ML18102B654

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Organizational Effectiveness Assessment Rept for Plant, Redacted Version
ML18102B654
Person / Time
Site: Salem  PSEG icon.png
Issue date: 03/24/1995
From: Jamie Benjamin, Eliason L
Public Service Enterprise Group
To:
Shared Package
ML18102B653 List:
References
NUDOCS 9711130280
Download: ML18102B654 (32)
v • d • e


Text

ATTACHMENT 2 ORGANIZATIONAL EFFECTIVENESS ASSESSMENT REPORT FOR SALEM NUCLEAR GENERATiNG STATION MARCH 24, 1995

  • 9711130280 950407 PDR ADOCK 05000272 P PDR

ATTACHMENT 2 INDEX Page Nos.

INDEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . *, . 1 CHARTER . . . . . . . . . . . . . . . . . . . _ . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 OPERATIONS AND MAINTENANCE*. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 ENGINEERING/TECHNICAL SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 SALEM OVERSIGHT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 SALEM CORRECTIVE ACTION PROGRAM .. . . . . . . . . . . . . . . . . . . . . . . 19 OUTAGE PERFORMANCE ................................... 23 EXECUTIVE

SUMMARY

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 APPENDIX TOP PRIORITY ACTION ITEMS

  • I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I 29

. 1

ATTACHMENT 2 ORGANIZATIONAL EFFECTIVENESS ASSESSMENT CHARTER:.

Perform a management-level assessment to determine~*

1. Why co"ective actions previously defined to co"ect performance weaknesses and deficiencies have not been effective in achieving sustained performance improvements, and, *
2. Identify organizational and personnel weaknesses that will hinder cu"ent performance improvement efforts.

This self assessment will evaluate the Salem organization's ability to effect a prompt improvement in operational perfonnance, followed by continued long tenn improvement, such that NBU goals to reach top quartile perfonnance can be realized. Substantial effort has been previously expended to identify perfonnance weaknesses and implement corrective actions. Many of these problem areas will be reviewed during the course of this assessment to evaluate corrective action effectiveness and gain a better understanding as to why sustained performance improvement is not being achieved.

The conduct of the assessment will include observation of activities and interviews. with personnel that represent a cross section of responsibilities and levels. A briefing of PSE&G management will be held to convey findings and recommendations. Updates will also be provided to NRC management. A final report of the Team's findings and conclusions will complete this assessment.

~Nuclear Officer 2

ATTACHMENT 2 BACKGROUND A self assessment of the NBU's organizational effectiveness was initiated by the CNO because the current improvement actions at Salem were not yielding the expect_ed results. The actions resulting.from previous assessments were*aimed at achieving a high level of operational safety and reliability at Salem. Since problems have persisted, the question arises as to whether current actions are adequate, and if they are, why haven't we achieved the desired improvements in plant performance and what else should be done to achieve performance goals? The assessment is focusing on organizational effectiveness and personnel performance.

TEAM COMPOSITION This assessment will be performed by a team of highly-qualified, independent persons with demonstrated skills in managing quality operations and performing critical assessments. The team will report the results to the CNO. The following is a listing of team members, their affiliations and associated areas of responsibility;

  • Ken Harris (formerly FP&L): Operations (Team Leader)

Jay Doering (PECO): Corrective Actions Carl Andognini (formerly APS): Maintenance/Surveillance Gerard Goering (NSP): Engineering/Technical Support Bill Mclane (PG&E): Outage Performance FUNCTIONAL AREAS AND PRINCIPAL ISSUES FOR ASSESSMENT:

  • Operations

- Operations "ownership" of the plant

- Effectiveness of interfaces and communications

- Effectiveness of operation's control of activities in progress

- Practices relative to work around and procedural adequacy

  • . Maintenance

- Control of m": 1nce activities, including planning

- Conduct and scheduling of maintenance

- Support of maintenance activities

  • Engineering/Technical Support

- Effectiveness of system engineers in support of operations

- Adequacy of engineering prioritization to support plant needs

- Effective use of design engineering in support of plant operations

- Effectiveness of communications and interfaces between engineering, operations, and maintenance

  • Corrective Action

- Management involvement/ownership of corrective action program

- Effectiveness of root cause determinations and follow through to problem resolution, including operations/engineering involvement 3

ATTACHMENT 2

  • Outage Performance

- Milestone planning and scope control

- Communications

- Outage management controls

- Outage planning/scheduling controls The following are typical questions which may be asked during interviews with NBU personnel:

  • How effective is the organization in dealing with known problems by finding root and contributing causes and instituting effective and lasting corrective action?
  • Have clear expectations and standards been communicated from the next higher management/supervisor level?
  • How do standards/expectations and planned actions at Salem correspond to those current in the industry? How effectively are they conveyed, accepted and implemented?
  • Have managers/supervisors accepted these standards/expectations and have they rolled them down into the organization such that they are accepted?
  • Do support groups place adequate priority on operations and are interdepartmental communications effective to resolve emergent work? *
  • Have managers/supervisors adequately self-assessed their own performance and identified needed improvement?
  • Have managers/supervisors defined and planned their work in accordance with prioritized work activities consistent with available resources? Have managers/supervisors identified appropriate results and performance indicators?
  • Have managers/supervisors reached agreement on their plans and priorities with the next level of management? Are managers and superv.isors held accountable for performance relative to plans?
  • Have managers/supervisors identified needs for additional resources and taken action to acquire more; and has management supported this action?

~ What is the overall assessment of the situation and trend in each functional area and across organizational interfaces?

  • What short/long term actions are appropriate to put Salem on a well-defined path to top quartile performance?

4

ATTACHMENT 2 SCHEDULE The following is an overall schedule for the conduct of this assessment:

2/27 - 2/29 On-site 3/6 - 3/10 On-site 3/20 - 3/24 On-site (Management Debrief - 3/24) 3/27 - 3/31 Finalize report Completion: March 31, 1995 DELIVERABLE:

The organizational Effectiveness Assessment will be documented by a report in the following format with Sections III through VII each having an Overview, Findings, Observations and Recommendations:

I. INDEX II. EXECUTIVE

SUMMARY

III. OPERATIONS IV. MAINTENANCE V. ENGINEERING/TECHNICAL SUPPORT VI. CORRECTIVE ACTION VII. OUT AGE PERFORMANCE 5

ATTACHMENT 2 OPERATIONS AND MAINTENANCE

  • OVERVIEW The integrated assessment of the :.::::::::::::::i:::::::::::::::::::::::::::::':]:::::::::::::::::::::::::::::::::::::::::::::)):::::::t:::]::::::::::::::::::::::i::::::i::::Il]::::::::::::::::::::i::::]::))::::::::::::

consisted of a review of departmental documents including procedures and including shift turnovers were conducted.

OBSERVATIONS

  • The organization clearly lacks a "team approach" in the resolution of problems. Some examples are as follows:
1. In the determination of a "Root Cause" for an event, a team approach

~:~~~=~=~:;uncehe~!d, and if they are, it will be on a request basis.

  • 2.
3. Design change packages do not always receive operability and maintainability review prior to finalization.
  • From both the :::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::,:::::::::::::::::=:::::::::::::::::::::::::::::::::::::,:::::=::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::W perspective, the 60 day time limit for the upcoming refueling outage on Unit I, which negates the ab iIity to i nsta 11 :::::=i:::::::::::::::::::::::::::::m:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::*::::::::::::::::::::::::::::::::::::::::::i:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::i:::::::::::: in conjunction
  • 6

ATTACHMENT 2 with the commitment to install ::::::i:::::::::::::i:::::::::::::::r:::::!flfl!li=::::]:::::::::::: is incomprehensible (could be interpreted as sending an inappropriate message relative to providing resolution to long standing operational problems). Little, if any, t:::::t:r:t:t

)ilI[!:m:::li!I~!~tf.tMUm: communications has been received by the organiza.tfr)rl ..on the matter and the teams assembled to conduct feasibility studies for the installation have been disbanded. However, conversations with f=t:m:=:J:J=::

1 1:1 1:1ilij j j j lj j / l/ / l /jlj/j/: : ! i~!~!jl~!gh:~: ~~~~~~~gt~::u~~~n~~~~a;~oi~ ~~ilj:ljjj)jj~!~!~l!!;:::::!!j~j~!ji:!:!!!~!~l~!!l)~.

  • The : : : : : : : : : : : : : : =: : : : : : : : : : : : : : : : :=: : : : :; organization, es pee ia Ily in th e:: : : : : : : : : : : : : : : : : : : : :=: : : : ==:: : : : : : : : : : : : : : : : : : : : : :=: : : : :i: j: : : =: :, does not have a prepared work package backlog; therefore, there are periods during which qualified personnel are either idle or involved in tasks that are of a low priority or that are below their level of qualification. Either the

=~?~or

  • In both the l)!j]j]jl)lj!j!j\j!jlij!jlj]j]j]l )![:j:Ijtjtj!j]j]j]j]j!j!jljl i ,!:j:j::::::tI:l!l!l)!Ij!)l)lj!j!j!!:J:j:j:::::::::::::::::::::::::l!)!)tjljlj[j!jij:j::::::::::, work is either delayed, rescheduled or postponed because of "spare parts." A review to determine whether the spare part was not in the warehouse, the work package involved insufficient or inaccurate parts lists or the ordered parts were not received prior to scheduling of the task was not completed. The perception of both departments is that having adequate parts available.

is not supportive in The : : : jij !i i i i l i i i i i[i j:jl: : : :i: : : : : : : : : : : : : : : :'!)Il: :!Ilili ililili:): : : : : : : : : : : l: :!il)l!j)j)j:]j : :;: j:]j)j!:lj))!Mi l!i!i!i!i i i:!: : : : :)j')))j)fi l i!i)i)i):)!))j:) Iocated outside the unit control rooms does not function as a work control center and as such cannot meet the needs of :::::::::::::]illtlll]!L Currently, it's primary function is to perform tagging to suppori"".ma"i'n.te. nance; but, even for this function, staffing levels are inadequate .

1. t:tw:::t:t:tftff are unavailable to provide leadership because of the amount

~'f~'j"~'~=====;=~ent in meetings and resolution of ATS items, etc.

2.

  • 7

ATTACHMENT 2

3. :1It@If1@!1I@:::::tn:m continually fails to obtain input from the individuals fn'~"()'h/e.cfT~.,. a,. specific activity prior to making a decision. As an

~~=~=~~~f1i~~;~~~:~~~~~~~d~~~:;d~~~rn

  • are unwilling to accept
1. They perceive that the s: : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : i: i: : : : : : : are the "t::::::::::::::::::::::,::::::::::::::::::::::::::::::::::: bag-ma n."
2. The position is a glorified clerk.
3. Financial incentives for the position do not exist.

~~=i~:i:!::~=::::~:!:~:~::~::!:!:::::jl!JJjJj!!J!ljJJJJJ\::::m:~:i:i]::i::~:;::i:~;:~::::::~::~:i:i:]i:i r!~~~~~;h:hse t~~n~~:~~t~:st~:r 4.

the position.

  • 5.

Observations indicate that events or even near events are occurring that

~~~~~n~~ s~~~ i:~~~~ra~~odnusc~e ~: ~11~~;~a~eeitn:~f;~ ~a:~:i: : :lilil\ljJj jil JIJIJl lJl J jlJ J JIJlj l jl il l l i l !ij!il! J!Jj i jl ljJ j J jJ j!j :'.: : : : : : : : : : :

Person ne Iin the :t:[: : : : : :[]t: : : : : : i: : : : : :=: : : : : : : : : : i: : : : t lI: : : : : : : : : i: : : : are co nee rned th at unitizati on wi 11 not appropriately address the areas of specialization.

RECOMMENDATIONS

~~e~~~:lh:~:t:i~i?t~~ ~l~~~eh:h:t

  • I nte rd epa rtme nta I barriers th at currently prevent : : : : : : : : t:I: : : : i: : : : :i: : : : : : :t: : : : : : : : : : : : : : : : : : : :[lI][l departments from acting as an "Integrated Team" must be eliminated and
: :r: : : :=:1: : : : ]fif!fli:l guidance provided, with appropriate accountability, to ensure iha't""'i'm.~l'i'e.mentation has occurred and interdepartmental relationships continue to improve.

8

ATTACHMENT 2

  • ::::::::::;::::::;;::;:::;::r;mm:::::::::m:::::::::; guidance and expectations relative to a 60 day Unit I outage and the feasibility of installing the digital feedwater control system must be communicated to :::::::::::::::::;::::[:::;::l:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::.
  • :~:~! ~1! ~!i!l!!:!:~~~=~:ae~=~~i~e nt~: a~aa~l~~~e~~i t~~e:m:~1i:~:i::::::i::~:i:m:]:~:i::::::i:~:::::~:~:;:~:i:~i:
  • 1 1 and must take appropriate corrective action.
  • The cause for work being delayed, rescheduled, or postponed because of spare parts must be identified and corrected .
  • A comprehensive assessment must be conducted and appropriate actions implemented to provide the the necessary incentive to be co me :::::::;:::::::::::::;I:::::t:::::::::::::::::Iilililili![li i1!1[.
  • To reduce events, !ii1i\!i!il(!!11ii!l!lii:!!!ilili!!lliiii!ii)ii):!/!i!!i[!!!!:!!::!:!:!::::::::::Iili!!:iii!i1i!i!1i!!1:!ii must immediately provide guidance and expectations to ::::tft:::::::::::!f]!))!ftlti relative to the fact that extra caution shall be exercised prior to****"ihe******c:*a*na-u*c*t of daily activities. The scheduler pressure must be eliminated and individuals must be encouraged to STOP prior to execution of any activity if doubt exists.

9

ATTACHMENT 2 ENGINEERING/TECHNICAL SUPPORT

  • OVERVIEW This assessment consisted of a review of many current internally and externally generated assessment documents. Interviews were also conducted with i!f{i]!]j[))i!i!'i\!I\\{\

OBSERVATIONS

~;i~~ll~~n!!!!-

retains a PSE&G fossil based focus. This attitude of "we can fix anything once it breaks" results in general fire-fighting that, while giving the organization a good feeling when fires are well fought, does not form a solid

~1~~:r~~::*::~~11:~~~~1~~~~~~~s1ve and lead responses to problems in the day to day operation of the plant is 1

~irt ~~i:]:'::t::~::~::::::i:i:~:lli:::::i\11\i\liil\!i\lillilliijij\j\\\l1~il~::!:~:~:!::~:![~o~~::~e~~t ~sai ng:n :~a~ ~fc~r~f ~;a~~r~~ ip 1

and direction.

  • 1

~~:~:m::i::::::i=:t:i~r~:~:a~i~~ ~~~e~v~~~ nf~~~ti~ ~~gtfi ~:~i i i~!IBifilI)j l j Jl Jl jliJj!J J J j jJ l iJ IJl lJl J!IJIJIJIJIJ Jlil l lJ!JIJ: : ~i\~ ~: ~!i!: .: :

From a historical perspective, the basic difference between the  :::::t@tltl Bii~~;~;~~~:~:n~~!

this line of questioning was pursued further as to what has or is being done to address this difference, the response was unsatisfactory. There is no evidence of an investigation of this difference or an action plan to upgrade

~:~e::ii!!i!if!:l~~:~iji:~li!i!l~j~]~!~i[~il!~:l:~:!:::::!;l!if!B!i!ii~t~~~ ~h~ i: ~!fi: i: : : ~ n;h~! ~:~oa;~~:~hat has situation has been allowed to exTs*:r*****tor years whh. . no effective action being taken by the 10

ATTACHMENT 2 day to day operations. There is currently a general approach that both the

  • ~i1::::::::::::::;;:;:::;;:1:M!]i!i::::::::::::::::::1:::::::::::::::1:::::::::::::::1:::::::::::::r!)):::::::::::]:]::::::1:::::::::::::::::::::::=:::::::::::=:::::::I::::::::::::::: wi 11 get involved with issues "when called." This on call approach is directly opposite to the intrusive
~::i:~:~::;:i:::irw;:~~= i~h~~~ i~ee~~e~!:~ i~~ t~: : :i~:]: il :~ : i:~: ~: i: ~: i: : :!IJ!IJl!J JIJ l l J!l!l!l:IJIJl lJl lJ Jl l lJ: : t!: : :!:!:!: : :!:~!

owns an emerging problem at the Plan of the Day meeting. The

=:::::::::t]:]::j))] should be reporting on the problem and the needed actions for 11
  • a*aa;;0*5*5fng it at that meeting.
  • There is a lack of an integrated process for the prioritization by the
i::::i::::::i::~::::::::::::i::::::::::::: in the fo11 owing are as:
1. Technical issues
2. Plant modifications
3. Corrective maintenance The lack of prioritization results in the mindset that everything is of equal importance and the organization and the individuals feel overwhelmed. It is
i::::::~:;::t::~::i::i:::::]::J::j::~::J:i:: ~r~t !:!:~:~:i::~!!I!li~J:j!j~j~J!I~l!:!:~:::::!:!::l::~:!:::::!:!!i!l!:~t~::;se t!:::::!:~:j~jj~J!:~~::::j:j:jjj I current operational needs. . I
  • The : !ij!j j j j!j j j j j j j:j: : r: ;: : : : : : : : !Ili l i]j j j!j j:j :j j j j ]: i: : : : : : : : : : :;: : : : ;:;: : : ;[: 1!:I!i!:i1!i!j : and spee ifica 1ly, l ij j j j !j j j j:j j!i i:j jijijli j [![:irli i!ili!::::::::ri1!tiijl!i!l have become integrated into many relatively low value added processes.

1]:!: : : 1: : : : : :1: : :1: : : : : :11:: : must protect : : : : : : : : : : : : =: : : : : : : : ]I: : : : : : : 1: : : : : : : :lI :li !t!i j: : : : : ava iIab le ti me ca ref uIly to ensure they have sufficient plant time to allow them to be effective in real time support of current issues.

  • In an attempt to respond to the feeling of being overwhelmed, the :::::::;::::::::::I[::::::::::i::::::::::::
: : : : : : ][i i i i[:[]: : : : : 1: : : :I:Ili i!i! ili i!i ]j !j j !j ! has formed a spee ia I group of ::::~::::::::::1::::::::::::t::::::::::::::::::::::1:::1::i::=::::::::::::::::::,:_-*that**a1:e to be "first responders" to requests for technical support. This
  • There is agreement that the technical resources available to the Salem 11

ATTACHMENT 2 of these resources to solve the most operationally important technical issues

  • in a timely manner. When a serious reoccurring issue becomes visible, the focus of these technical resources occurs, and a final solution is developed.

The integration of these technical resources to support the t:::::::::::::::f::rM:l

I:::::::::::1m:::1 work has not occurred such that this support occ.urs****-rr;*** a seamless and timely manner. Expectations have not been communicated to the ;: : I:i ! iJ!i J!Ji i: : : : :Ii!i]j)]:jI:J)::J:J: ;: : : liJ!'iJi :J: : :J: :J;: JiJ!J!JjJ!:!JiJil!Jj jJj j: :I : : : : : I: :'J!=:J'i l: : iJiJ'Ji:jth at design sup po rt for o PE! rCi~i o r1Ci I is~ lJ~~- .

need a high priority and that technical support is to engage :Jr:::r:rr::t@I'Iflft::@tt/'\:

immediately when uncertainty exists but will retain ownershi";~'f"'~'h~T;';~';.''''''

  • A program to bring the ::1:::::::::1:::::::::::::1::::::i:t::::=:::::@:::::::::::::::11=:1:::1:@:::ttll!l!!\j)j:::::::;:]:!t!::::::::::l]!i'ilil!!!!j'j!j!jlj\j)j\l i!) together for sharing of best practices*;*****r9*5*c;*u.rc*e*5**:****te;*a-*m****"huTfdfn*9*. c;*;:******P**9**r*s*a**r;**;;*9r* rotation is in place but is not effective.
  • The re is no evidence th at the :_!:]:i:t!:t:::::::::::::::::::t:::::::tilililililil\!j!j!j\j ]j j :j j j\::i:::::::::l!Jl:l:jl!i!j!j!j ::;::::::::::::::::::f::::::::::;]::=::: meets on a regular basis to address strategic technical issues or to prioritize resources or li iJi !li l]!j!j!:::::::::::::::::i:::=:::::::::;;::::::::: issues.
  • !.~.-~

@:li!i!i!i!iliil]!

. . JJJiJJJiJjjJJ]i\ii!(i!iiiii!i!i!i!i!!i!ii!iii!tli!iiiiiii!!!i!ii!iiii!ii!iii!iii!!i\ii!iiiiii!iii!iiiii:!iiiiiii!i::::::;:!riiiiiiI!!\!iiii!ii:iJ!:;;::!i:::;: which wi 11 address many of the : :;: : : ; ; ; :;: : : : : :;: : :;:

problems that plague the plant is being delayed due to outage schedule constraints. This modification has high priority based on ope ratio na I need. The i=!:!iii!!!i!ii!!i!ii:ii!i!!f:i:!i!:i:i!i)i:!jii!!ii!i:::ii!Ii!i:iI:!i:i:i!ii))ii!:i:!iii!ii!!!ii!!ii!iiiiiiiiii!!!!!J to date has not deve Io p ed a plan to address the schedule constraints and the need to install the modification within the schedule constraints.

  • ~~~~es i~ ~ i~ :~ ~i~:1:i:]: t: i:]J :;: : :l!J J JIJ!Jl l lJl !l lJij j\l l l l!J il!l Jl Jlj j j jij j\Jlj ljlj \jilj \l j lj jli j lj j j! Ji!i!i~i~ ~ ~ ~;~ ; i~~~=~ha~~al not being allowed to resolve the issues using normal processes. The result is confusion as to who has responsibility for an issue and being ineffective in dealing with problems .

weak support area. The issues appear to have been caused by historical inattention to preventive maintenance and poor quality of older

~~~~~~:~~~£~~~~~if9~::~::~~~~~~e~ ~~~er

  • :~::s:s:s:::::ir:0::1:a~:v:~i~~~~c~~~~une~sc:P:~~~:ds~~P~m~~~~:~~~~:~ \hhea?I:I:!:::::~!~:!::: final a~*5r9*n=*:=*=*==***this approach can and has resulted in design solutions that are not responsive to the problem and tend to be complete change out of systems 12

ATTACHMENT 2 with the latest technology rather than an engineered upgrade to the existing equipment.

  • There is limited indications that ::::::::m::::::::::::::::::]::i:J:j:jij]j]jf:iij[jij[jii[j[j[j[j[jijij[j: interfaces with other nuclear plants to discuss approaches to problems. This appears to be a historical situation and is currently not being addressed in an integrated manner. When discussed with :f:{::::::r:::::::r::::::::::::))j:::::::]rt::::::ft, the general response is that people are too busy to talk to anv. . . isTd*0****cl"rif~inizations. o.u.

~~~!!t~!i~~~:~~~~~~;~~~~;~r:~:i.~o, Attention to meeting goals is imiiactfn*9**1he....tec.hnical section's ability to focus on support of day to day operational problems.

RECOMMENDATIONS To allow this organization to succeed, a critical examination of the current

t:::::::::::fiflijj[tilii:iiiii:iififillili!i!lil!iijlj((fiiiiii:iiiiii!ii!i!ll needs to be performed to upgrade its capabilities to provide the leadership and management skills to address the current shortcomings at the Salem station. There are numerous examples in the nuclear industry where the proper application of strong leadership and management skills have made dramatic improvements to plants with significant problems. The application of these skills in a timely manner at the Salem station will address the negative observations discussed in the above finding and will allow the organization to succeed.
  • The existing opening of :::::]i!i i::::::::::::::::::::::.:::::::']t::::::::::::::::::::::::::::::i::::::::i::::::[::::::::::[:::::::i:::::::::::::::::ii((:::::, which is to be fi Iled by an outside individual, requires an individual that has experience with an aggressive and well recognized nuclear system engineering program.
  • Additional external experienced individuals should be placed in the organization to ensure that full time facilitation of the necessary changes will not be diverted by external events that could impact the line individuals' attention to the change process.
  • ~~~~~~ i!:!~:i:~: ~:!: : :!:!:~:!:!:!:~: : :j l/ljl l l l il !:!l i!l i/i l l l il !l : : :i: t: r ~:d ti:i:::::i::i:i:~:i:i:[:ffi:::::~:i::1':~:]:::::[;i::::::i::1.ha;~i: ~=e presently an effective group and by moving the group to a closer physical 13

ATTACHMENT 2 proximity to :::i::::Iiii!i'lii'ii::::::::@::::::::::::::::::::::::::::::':::::::::::::::::::::::::::::::::::::::::::::::::, the pIants ope ratio na I needs co u Id be

  • more effectively addressed. Having a dynamic, quick response group that can address operational work around issues in a timely manner is a critical
r::i::;:]::::::~:i::~:::~1~~::!:::::~:!~!!i~:;!t!!!:!:~:!::::~h:~i~I ~;i~~~ :nodu ~p~~as~r ~~:h J:~ :J:! i! ~! ~:!:!: : : : : : : :
  • A cross functional team should be given the task to revise the scope and installation plan for :::t::::::::::::i::::::::::::::::t:::::::::::::::::t:::::::::::t:::::::::::::::t=::::::::::::::: system at the next outage. Input from other sites can be used to ensure that the major benefit from the project can be realized and the installation would not extend the outage beyond the current budgeted schedule.
  • Rank in terms of value added the various programs and processes that the

~he~~~~~~~~;~,i£i~P~~:~l~o~~;::~~=

and ownership of the daily and reoccurring operational problems of their respective systems.

  • Institute a process to be applied to the current backlog of technical issues to ensure that the most operationally significant are being appropriately prioritized .

14

ATTACHMENT 2 SALEM OVERSIGHT OVERVIEW Oversight at Salem consists primarily of audits and surveillances performed by the be accompanied by recommendations. ::r::t[t::i::: is supposed to provide oversight of plant operations for the purpose of detecting nuclear safety issues, although it does not appear that this is being done on a systematic basis.

OBSERVATIONS

  • The ability of the ?J?ttt?t:::ttt=t:tltt?I to support needed improvement within the line organization ~=~=~=====n=;;;n~=~=~t'd'~'~'!o low performance. Weaknesses include;
1. Audit report quality was inconsistent. Though occasionally good, overall they tended to be poor.
2. Interviews with ::::!l!l!l]ij[f!I!::::::::::::I::::::[:[i!l]Ill!:::::::::::::::::[:fil:::::t::: indicated that l[I!::: has lacked credibility in the past due to instances of poor performance.
3. has not made a routine practice of assessing themselves by comparing their findings against those of external oversight.
  • l[I[t::::[!(((([![II[l[l[l[!(([![IJ'lJ[Ill did not consistently use findings as an important tool to leverage organizational improvement. Over the past five years, the number of findings decreased even as the plant performance was decreasing. Other indications of this are;
1. A review of audit reports reveals that findings are often not issued even when significant performance deficiencies are noted.
2. A well executed audit of Corrective Action Programs was performed in the third quarter of 1994 resulting in a finding being issued to the
: : :i: : : : : : : : : : : : : : ti: : : : : : : : : : : : : : :=: : : :=: : : : : : : : : : : : : : : : : : : : : : : : : l l! j: : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : :i: : : :=: : : : : : : :. The agreed upon 15

ATTACHMENT 2 corrective actions appeared potentially effective, but due partly to lack

  • 3.

4.

of :::::;:::::ii follow through on the finding responses, they were ineffective.

Historically, extensions to due dates were easily obtained and frequently abused.

When j:itl::::::ii]i[i\\\\:::::::::]:j:::;:::;:::::::[il))i:i]iill: decided to move to a greater emphasis on performance based auditing, they were unable to articulate what that

~f:c~:~e~~ l~jiiiiJj!][:i::j::::::~:~:~:i::~:~:;::~jji:~::~::=:{orJ:g:g:;=::!::~:::::!:!:~:::g~!j~i:~se~ ~i ~~~~s were constituted a performance based findings tended to inhibit the writing of additional findings.

5. Another negative incentive for issuing findings was the additional work load created for the issuer of the finding who would take on the added responsibility for follow up of corrective actions while still maintaining responsibility for scheduled audits.
6.  :::::::::::::::::::::::::::::::ii:::::::::::::i::::::::::[:i=::::::::::::::::::::,::::::::::::[:j:[]i! had difficulty in issuing findings due to_._._.i._~-~bility to maintain independence while in close association with the =::t:::::::t

!!!~!r~~~~~~-o~::~l~~h~:~

1

  • Inappropriate behaviors within
t:::::::::::, For instance; reduced the impact of
1. In the past, some (estimated about 30%) ::::::[jjjjjjjj]j!!i!i!l\::::::::::::::::::::;:::::l]!] would strongly resist the issuance of QA findings. While this was highly dependent on the individual manager, it indicates deficient leadership in proper behaviors and appreciation of the role of i!!:i:iii!ijjjf.
2. An event occurring in Dec 1992 is frequently discussed indicating that it remains an issue with some :::::::::::::[j((jj['[![jj:::j[ji[!il!((((j[j[i::.
3. 0 ne :\j]jjjjjj!j[!i[j\:::=::::::::=:i::::::::::::::=:::::::ifil]![f[ indicated th at recorded findings in their performance evaluations.
4. The ::::::::::::::::::::::::::::=::::=::::[:I::::::::::::::::i:::rn:t:l!! expected th at the i!i!i\[:i:[i[![l!i((i:::::::I!i!i!((['ilji[:::::tlii:[::::::::::::: was "pa rt of the team" implying that they should participate in activities that were in fact:::::::::::::::::::] responsibilities. This was also a problem for
  • 16

ATTACHMENT 2

5. Monitoring of the effectiveness of corrective actions resulting from

!lj]j)ll!!l! findings is not routinely done by ::::::::::::::::::::::=:::::::::I]!i))i!!lililililil:[:jmJm::m@::;::::::I. (neither did rn&E raise this as an issue.i

1. A new ::@::::::::::::::::ri::::::::::::::::]::::::::r::::::::::::::::::: was named who has the high standards, the unders1:8"nciin*9**th'e***::::::::I:::::: fun.ction, and the leadership necessary to use the :tIIl organizatio.n .. io leverage organizational improvement. is able.. 'io. clearly articulate the important areas requiring improvement within the site organizations.
2. Substantial changes are being made to the lead.ership within the !]t!tJ:

organization. A systematic approach is being taken to assure that"""""

,J)!j)!)j)ij)ijJjIJi)J::jJji)j)lj!jjjj]jjjjjjj)~j)j)j)!I)!l!lli wi 11 fi 11 .jJ!i!,JlJijijij)litJ]jjji'ii:Jj~);::Jiil)i)j)!)\i)j)i))j!)!jj)jjjjj;::Jjj)j)j)!))j)!j!j))j)jJIIEiI!JlillJ)jjjjjj positions*

3. Sound strategies on implementation of the audit program are being developed which will produce the greatest organizational impact. This includes a shift to a more performance based use of ::jj)jJ]Iji[i) resources, and plan for scheduling activities which optimize the benefit of the audit program.
4. Innovative means of self assessing ::Jjj j!j)j!j!j j j effectiveness have been designed and are beginning to be implemented.
5. A l:lll1iii!]jjjj precess jljJ=::::::::::::::::::::::::l'.Jl!il]jjiiJjjjjjjjJ!j:J!i!jjj!j1]!l!l!l!l!il!Jjjjjjjj:j!j!j!]ll1i!]Ji!l11J!jJjjjjjjj!: wi 11 assist the organization in focusing resources on priority issues.

6.

RECOMMENDATION

  • The revitalized J:II!@ij organization being implemented, including the initiatives identified above*;"""will clearly address the historical performance issues. This effort must remain highly sponsored and :jtJl!l]: should provide continual
  • oversight until a high performance organiz.~itTon is achieved .

17

ATTACHMENT 2 be clearly communicated to :::::::'::::::::,::::::::::::::::::::::::::::::::]!i]i!i!i!lil!l!li:::::::::::::::::::::::::::::::::::::: that ]:::::::::::::: feed back is a valued input for continuous improvement and validation of self assessment.

l'llf![!f::if should upgrade its "Review of facility operations to detect potential

  • nu.dear safety hazards" (Tech Spec 6.5.1.6h) to a more rigorous assessment process.
  • should receive strong sponsorship from should monitor :-::::::tljl performance .
  • 18

ATTACHMENT 2 SALEM CORRECTIVE ACTION PROGRAM

  • OVERVIEW The Corrective Action Program (CAP) at Salem was evaluated as follows; 1.

was used for many of the interviews. Concerns were drawn from the interviews based on the experience of the interviewer.

2. Corrective action data was reviewed including incident reports, Action Tracking System (ATS), and implementing procedures to assess the proficiency of the Salem organization at learning from experience.
3. Meetings were attended where various elements of corrective action processes were implemented.
4. A historical review of the organization's response to external assessments was conducted.

While the programs which support the corrective action process w_ere examined in detail, the overview took a broader look at organizational learning.

OBSERVATIONS

  • There is ample indication that t:tttttlt!I!t!tff[lJid continues to experience problems which could have b~=;=~=====p=;=;~=~,,~t=;=~fi'F'adequate root cause determinations had been made, and corrective actions taken, in response to previous events. For example;
1. Repeat problems with :::::::::;::i:i:::::::[i[iii::m::::riiiii[i[I[i!iiI(([i[i[i[i[i[i[i[i[i had not received sufficiently rigorous analysis and correction to prevent their contributing to a recent event which required another root cause analysis.
2. A recent serious clearance error is symptomatic of failure to learn from a number of minor attention to detail tagging errors attested to by 1: : : : 1 : : : 1: : : ~: : :1:;: : : : : : : : : : : : :1w: i: : : : : : : : i: : : : : : : : :1: : : : 1 : 1:;:::::.

3.

problem which they were intended to correct.

19

ATTACHMENT 2

4. Repeat events were identified by analysis of Incident Report (IR) data over the last 15 months.

94 IRs indicated inaccurate drawings 64 configuration control problems were identified Difficulties in control of maintenance activities were identified 36 times Tagging problems appeared as causal factors in 32 IRs

  • The present processes which support the CAP are not up to current industry practice, however, if implemented in accordance with the governing procedures, this would greatly enhance the CAP process .

1*  :::::::Illl1]jj:jjlllt::::i::::::::::::::::il:l1lti:l: has developed a good data base of event data and have developed sound insights into where the organization needs to imp rove. For the most pa rt !j!j!j!j!Ji!i!!J:::::::::::::::::::J!j]j!j!j j j j jI::::::::::::::::::::::::::JJjj j!j j j ))!i!!!:I::::: is "to busy" to take advantage of their work.

2. Incident reports are not classified as to how rigorous an evaluation is to be performed. This has resulted in an excessive burden on the line organization resulting in a reduced appreciation for benefits of properly executing the program.
3. Causal factors used to formulate corrective actions are too shallow.
4. Corrective actions tend to address symptoms and not underlying causes.
5. There is inadequate follow through on corrective actions.
6. The data analysis which is being performed is marginally useful in the format presented and is not used by most :::::::::i:::::::::i:::::::::::;:i::::::::iim::::::::::: to improve organizational performance.
7. Generic considerations are weak.
8. The J:fil:!Iff[!!l!!I:!jjj!j1j!jf[I::::1:::::::::It:::::::II!i((!!j[ does not verify the effectiveness of corrective actions.

20

ATTACHMENT 2

9.  : : :it: : : : : : : :t: i: : : : : : : : : : :t: : : : : : : : : do not review IRs at close out so are not aware of the quality of the investigations performed by their respective organizations.

1 O.  : rn:;:it: : : : : : : : : : : : : : : : : : : : : : : : : ;: : : : : : : : : : : : :I: :IE: i: : : : : : : : : : : : : : : : : : : : : i: : : : : : : : : : : : : : : : : : : : : [:l:Il: : : : tl: :I: : : : :i: only reviews IRs if they become LERs.

  • : : : : :t: : : : : : : : :t: : : : : : : : : : : : : I: : : : : has not adequately supported implementation of the CAP. The following observations were noted:
1. Clear responsibility for upgrading CAP has only recently been established, and the leadership for this change originated with the
: : : : : t: : : : :i: :i: : : : : : : : : : : : : : : : : : : : : : : instead .of : : : : :i: : : :i: : : : :i: : : : : : : : : : : : : :I: : : : [I: : I:.
2.  : : : : : : :t: :tlI: : : II:: : are preoccupied with short term priorities at the expense of focusing on longer term corrective actions.

3.

'~:~:;:!:!::l::i:~:~:: ;::=::~::r::~=:~::~t:~::f ~:n~~~ga!~~~t~fat~~Y:r~~~~~a~~e;~e~~t~~usal factors eft~'~'t'ig'9't'h;~ performance of their organizations. No feed back on the usefulness of event analysis reports has been received by the originator of the reports and at :;: : : : :;: : : : : : : : : : : ]: i: : : : t: : : : : :]: Ii l: : :i[ !: : : : : : : : : I: :i]: : : : : : admitted to not using the report.

0 4.

~~~~~:e~t..t~~~~evc~~v~f !:!~1:!:~:!:~i:~:'.::!::::~:::::;h~~i:~r:i::ir:i:tm:i::0~:a: :s:*~~=n corrective action : : : : : : : has spo nso red dies.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,. ,.,.,.,.,.,.,.,.,

5. A mentality of "if Salem didn't invent it, it can't be the best" was mentioned several times as being a historical factor. Travel to witness programs at other plants is infrequent.
6. Post job critiques are inf re que ntly performed. ::::::::::::::::1:::::1::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::
1:1:::1II:l critiques were identified as being weak.

RECOMMENDATIONS

  • The following actions are recommended to improve the Corrective Action Program;
1. Continue with the current plans to establish a corrective action program with single point accountability and strong

!:~i!:l~i:j:!:::::::!:!::::::!:~:g~~~;~c::~~pi.nt~5:::::::i::~:~::f: : : [: ~: : : ~: ~:i: t:~:l:~:i: l: i: : : ~.h is function 21

ATTACHMENT 2

2. Consideration in developing the program for upgrading CAP should include as a minimum:
i. A resource loaded plan which defines the development and implementation, including user training and a period for monitoring effectiveness.

ii. Site visits to other plants identified as having strong corrective action programs.

iii. Integration of all site corrective action processes into one data base, with one comprehensive set of causal factors.

  • ::::::::::::::::::tt[:I:::::::i:::::::r:::::::::::::::::::t:::::::::::::t:::::::::::: s ho u Id put in place appropriate ::::;i:::::::::::::::::::::::::It\::r::::i::::::::::: systems that promote strong organizational alignment, high accountability, and appropriate ::::r:::r:=:=:i:::t:t:::::::tftf!f! oversight. The current initiative to establish a biweekly me*e-tTn'9.,.,.,;;;.;fih'..,P'.erformance indicators and attendance down through 1 1 !i 1i ;,\i i i:j:i i!i 1i1i1i\i i !i!i !lilili i i1i1! i .1!1i1 !li'ili i 1i:i~i!1i1i i i:i i! 1ili i i i: may represent the rig ht approach but the design and implementation need rework. A visit to a plant where this is done well is a must.
  • Commitment Tracking reports and performance indicators sorted by organization and indicating the types of commitments should be made available on a routine basis in an accountability forum involving ,J!fi!i!i!i!\i!iI@!!:
1\i!iiiii::::::::i:::::ili!lilifl:::i::::::::::::. These reports should track backlogs, aging, overd"u*e*5*:******9oals, use of extensions, and prioritization. Indicators should be accompanied by analyses and recovery plans.
  • Adherence to the existing programs supporting causal factor analysis, e.g.,

the IR Program, is mandatory. Although not optimin, the current process must be followed. il[llt::;::::::)[![![![l[1[1[:[:[ti:::::::l:::::::::: must insure that significant plant problems are entered into the system for evaluation. Hardware nonconformances must have bases for operability determinations.

22.

ATTACHMENT 2 OUTAGE PERFORMANCE OBSERVATIONS

  • The PSE&G Nuclear Department procedure NC.NA-AP.ZZ-0055(0) - Rev. 1 requires the establishment of *outage Milestones and Scope Control, but many of these controls have not been implemented. Many Design Change Packages are not issued with adequate time to properly plan and prepare for implementation in a properly scheduled Refueling Outage. Scope is continually being added and little or no Scope Control is being implemented.

i]ii!ii((i:[:J:J:J]Jtlll!j:::::Jlll* is starting to schedule the development of Design Change Packages. Up until this time very little scheduling has been done of the design process. Thus true estimates of how long it takes to develop the design and associated work packages and materials procurements have not been done. Because of the lack of these schedules ::r::tttt:r:::::rr:::::r::I *:*:*:*:*:*:*:*:*:*:*:*:*:*:*:*:*:*:*:*:*:*:*:*:*:*:*:*:*:*:*:*:*:*

has been unable to track its performance to ensure it meets scope cutoff dates.

The Plan-Of-The-Day (POD) is a very large document and does not provide the basic information of the accomplishment of the past shift and what is the focus and critical path work to be done today. ::::::::::::::::I::::::::::::::::':::::::::':::::::::::::::][j)j)j !j!j j:

Jt::::::t::::tJ:r:::::::::tt:::t were not sure what the critical path was to getting the units h~ick***a**r;*****nn*e and very few could determine any required sequencing from the .

Outage POD.

j!j!JljjjjJjJjJjJjljjlJ![lJiJjjjjjjjjjjjjjjjjjJt!Jljlj!li!Il!][jjjjlli!i!l:::I!l!i[l[:J!jll]i!i!:l!::!l:i))il!:i: are very frustrated in trying to provide information to work planning to improve future Work Orders because their changes are seldom incorporated.

r::::::::::::::::::::::m::::::::::t::tJ?tilt is understaffed and is not producing the quality of Work

'F~'~2'1~~~'9'~=;======~=~*~'ded. are rushed and the quality of the package 23

I ATTACHMENT 2 The process is very poor. This manual system requires numerous unnecessary trips to :::::::::::::::::::::::::::]::]::::::lt::]:::::]il* A new automated electronic system is about ready to be placed in service at Hope Creek, but is not scheduled for Salem until some time later this year .

The present Outage Meetings have become a problem because ]111IlI 8:~:g:g:::::!:!:!:~:1:~::g~ft~:~: ao~g:i:~: : : i: ~: : : ~:[: ]: ~:~:r:i:~]: : : ~: ;:~:i:~: : :i:i:~: i:l i: i:~:i: i: ;: : :i:~: : :~:]: i: : ~~!a*~~*;t the waiting for this change in direction before they start their daily work assignment.

Quite often the status that is given in the 0800 meeting is given to protect

]j1[:[1[1[:::t]::::::::']:l[))]jj[][M': image rather than reflecting the true progress of the outage.

These reports are usually corrected after the meeting in smaller one-on-one meetings.

does not always provide adequate support during the outage.

]!:[:[:[l[:!:l:[:[][:[i[:]::::::::::::::::::::::::::::::::::1::::::::::::::::::::::::::::::=:::j:!:::::::.,p.<>.~.i.~io n in the :::::::::::::::::t::::::::l:))il[i[:::::j:[:)) structure does not provide proper j:Jlll]::::::1:::::::::::::::::::::::::::::::1::::: authority to match the responsibility for running the outage.

Preparation and the direction of the outages has improved from the past but it is still poorly organized and does not function well. The shift to shift direction does not drive the outage. The interface between organization for transitional jobs is very poor. The contact pain.ts for various organization vary from shift to shift and critical path jobs are often delayed in the transition from one group to the next.

24

ATTACHMENT 2

  • : : : : : : : : ;t:;: :[ili li]~j !)jf i\!j j!j j j!j j[)j!j!:jl: : : : : : : : : : : : : : : : have been poorly organized. ::::::::::::::::::::i:::::::::i::::::::::::::::::::::::::::::::::::::: a re not ............ .
  • selected properly and they are not trained on how to develop and run a :t:::::@tl
m:::1;::::i.&lJ.:::m::::;:::::::::;. ::::::t:i:::::::::::::::::::::::::i:::::::::i:::: do not function well duri_~~L~_he outage because*.*.*.*.*****

of the lack of support and understanding and what::::::::::::::::::::::::::: really are.

Following the completion of major repetitive task and at the end of each outage a large number of ideas are discussed to improve the next outage but only a small number of these ideas are captured and incorporated

  • Outages scheduling is a major problem. There appears to be inadequate focus or enforcement of the schedule.

j~j~~jijjfjjj[~:~j!j~jj![!~j![!ji[:j[jlllllllllillllllllllli!ll!!llll!lll!lll!l!ll:::::t:i:l:1::ffi::i:[tjjJjjljjitita~~o~:t~~::~~~ ~o~~t rf~~de~~~ ~:t~I they are needed to support the work in the field and they become critical path until they can support the job. Jobs are delayed because different jobs end up trying to work in the same exact location or even on the same component.

The schedule is a record of what has been done and not what is to be done .

j![!i!i!j![: : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : : t: : : : : : : t: : : : : : : : a re not given a sch ed u Ie to f o Ilow. ]: : : : : : : : : : : : : : : : : : : : : : :

ttttt::tttt:tt:tr are not given the schedules for their work to review and

'~'~'~'~'~'~':t".''''They feel that this must be done for them to properly organize their crews outage work.

Inadequate time is taken by all ::::::::::::::::::::::::::::::::::::::::::t:::::::::::t::::::::::::::::::::::[::::::::::::::::::[::::::::::::::_ to review and comment on the outage schedule resulting in no one having a high confidence in the schedule.

RECOMMENDATIONS

  • Develop an outage scope control program that appropriately addresses late scope additions. Pre-outage milestones should be utilized during the planning phase of the outage and be directly incorporated into the present scope control procedure*.

25

ATTACHMENT 2

  • Revise the Plan-Of-The-Day to provide a more informative and user friendly one or two page document. Contact other nuclear facilities for document design.
  • :1=:s:::::]::~:~:m::~}~fu!I:f ~~=~o~~~I~ i;~~~~een~ h~~!!j!l]!:::1::::1~!i~i'l~!ii!i!!i!ii!:l:!lj~]~i!iii~!!i!i!i~!j/!1!~ii:i]i:i:!i!!~j~:~~I, and fm"pfe*n;*9*r;"t'*"*a*11 related activities during outages as well as normal operation, it is recommended that INPO be contacted for an outage assist visit.
    • 11::::1:::::::::::::::::tlt::1::::::=:1:::::tlt::t::1::1::::::::=:::tll!ll s ho uId be revised, organized, and ope rated c'o'nsls'ie'nfiv'*'*wfifl*=*=*t'he'*=*=p*r=o*g rams of other s uccessf uI uti Iities.
  • 1[!1!!1[![:!l1l1!1t!]i]i1[1!!!I11111111111~]1]l1!1l:::::::::::::i s ho uId provide the Iead e rs hip and guid a nee to insure that all schedules are adequately prepared, reviewed, and implemented .

26

ATTACHMENT 2 EXECUTIVE

SUMMARY

27

ATTACHMENT 2 28

ATTACHMENT 2 APPENDIX 29

ATTACHMENT 2 30

.. ATTACHMENT 2 31

...

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