ML18059A326
| ML18059A326 | |
| Person / Time | |
|---|---|
| Site: | Palisades  |
| Issue date: | 08/20/1993 |
| From: | Slade G CONSUMERS ENERGY CO. (FORMERLY CONSUMERS POWER CO.) |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| NUDOCS 9308250268 | |
| Download: ML18059A326 (6) | |
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consumers Power POW ERi Nii MICHlliAN'S PROliRESS Palisades Nuclear Plant: 27780 Blue Star Memorial Highway, Covert, Ml 49043 August 20, 1993 Nuclear Regulatory Commission
- Document Control Desk Washington, DC *20555 GB Slade General Manager DOCKET 50-255 - LICENSE DPR-20 -- PALISADES PLANT - REPLY TO UNRESOLVED ITEM; NRC INSPECTION REPORT No. 93008 NRC Inspection Report No. 93008, dated May 28, 1993, forwarded the results of an unannounced NRC inspection* of authorized activities at the Palisades Nuclear Plant. The inspection report identified an apparent violation of NRC requirements and an unresolved item pertaining to a perceived increase in the
- number -0f operator errors at Palisades. 'The inspection report also requested that CPCo provide a written response to the unresolved item.
By letter dated June 25, 1993, Consumers Power Company provided a reply to the Notice of Violation and stated that -0ur reply to the unresolved item would be provided at-a later date.
- ~ - --..-
The reply to the unresolved item was -Oiscussed with -NRC Region III management
.on a number of occasions foll~wing the issuance of IR 93008.
NRC Region management and CPCo agreed that the reply to the unresolved item identified in
.IR 93008 would be delayed_ until after the enforcement conference on the.
proposed-violations identified in IR 93016 had been convened.
The perceived increase in the number 6f -Operator errors was one of the subjects of an enforcement conference held August 10, 1993 at the NRC Region III headquarters.
At that meeting, Consumers Power Company discussed the operator error issue as well as the much broader aspect of recurring performance problems in general. Consumers Power Company discussed the actions that had already been taken and the actions that were being developed with respect to the operator error issue, as well as the performance problems in general. The attachment to this letter discusses only the actions that have already been taken and the actions that are being developed which are specific to the Operations Department and the operator error issues.
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Gerald B Slade General Manager CC Administrator, Region III, USNRC NRC Resident Inspector - Palisades
.Attachment 9308250268-. *930820 PDR ADOCK 05000255.
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./¥,of Y,I I A CMS' ENER6Y COMPANY
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ATTACHMENT Consumers Power Company Palisades Plant Docket 50-255
- REPLY TO UNRESOLVED ITEM NRC INSPECTION REPORT No. 93008 August 20, 1993 4 Pages
REPLY TO UNRESOLVED ITEM Unresolved Item The inspector reviewed the licensee's corrective and preventive actions for several recent operator errors. These errors were of concern because the number of errors has increased over the past few months.
Individually or collectively, none of the errors caused a significant safety problem.
The generic topic.-.Personnel Errors by Operators - wi11 be addressed as an unresolved item (Unresolved Item 255/93008-0l(DRP)).
Evaluation of the Unresolved Item and Corrective Actions Consumers Power:Company recognizes that the number of operator errors experienced in 1993 is undesirable. Jn spite of our efforts, the number of operator errors has not decreased over the last two years. This trend is significant to us.* We~believe that recently implemented programs, along with increased management and supervisory attention to plant evolutions, will reduce the frequency and significance of human error.
1 The Nuclear Operations Department {NOD) recognized in 1991 that to continue to
.imp rove.performance we must -increase the 1eve1 of ownership. within the organization. *1n.199l_we initiated efforts to return the full responsibility for the completion *of work to the individuals who perform the work.
Within the Palisades Operations Department, the supervisors maintain overall Tesponsibility for the conduct of operations, ~but the operators are being given more res pons i bil i ty for their work through increased i nvo 1 vement in the-.
decision.makin_g.and planning processes.
During this evolutionary process, Operations Department supervisors have been sensitive to the level of significance of the evolutions chosen to be used for development of.operators' planning and directing skills. While this process was intended to improve overall performance, we have not seen a decrease in the number of personnel errors.
-Corrective Actions Several actions have been undertaken within the Operations organization, *with the overall philosophy of increasing participation within the organization.
One such action was initiated in October of 1992 when the entire Operations Department participated in an JNPO sponsored one week team trainirig course.
The training focused on team skills and cooperation within the operating shifts.. We recognize that continued.. development of our employee's conununication and team skills,.as well as technical training, are critical to the overall success of both the department and the plant.
..,:.,*~.
In addition to the team training discussed above, all of our supervisors and many of our reactor operators have received professional development training through our corporate training department.
Some of the topics include Managing Change, Problem Solving and Decision Making, Supervising in a Changing Environment, Self Directed Work Force, and Coaching for Improved Performance.
In late 1992, a formal curriculum including many of these
~ourses was instituted for all of the Shift Supervisor qualified individuals.
2 In addition to the above actions, a policy of constructive discipline has been
- _more consistently applied with the operators. This policy has emphasized the individuals' responsibility for their own performance.
Failure to use procedures or follow policies results in disciplinary action ranging from
- counseling to time off without pay, depending on the severity and the repetitiveness of the infraction. While recognizing that discipline is not a strong motivator, it is being integrated into our improvement efforts to ensure a clear understanding of the responsibilities of the individual.
- palisades, as well as the entire industry, has recognized the importance of human performance in nuclear plant operation.
INPO SOER 92-01 provides guidance on improving human performance through efforts in the three areas of self-check, procedure usage guidance, and human performance trending.
The Palisades.Operations Department has established initiatives in all three of these areas over the past twelve month~.
~- -
in November.~f 1992, the entire Operations Department received self-check training developed through interfaces with other utilities that had successful programs. A self-check policy has been instituted, and efforts by supervision to coach their employees in this area are ongoing.
Early in 1993, a major effort was undertaken to develop clear and accepted expectations for procedure usage. A core group of operators led by a Shift Supervisor reviewed Technical Specifications and Code of Federal Regulation requirements along with INPO good practices and other nuclear plant efforts on defining procedure usage expectations. The end result was a document developed by the Operations staff that.defined a level of expectation that the staff had ownership of and understood.
The short term effect of this ownership has been reflected in an increase in the number of procedure comments that have been submitted for correction, and the number of occasions in the present refueling outage where activities were stopped by operators to*
- get requirements clarified before proceeding.
In late Spring of 1993, the Operations Department management instituted a program to assist the operators in self-identtfication of errors, near miss errors where self-checking prevented an error, or conditions that required the operators to work around a deficiency. A form has been developed whereby operators or supervision can identify problems and suggest corrective actions.
This system is used for problems typically below the threshold of the plant corrective action system.
The information developed through this system is communicated through feedback from the supervisors to the operator shifts in the form of lessons learned or corrective actions taken.
The data is also being trended to identify developing problems and head them off.
Many of these new programs have been recently instituted and their effectiveness has not been totally proven.
Continued efforts in these areas will be necessary to see any. resulting net improvement in human performance.
3 Management has recognized a need for increased involvement in operations.
We understand that our "oversight" functions have not been entirely successful in preventing the recurrence of performance problems* - especially those related to human/management performance, therefore, a number of corrective actions have already been taken which include:
- 1. A memo to a 11 site supervisory personnel on _lessons learned from the rod un-coupling event emphasizing:_
- a.
The need for appropriate pre-job briefings includihg coordination within the crew and between crews.
- b.
The requirements for procedure and work order usage and compliance.
- c. The need to stop workif the work is not going according to plan or
.the.procedure needs to be changed.
- d. The need for supervisor monitoring of work in progress.
2.- Onsite senior management observers have. been established as part of the
-Confirmatory*Action Letter,and will continue to monitor plant activities until the plant returns to se~vice.
- 3.
More frequent use of the pre-job briefing.
Many critical evolutions have been designated as "infrequently performed evolutions" and now require senior plant management involvement in the pre-job briefings for these evolutions. A pre-job briefing checklist has been developed and its use is required for all Operations Department technical specifications surveillance tests, special tests, special operating procedures, and other non-routine or complex evolutions.
Quality pre-job briefings and effective preparation for other evolutions have been stressed with Operations Department supervision, as well as with *the ~ntire plant staff.
In addition to increased dire~t management involvement, the Nuclear Plant Assurance Department (NPAD}, at the request of Operations management, performed surveillances in the area of human performance.
The areas that have
4 been included in these surveillances are self-check, procedure usage and compliance, and communications.
These areas will continue to be emphasized in an effort to reduce the level of human error within the Operations Department.
Additional long term corrective actions are being developed and were discussed at the Enforcement Conference held on August 10, 1993. Actions are being developed in the following areas:
- 1. Monitoring - A field monitoring program, including routine observations by plant senior management, is being developed.
The program includes team debriefs of monitoring activities to build
- consistency and provide follow through on immediate issues and big picture trends.
2..
Climate Improvement -- Emphasis on more two way communications, clarity on operator errors and discipline policy, and shift realignments.
- 3..Supervisory Performance - Emphasis on coaching and coun se l.i ng with management-observations and a customized development plan for each Shift Supervisor.
- 4.
Worker Performance - Emphasis on clarity of expectations, more
_specific feedback on _performance, and individual development plans as approp~iate.
- 5. Skill Development and Enhancement
~ The Training and Development Organization has been directed to accelerate the current NOD Business Plan's schedule-for supervisory and management skills development including:
- a. Training in support of management and supervisory work process
. observation program.
Specific content will focus on observation
.of.human performance to standards.
- b.
Workshops and training aimed at improving supervisory and management skills based on immediate needs.