-9s performed each month sorted by topic and level of individual observed.

Posting s Ops Mgr/SM(crew only)

Ops Mgr/SM(crew only)

Ops Mgr/SM(crew only)

Gold Card a.

Gold Cards generated per month sorted by OI-9 topic.

b.

Gold Cards generated per month sorted by topic and

crew, Ops Mgr/SM(crew only)

Ops Mgr/SM(crew only)

Exposure Summaries a.

Summary for the Department b.

Summary by Crew c..

Summary by Individual, in management level Postings Ops Mgr/SM(crew only)

Ops Mgr/SM(crew only)

ReViSiOn A OI-23 Page 5 Of 6 HUMANPERFORMANCE.IMPROVEMENTTRACKINGFOR DATE OI-9 OBSERVER COMMENTS COMPLETED SATISFACTORILY Shift Manager Revision A OI-23 Page 6 of 6

Washington Public Power Supply System Enforcement Conference EA 95-096 NRC Inspection Report 95-07 Arlington, TX July 28, 1995

SUPPLY SYSTEM AGENDA Introduction J. V. Parrish, Vice President, Nuclear Operations Discussion of Apparent Violations, Safety Significance, and Corrective Actions C. J. Schwarz, Operations Manager Regulatory Perspective P. R. Bemis, Director, Regulatory and Industry Affairs Summary J. V. Parrish

Discussion of Apparent Violations, Safety Significance, and Corrective Actions

~

Assessment of individual apparent violations:

Causes Corrective actions Actual safety significance

~

Asses@ment of programmatic implications

~

Generic corrective actions

~

Summary

APPARENT VIOLATION I Improper Operation of RWCU Valve

~

Discovered by Supply System

~

Primary cause:

Willfulviolation by the CRS

~

Contributing causes:

Supervisor involvement interfered with overview Poor verbal communication Supervisory contact with personnel too infrequent to detect worker attitude

APPARENT VIOLATION 1 Improper Operation of RWCU Valve

~

Corrective actions:.

Control Room Supervisor and Shift Manager involved in event:

Removed from licensed duties Requested termination of licenses Appropriate disciplinary action taken

, Operations Manager meeting with Shift Managers and Supervisors HOT LINE notice to WNP-2 employees Ensured no recrimination against reporting individual Nuclear Safety Issues Program staff investigated event Plant General Manager meetings with operations crews Mandatory briefing of managers "Time-Out" for WNP-2 workers Control room management oversight functIOn

APPARENT VIOLATION 1 Improper Operation of RWCU Valve

~

No actual safety significance:

Downstream piping was not overpressurized Relief valve protection available Automatic isolation capability available No adverse impact on control of plant

APPARENT VIOLATION3 CAC Valve Switch Not in Position Required by Clearance Order

~

Discovered by NRC

~

Causes:

Failure to self check Inattention to detail

~

Corrective actions:

Appropriate disciplinary action taken Implemented due to our clearance order error findings:

Human Performance Tracking program Human Performance Improvement program

~

No actual safety significance:

Valve was in correct position Redundant means used to ensure valve remained closed (fuse removal)

No automatic open function

APPARENT VIOLATION4 Inadequate Clearance Order for Vacuum Breaker Indication Repair

~

Discovered by Supply System

~

Causes:

Personnel error preparing clearance order Second review failed to identify the error

~

Corrective actions:

Incident Review Board {IRB) investigation The IRB report reviewed by Clearance Order Review Committee {CORC)

Appropriate disciplinary action taken Control Room Operators to receive training on reading prints

APPARENT VIOLATION4 Inadequate Clearance Order for Vacuum Breaker Indication Repair I

~

Corrective'Actions {continuedj Control Room Operators to spend part of their relief week working with CORC as OJT Developing a table top guide for clearance order second reviews Will assign an operations SRO as a CORC supervisor

~

No actual safety significance:

Workers took appropriate precautions for work on energized equipment Complied with Technical Specification requirements for vacuum breaker indication

APPARENT VIOLATION5 Removal of Incorrect Fuse

~

Discovered by Supply System

~

Causes:

Inadequate labeling Equipment Operator wire identification training inadequate to compensate for poor fuse labeling

~

Corrective actions:

Enhanced wire identification training provided to Equipment Operators Evaluating improvements to affected fuse labeling

~

No actual safety significance:

Momentary loss of power to an indication that had already been declared inoperable Error discovered immediately and corrected 9

APPARENT VIOLATION6 Turbine Trip During Testing

~

Discovered by Supply System

~

Causes:

Failure to self check Inadequate supervisory oversight

'nadequate pre-job briefing Poor labeling of levers Adverse environment - high radiation and noise 10

APPARENT VIOLATION6 Turbine Trip During Testing

~

Corrective Actions An Incident Review Board {IRB) investigated the event Painted turbine trip test and reset levers in contrasting colors, clearly labeled them Added step to test procedure referring to attached sketch of front standard Provided self checking training to equipment operators and on-shift operations supervision Reemphasized role of supervisor with on-shift operations supervision Developed pre-job briefing checklist, training operations crews on its use Event to be reviewed in licensed and non-licensed operator requalification training Appropriate disciplinary action taken 11

APPARENT VIOLATION6 Turbine Trip During Testing

~

No actual safety significance:

Transient bounded by FSAR analysis No complications during Scram recovery 12

APPARENT VIOLATIONS 7, 8 Mode Changes Made Contrary To Technical Specification 3.0.4

~

Discovered by Supply System/NRC

~

Causes:

Startup procedure did not have a step to cue check for TS 3.0.4 compliance

~

Corrective actions:

Startup procedures changed to require review before mode changes:

LCO status log Surveillance log Barrier impairment log Panel walkdown 13

APPARENT VIOLATIONS 7, 8 Mode Changes Made Contrary To Technical Specification 3.0.4

~

No actUal safety significance:

MSLC Allowed outage time in Operational Condition 2 was 30 days

~ ~

Actual time out of service was 27 hours3.125e-4 days <br />0.0075 hours <br />4.464286e-5 weeks <br />1.02735e-5 months <br /> (restored 11 hours1.273148e-4 days <br />0.00306 hours <br />1.818783e-5 weeks <br />4.1855e-6 months <br /> after mode change)

Vacuum Breaker Position indication Allowed outage time in Operational Condition t was 72 hours8.333333e-4 days <br />0.02 hours <br />1.190476e-4 weeks <br />2.7396e-5 months <br /> for an open vacuum breaker I

Allowed outage time was unlimited for a failed position indication.

Actual time out of service was 4 hours4.62963e-5 days <br />0.00111 hours <br />6.613757e-6 weeks <br />1.522e-6 months <br /> 14

APPARENT VIOLATION9 Incorrect Operability Assessment For IRM E

~

Discovered by Supply System/NRC

~

Causes:

Lack of understanding of critical lRM system operating characteristics Lack of a questioning attitude Use of engineering judgment without independent technical review

~

Corrective actions:

System notebook updated to include effect of signal noise on lRM indication Appropriate disciplinary action taken Refresher training provided to personnel who perform operability assessments Developing enhanced IRM system training Interim engineering management review of operability assessments 15

APPARENT VIOLATION9 Incorrect Operability Assessment For IRM E

~

No actual safety significance:

At least two IRMs were operable on affected trip system:

a scram requires only one IRM trip signal on each trip system.

IRMs not credited in WNP-2 safety analyses 16

APPARENT VIOLATION2 Service Water Valve Not Lock-Sealed

. ~

Discovered by NRC

~

Causes:

No reason for manipulation of valve identified from records or interviews Lock seal was still on valve valve was in correct throttled position Monthly surveillance to check position did not require direct inspection of seal

~

Corrective actions:

Checked similar valves Revised surveillance procedure to require verification that seal is intact

~

No actual safety significance:

Valve was in correct position No other valves affected

APPARENT VIOLATION 10 Failure to Take Corrective Action for Half-Scram

~

No PER required by procedure Management expected a PER in this situation

~

Corrective actions:

Supervisor coached operator and observed subsequent operation Communicated PER threshold to crews

~

No actual safety significance:

Response to event was correct Event was properly logged Reactor Protection System performed as designed

~

Supply System does not believe this was a Criterion XVI violation, since adequate corrective actions were taken 18

ASSESSMENT OF PROGRAMMATIC IMPLICATIONS

~

As discussed earlier, the events did not individually have actual safety significance

~

Evaluated for programmatic implications:

'afe plant operation, conservative decision making:

Prompt manual scram atter symptoms of power oscillations Contro[led, methodical startups Operator performance:

Good operator response to plant transients Error free refueling operations during the Spring 1995 refueling outage Plant shutdown for R10, economic dispatch 19

ASSESSMENT OF PROGRAMMATIC IMPLICATIONS Operator performance (continued):

2 plant startups before R10, 2 plant startups after R10 Good operator performance on requalification exams Recent INPO observations Problems with work control, communications, clearance orders:

being addressed Procedural adherence Only RWCU misoperation involved misuse of procedures; for other apparent violations personnel were following procedures but made errors Plant startups and shutdowns were performed in accordance with procedures 20

ASSESSMENT OF PROGRAMMATIC.-IMPLICATIONS Operability assessments:

Recent problems have been dealt with generically, conservative positions taken on equipment operability Electrical penetrations Agastat relays Nuclear instruments

~

Supply System assessment:

no programmatic implications 21

GENERIC CORRECTIVE ACTIONS

~

Programs to improve weaknesses identified by Supply System and NRC assessments I Implementation of Conger and Elsea recommendations Operations instruction for TS decisions Electronic TS LCO log Team meeting with managers/supervisors/

craft to ensure correct operability decision emphasis Root cause analysis training Enhancement of Problem Evaluation Request procedures Training given to operators on use of Licensing Basis Document search tools 22

GENERIC CORRECTIVE ACTIONS

'continued}

~

Operations "Step Up Plan" Culture change Leadership Performance Teamwork Communications Resources

~

Mid-cycle Self Assessment NRC Communications Document 13 Areas, including Operations Safety focus Initiatives Expected results Measurement standards

GENERIC CORRECTIVE ACTIONS

{continued}

~

Mid-cycle Self Assessment

{continued}

Example: Operations Area, Safety Focus C

Objective: Safety Culture Look for subtle issues Raise issues Deal with issues Initiatives:

Ol-9 program Management Oversight program Management involvement and guidance for Technical Specification interpretations Crew changes "Gold Card" program Measurement Standard examples:

Automatic Scrams Safety System Availability Safety System Actuations NOVs, LERs Personnel errors 24

GENERIC CORRECTIVE ACTIONS (continued)

~

Summary Comprehensive corrective actions derived from self-critical evaluations Results will be measurable and used to change or add actions Frequent status reports to NRC 25

THE REGULATORY PERSPECTIVE

~

Overall Supply System position:

The Supply System acknowledges 9 of the apparent violations occurred Apparent Violation 10 not a violation of Criterion XVI

~

Overall significance:

No actual impact on public health and safety Individual issues had no actual safety significance No programmatic implications

~

Mitigating circumstances:

Prompt and comprehensive corrective actions Significant personnel action taken for deliberate procedure violation Comprehensive corrective actions, including long-term integrated efforts 26

THE REGULATORY PERSPECTIVE

{continued

}

IVlajoiityof issues were previously recognized by the Supply System due to the mid-cycle licensee assessment 9 of 10 apparent violations in February 95, coincident with completion of self-assessment Two LERS issued for reportable events Six of the 10 apparent violations identified by the Supply System Only one of the apparent violations involved misuse of procedures

~

Conclusion 27

SUMMARY

OF KEY POINTS

~

No safety significant challenge to plant operations

~

No programmatic implications

~

Showing positive progress

~

Implemented systematic and integrated action plan

~

Supply System understands the problems and is aggressively pursuing the solutions 28

0 SSPV Problems C

O CR HVAC Problems Refueling Errors CR HVAC Problems CM Inspection CR HVAC Problems Good Startup Good Operator Requal Results Z

0 Q

M D

Q 0

O Q

2 A

tO Self Assessment 9 Apparent Violations (16 Days)

Poor Startup (3.0.4 Violations)

Good Startup Acceptable Shutdown y,

0 Refueling Errors Good Startup Good Shutdown Good Startup Today Good Startup RWCU Event