ML20012B158

Forwards Special Team Insp Mgt Effectiveness Review Rept for Plant & Two Draft Documents from State of MD to Be Released by FOIA Branch

ML20012B158
Person / Time
Site:	Calvert Cliffs
Issue date:	03/08/1990
From:	Russell W NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I)
To:	Murley T Office of Nuclear Reactor Regulation
Shared Package
ML20012B157	List: ML20012B156 ML20012B158
References
NUDOCS 9003130688
Download: ML20012B158 (34)

Text

{{#Wiki_filter:__ ) -e r; / UNITED STATES [_ [, 'l NUCLEAR RFOut.ATORY CO WISSION I REOlON l 476 ALLENDALE ROAD

• • • • • ,/

KING OF PRUSSIA. PENN8YLVANIA 1H06 i i i March 8,1990 i l MEMORANDUM FOR: Thomas E. Murley, Director, Office of Nuclear Reactor j Regulation t FROM: William T. Russell, Regional Administrator, R1 i

SUBJECT:

CALVERT CLIFFS SPECIAL TEAM INSPECTION i MANAGEMENT EFFECTIVENESS REVIEW i Enclosed is the Calvert Cliffs Special Team Inspection Management Effectiveness Review report and two other draft documents received, today, from the State of Maryland contact on Calvert Cliffs. Maryland received these documents from the author of the Regardies Magazine article entitled " Management Meltdown". I have been informed by Chris Poindexter that the Baltimore Sun has a copy and is going to publish an article based upon the report. Baltimore Gas and Electric Company does not have a ec'py as yet. The report is undated and the cover sheet is missing. Previous copies received by the Region from NRR in early May 1989 were destroyed sometime after the final inspec' ion report was issued. At the time of the Maryland Peoples Council FOIA request, no copies existed in Region I. ! recommend tha(t you have the FOlA Branch release all three enclosures and provide i a copy of what is released to Baltimore Gas and Electric Company, ATTN: Christian H. Poindexter,250 W. Pratt St.,24th Floor, Baltimore, MD 21201. Because this is likely to get press interest, I recommend a copy be provided to the Commission. This course of action has been discussed with the EDO. hY& William T. Russell Regional Administrator i l l 900313068890hh7 .hDR ADOCK 0$ PDC

e 4 Thomas E. Murley 2

Enclosures:

). Calvert Cliffs Special Team Inspection Management Effectivess Review report i

2. Recommendations, Pending Receipt of Licensee's Corrective Action Plan (Draft)

3. Calvert Cliffs Preliminary Root Cause Summary cc: (w/cncls.)

J. Dyer, OEDO J. Partlow, NRR W. Kane, RI i l l l

s .t* PREDECISIONAL... INTERNAL USE ONLY *** g, CALVERT CLIFFS SPECIAL TEAM INSPECTION KANAGEMENT EFFECTIVENESS REVIEW : q,,M:> %q n,. a '#~3EN EXECUTIVE

SUMMARY

w u e h:.<,, w From Februfry 2Tthrough[MaNh 31.a team o$ultMa* special' team inspection at Calvert Cliffs Nucl$ar;P,owert'Pla'rit CCNPP I and 2..The intent of the. insp' ction was* toideterwiriefthe"cau {PMe d* e apparent' declining performance and a teries of'oph,ational" events n last half of 1988. tions and maintenance group which performed inspectionsjn,the areas o,f operations, maintenance, quality' control, s'Urveillance', testing,"hnd.ibr%l 3 rec tive actions, and a second group evaluating the ' effectiveness;of'fic6hieeV management personnel in safely operating the facility..' ].y,,,,y ",'yQ ed 'bkTonIpYt'est,'# The operations group determined that the plant was'sta'ff'fessional'mann'e'r T nd knowledgeable persons who executed their duties,in'a~proThe operations' g'roup ' i were capable of operating the plant safely. significant deficiencies in the absence of written procedures for'.'co'ndu~c't'ing quality control activities and in maintenance procedures which"le'ft'too'inuch to the judgement of maintenance personnel and did not contain ad I In addition, corrective actions were not]always1 completed j,# documented. thoroughly or in a timely manner. The four person group evaluating management effectiveness conducted.approxi - y 6 at'all levels mately 320 person hours of interviews with management and staff,inc' a'ct'ivi-and in all departments, observed limited operations arid maintin C ties on back shifts, reviewed programs and events..and observed'.oniand 'o'ff site review comittee meetings .In sumery, the teamlidentifie'd the',fol.1'ow-ing causal contributors..pait a'nd.presunt, to the declining"peYformance'st ' '4 " "* M '

Omq)

a.nA CCNPP.

'v For the life of the plant up to the present,' site endic'drp6raie[N6 age-ment demonstrated by their budgetary controls,'. allocation.o0' resources, o and operational decisions an operating philosophy which emphisited" - productionoverqualityandsafety. .:c % 1t w g.T v o Plant staff has developed a Nohn Wayne" approachNo'suppori@g?thef production goals of the facility, in which each person;does'whateverPlant st o to be done to keep the plant on line. conservatism, procedural adherence, prograssantic. controls, and.the. ~ i ' t-involvement of the quality organization to achi.ev'e that mission.M.m

n.. a i..,,, t. n m Management failed to recognize and respond to ch'and int't'h@n 5 Management has remained isolated and su$prisingly un o

industry, the regulatory environment, anQ$ithin'twiware,of pr6gress in programs, procedures, and systems throughout the industry" arid in the' inplacetodayatCCNPParereminiscentofstate,o(theja evolving regulatory arena. Many of,the practices, systems yuim u M g years;ago. .g. Once the need for change was recognized, the plant's apprbacN %ishTnge management. tended,to be simpitstic and unrealistic. This tendsneyfhas o causedplantpersonnel}tounderestimate.3he[tas,kgejrg

• g.j'

.Qg[.Q.s 3;il'.l' y.. ., y ' ... y, P *:p

• nL.

3 W

• • • PREDECES,IONAL... INTERNAL USE,0NLY,*WM1 %',p Aq.],o g;.7,;

. u. d

l '" PREDECISIONAL... INTERNAL USE ONLY ** l t , r w u3yy.* op The production bias, budget constraint @ird a6EtM)" prog}amsNha't N, - $ i ! o reduced manpower sent the message to the.Wrk. force to do morejithi ti less, and do it faster and cheaper. That' emphasisiset the; tone :fori. c worker's disdain for procedure use and adherence,qand was;a;' factor;in./ '"I. < -l poor procedure quality. Management's emphasis 'on ou$dt' effec'tWe~1)N 3 I i guide's-tofignore%n 'th'e'y + demonstrated that procedures were merely'at mes' age'was absoibeP S i I: interfered with production goals, and th s ""NW N P"" '*

• W i m t plant's culture.

y N. t e Isolated, inbred,'and somewhat unsophisticated', he 'p1'aintTtYf'f7ge'n'u'inW! l o ly belicved it was among the best in the industry. ;The'ojHirat'iona'1** i t i events and enforcement actions of late 1988 had little. imp'act on th'e"waf" businest was done. The fatality was a significan't' emotion'a1Feven't~fbr'N the entire staff, and for the first time thtre was some grudg'ing ac-knowledgement that procedural' noncompliance 6n'd a'caValler%peVaVin' 0 868 style had gone too far. Management, however,'Vas baFely41e't'o'%c nize symptoms, much less diagnose root causes,'ar.d'begin to'N 1"#e1'ehd ih' n

• i

'd"3 3 'W 8 i plant back to health. M :.1.:m, ir an c.y:8 irap i Lanoing on the NRC's' watch liet threw the plant iWt'o a'sYate"6f foYyan$ C; ^ l o irational and emotional confusion, and placed'ths ple'nt in'aTreaciliveTN mode that substituted the compilation of unco 6rdinated,";unpr',ioritiz'e'dS"W lists of symptoms and action items for a compr2hensive ' change 'str'attgyM The fomer Vice President (VP), Joe Tiernan, by all'acedustsiaifan:.C ' o effective plant manager but as a VP did not exercise managerial contro1~ I over the facility. He did not. hold subordinates' accountable',-assumed (often incorrectly) that his orders had been followed, and was<not kept'. well informed persons'repo.rting.directly to him:^!n a Nide6tipsd' *

• s'H e emotional ' address to 'the plant stiff following;tliedatalityPTiernarP*) P'J demanded procedural compliance but failed to follow through with a demonstrated change in operating philosophy that the. plant staff could recognize. During interviews the former kP volunteered 4that, irFretro-spect, he should have been relieved as YP as early as*1986e

"N W w.1, ,.., ; u.yy, c;. The remainder of the executive team lacked an unMrstanding@then o managerial and leadership skills necessary for. success _given the complex " project management " matrix organizational structure chosen during' the " r 1986 reorganization. ,p Middle management was and is ineffective in tr'anslating oivanizational o goals and operating philosophy into defined performance expectations for the work force. That work force has been accomplishing their assignment of supporting plant operations without benefit of adequate procedures. systems, or programs, defined work priorities or performance expecta-tions, or QC involvement. I Save for the new VP, George Creel, dozens of plant personnel interviewed o were unable to identify recognized leaders among plant managers and: supervisors, nor were they able to identify Individuals deserving

• respect.

..m 3 9 m n with virtually no new infusion of e'nsf Management is inbred,imore Gas and Electric Compary (BG & E)1Ty4 o .M from outside the Balt e 2

• • • PREDECESIONAL... INTERNAL USE ONLY ***'

4: %r.,...nw,. s-

l I,

• • • PREDEC1510NAL... INTERNAL USE ONLY ***

,.gbh '"i..

• M f) f

.i lM

1. O.4%

w..A t .n, t; + . y 9,p organization at any management level..A reN ev)of)tkef,ne, j Supervisors (GS) for example, determined, that the.;same gr,,d o D uals has been~ supervising site activities'for^the.la'st ie i i 4 some rotational assignments wi. thin the 'jroup, Q.G.#' m'. "" 4 ( y ' f. y..f n ^ With its heavy emphasis on' production,managementiest s o inwhichtodisagreewiththecorporateemphasisTenVppe'd6dti o l branced as uncooperative, often to the detrimen,tgfiorie' " y}g, To sumarize, management" demonstrated the foll'o'i'n'g 'opMNn 1bsophh"W.' ^ w with key elements arranged in ^ declining order of manageme'.t*. 1,. .v. C..,r"qo i! w ?', n 4

• N.' " ' " * " '

money schedule productivity w : sd.* v.sw swu minimum investment ,, ;4., g.,.. %, g, ',,..., g, g., regulatory relationship ', s.;,,,,. ', safety ~ " ' ' ' ' '; ~'.' conservatism quality ,..,,, g. y Management's current one-dimensional approach t'o restoft' rih"cNie CCNPP is overly simpitstic,and emphasizes reversing.the' order this]jff[. Theteam'consideredthisstrategytobe*onlya. start'iniLp1Vt63 'diore Ittonal appropriate balancing 'of friorities in the complex" matrix structure in place at CCNPP can be visualized a's thedynam;or,ganic,';thfe 9 sional, project management model represented by figure A'.',[*.,.,. g,[,h.' i ' ' Quality and saheIaNlt eNehf&hf approach, which' establishes fihis* balance,lly' com .f' ev'eFy management' edidonfir Ihe ig he'"a'nd ' ' l take relationship of costs versus schedule M ty and gives a full and equal treatment to g performance expectations imposed on the Skfety facility by regulators and the public. En Schedule 4 h pess'ima FIGURE A !icensee management readily ednowledged the deficiencies identified bythe operations and maintenance group and promptly began corrective action to' " resolve problems with Quality Control (QC) and maintenance procedure ituality. I The Itcensee was more reserved in its acceptar.te of the concerns expressed by ' the manager. ant effectiveness group, but did state to the team that each of the group's findings had previously been identified as part of their compre-hensive corrective action program, which was under development at the time of. the inspection and was not reviewed by the team. Licensee senior management - l I expressed an understanding of perceived deficiencies in communication effec-tiveness, leadership skills at all levels of supervision, and their~ ability to manage change. 1' 3

• • • PREDECE$10NAL... INTERNAL USE.ONLY ***

't J, f

j

• • • PREDECISIONAL...!NTERNAL USE ONLY ***

ve? The VP resisted the team's suggestion that the natselof. the findiiWs$in'di - I cated the need for prompt and forceful leadership,ori hii part..statirih,is. ) intention to allow change to occur at a gradual. pace and;permiikis managers ~ to learn from their errors. l.ikewise,theVPrecognize'dthatThe.'is'viEwedas,.A ) a strong leader,'but stated his intention to perinit his.mana ets to: display 'b ' I leadership and develop reputations among the plint ;s'.t'iff..a's i eadef,sb.,,e .. m.... sccctgpsta.g The team found the VP to be a manager who demonstrated high, personal"and professional standards and demanded the same of.his subordinates. He3 as been; h a student of management and is recognized for the, advances.ma'de.]' .BG,EE's 3,im fossil operation while under his direction. The tea.r,'deternine smajor weakness to be a lack of nuclear orientation or a vision of how a well run, safety conscious nuclear plant is managed; he does not have the handiCori ~ 3 experience that would give' him an effective nuclear conscience.HThey1'e'am concluded that the VP (as well as two of the three managers)le 'p'r,notih' ave ' .l .does management of operations or recognize the warning signs 'f'declin'oac'tlVe sufficient time or experience in the nuclear environment.t'oNt mance that would likely be obvious to an experienced nuclear manager:jper,f o ini W r. s Of particular concern to the team was the VP's stated philosophy that as'VP be is a corporate officer with an office on site rather.than.an cn-site VP who interjects himself into daily operational, events:or.idirects,' proceeding slowly with the intention of institutiona,1,ir response to' situational events. The' team understood'the gjheimp . HdelivFr.g extent of the change necessary to return the plant"toe'x ellen;gla,sp the team continues to be concerned that the VP doe's,ndt..fdlly ' th'e ' ' c cera while his preferred pace,for that change'may be appropriate for a fossil plent, it is not adequate for.a. nuclear plant with the range and ' severity of deficiencies ide..nt. ified atCCNPP. l- ^ ,.... s.. ..i, ' n s t QR u w ', N, p.b' K. 3....w), I e.f y * ~. t s.., .M:... :v..n. m mnn d t es.: .n

.n ::.or w tu?r

<:.<k. ..-N.~., v.i n:n, .,.,.... - t (

c.. "'.

..>i, i M % & TU ;' ..:.u...w :.:n 1 .,~ a.,

<.~.. :.

...:....sn:,:::: sn: ." ::. o t m 9, bi h b y). I 'd ? '.' M..&nf 5. c . : *. q :,:. e t.,( 4 s f. 4 .... ~

• • • PREDECESI.ONAL... INTERNAL USE ONLY).***

.alJ ~

• • • PREDECISIONAL...!NTERNAL USE ONLY ***

r au -en :. ~ rl.. ?.b.. CALVERT CLIFFS SPECIAL TEiM INSPECTION. MANAGEMENT EFFECTIVENESS REVIEW a ! u ? b ats'it h a!,ke d M 1 1 t., W.* ek

• tM r. s-t

,x $ ( # p@. h,t W sct h i h.T a. Ud W t',tur 1.0. INTRODUCTION ,Mw Iauttsid3tvynns ' n*mtn - >t-oMm.a9tMN3 % 1.1. Objectin <r....,, From February 27 through March 31, 1989, ateamof12NRC'inspec'to'r'hindHf4.f contractors perfonned a special team inspection at the CalvbrtrCliffs#Nu'elet'r ab i Power Plant.1 The team consisted of two groups,' an'operatibn's4ndlWintena'n'ceM., t group that inspected in the areas of operations, maintencnce,%'d igYoupr va (0C),surveillancetesting,andcorrectiveaction,andasecon e ating management's effectiveness in safely operating the plantFL.THeMteWm's'W.** findings are detailed in Report No. 50-317/89-200 and 50-318/89:200.*m W tro 4 7 >- u.c.u um ente t pu s sts :p;m The objective of the management t'eam was to assess ma'nigamen't 'e'ffEctiverieYsm* f n planning, organizing.. staffing, directing, and contro111ng';the"opeYa'tidn's' N of the facility. The team empnasized in its evaluations theYiderit'ifititio'nfof 9' i management related root causes and contributing factors to recognized.funda ,l mental problems affecting safe reactor operation.

• i m $ 't+00lD00).mf 0'i

' u u ht>n owytot.tGMMmo 1.2 Manag'ement Team Composition He bic: bria gelteb zh.'n 'm nl xHubeMesnott:td 1 The management team members were selected specifically to provide sib'ala'nddp

• credible team representing diverse backgrounds. A former Nuclear'Vice-Presi ' '

dent offered a corporate manager's perspective that 'was rc'esipidnien't'ed/by the' extensive operating and training manager's' background':of ai s'econdtteam. member. A third member, s. recognized. expert in organization'al' desig'n' with nuclear corporate exposure : brought an acadsmic influence:to-tNe< group. The management teamsleader was a team leader from Reactor Special 4!nspectionso l Branch withlan heademic background'in management and.a broad'rangetof, experi-ence in plant' operations and NRC inspections. The management tdem Nas-I limited to four persons to facilitate team building,* productive cosaunica, l tions, and effective team management. $ tv. u.v;y w n.t l : Q, .2 :.n M p tifa m ir 1 1.3 Evaluation Method i L ( ...> h. .:,sion3dosrpHl' + Theteamdevelopedamanagementeffectiveness'modelandmeth6dedesi6ned:.to#ri (1) systematically review and evaluate the licensee's organizatio6alestrue'.wh ture and identify the attributes necessary to succeed in that structure,'(2) inventory and assess the management and leadership skills of tmanagers andr supervisors at all levels of the organization, and'(3)cobjectively: evaluate I the effectiveness of managers in applying tnose skills'withinttheibrganiza-tional framework. A detailed description of the management' effectiveness group's approach to the inspection is provided in Appendix B. p: .. er rs 2.0 DETA! LEO INSPECTION FINDINGS ' + ' .

• l'11 2.1 Organizational Structure N.3 i3 s.

2.1.1 Special Challenges of Matrix Organization ix-ni . : n.n 3 i on o w..! $97%g.s ;. p y 5 /

• • • PREDECESIONAL... INTERNAL USE ONLY ***

,,n..,. j. %.V'M M.jy.pgf L.Q %

• • • PREDECISIONAL... INTERNAL USE ONLY ***

1 I H i %. a,'t,y The team evaluated the licensee's'chusen orge'nf 24tional,4 structure sithout l addressing the question of whether the chosen structure is the.mostjepproprj. ate for the facility. Having no justification for stating thattth'eichosen: structure was more or less conducive to effective management activ,1,t.1,es1 thin 0[' " ' ' any other structural model, the team concentrated instead on ide'n'tification of attributes necessary for management effectiveness within the(chog' n@odel.. 3 design known to require a great deal of energy. and;unders',tandkorgali The Itcensee has chosen a complex, project management,3matr,ix j ng.a.t' a,1;1 levels. Unlike traditional, vertically aligned organizational desijns ;neov.3 which individuals have functional authority that is generally.comensu;r,1.nf.n,,,.;: t with the responsibilities that person must discharge,.in the Ticenseelsp.te y a matrixdesignthereisvirtuallynoonebelowthe-.heve.1of,*p,la'n'tmanagerdwh '6 i has the necessary authority to accomplish objectives.without,,hav,ingsto, q,.h.g1 j negotiate and share resources. Many persons who do not have the word " manager" in their job title have management responsibilities,:for,, comple, tion. of projects, creating a situation in which specialized project. management,ank,q leadership skills are prerequisites to success. ,, e .,9 i n, s +,, %fra mmy n . '.a. ?. The team concluded that licensee management and staff at,al.1/: levels,to,fethe m s organfration were not aware of the special challenges presented by s complex matrix design, and could not identify or address those attributes, required to,; function successfully in that design. Specifically, the organization'eur-rently lacks: .ugm 3 y 3p,qg.7, 7,g - A shared vision of clearly comunicated and,,p*nsistently,w,in;;,t& n i. .1 w.m t..,- co ee o demonstrated organizational goals and.objecti,ves, f.wm.ns y ., w,e o Shared information r. u n y tvit.y A An integrated, site-wide planning and schedulipg/ system.r,,c, ion,s. ' .l, i o A (emonstrated understanding of the interdependence of.funct o Middle management. effective at translating for the.workforce the o broadly stated policies and goals of management into meani,rigful, performarece expectations and work practices g,.,,. s.,. '.c a c g,g g,g f The Itcensee appeared to lack an understandinh thit, ibeNNbeiihn',# virtually every activity is a project, not just obvious pry' ject activ.ities r-like a major outage. Although the majority of each person s workTohtHbutes' to a project, the following attributes of successful project management,,.,we,re..g s found to be deficient. j., .. e 6., u,v o n g,,; 'ws ' t. 0ttnebt 6 n-The Project Management Manual for CCNPP.do:es no.tprovide3agreadk1y.1 l o I understood definition of functional responsibilities or, account,,,, ~,.y There is no apparen't,emphasif

?

abilities within the organization. e on ownership. 9 .,q n. y The facility's lack of a site-wide h1anning and seh'eduliniTystem'... o l impedes the distribution of shared infomation. Access.to comput, erized information is virtually nonexistent. While in a tradition-al vertical structure information is a commodity which maynbe.. selectively distributed to control people and processei'succes..sful l project management requires all par,ticipants. to be. informed and communicating. Conflict management is not recognized as a management skill, nor is o l i r l 6 a 7 . *** PREDECES.IONAL... INTER !AL USE ONLY *** Q , y,,1 f

i i ] '" PREDECISIONAL...!NTERNAL USE ONLY,*".,, 1 j ) it developed. Because conflict is inherent in the all_ocation cf. l s scarte resources, that conflict must be constructiyely p solvediby # l involved managers. , j.,. g s"' j 1 p decountabilihior proNet comp 1'etion YdiN$$hh*r o organization, and generally. is not clesrly.'definedifor hypa t,1h pants. m j,ggggg -w.n :. suwins e t An analytical, systems-oriented approach to gject mana t ds I o l generally considered unnecessary., .. M b h da' h M O The cultural fabors of trust' and resht aN, rk1 h o " l.",h:' m m uf,$ M {pnt.u.to.- ..e M McMur. tams dhMft"' s N' NNf - l 2.1.2 Organizational Dynamics The team concluded that in the practical sense ECNPPSahlikded N g tionallyintothreeseparate.operatingentities,each. functioning;)fati}onMg sore cr'q 3e less independently and divided horizontally by barriefs of c'aiimun philosophy, attitude, and class. These three, entities..are..(L)3thenth'r'ee. 9. 3 Managers of. Quality Assurance. Engineering tand 0perations'/ Main,tehenVif'(Plan t i Manager) each of whom report directly to the Vice, President 4(2)itW1v'e. t' ' General. Supervisors (GS)r and (3) the work force sonsi'stin of AssTs't'an entity, the Vice President, was too new to the job atThei oli$,h' p'ot General Supervisors (AGS), Supervisors, and workers..', tion to draw conclusions about potential barriers af,fectt'V;his' bhianha'tionW n divided vertically with, distinct comunications barriefs 'across,paniz'ation'i al relationship. Theteamalso.foundsomeevidence;that.tger lines. -These. vertical barriers appear less pronoun'ced than}th,e,,tle disconnects.. .s 3 cy gy,f.g,,. 1,. Profiles of the characteristics and skills of the site's execut1Mte*id a'$ d included in Appendix A to this report. .,.c 7.,99,9 l The tea'm's analysis of the role of the three manageM'(th,firYt indeYiEddit9 e t entity) indicated that if they were functioning effectively.they,#would,be' thih major architects of policy, would be a source of clearly.. understood'eypectan tions broadly stated in tems of organizational goals 'and, objectifel,'and,l would strategically plan.. organize, staff, dirwet, bur'ce c activities.3 More importantly,;they would be the s 7, light' that defined and demonstrated a safety-oriented ~op'erating' ph'ilosop l and provided leadership examples. The equal status 1of,all 'three on',,'the?" * /.' i site's.organizationchartimpliesequalresponsibilitiesland" author,itiesll,*'?, however, the licensee knows and the team confirviedjthat.the plant" clearly had more responsibility and authority than the Engineerin(manager'and,) 6 managers. ,,3,y g 3 ; The team concluded that the three managers seemed confused adlac$dNns'.' Rather than demonstrating an o>erating philosophy that emphasizes, safety.and' quality.. the managers are and 3 ave been a major source,of, mixed'messag'es that' corner-cutting and procedura1 noncompliance amongsthe work demonstrate a production bias, an emphasis that has been the.bajor in s 1 4 .i,. 7. ,; J ~. L

• • • PREDECESIONAL..!NTERNAL USE ONLY ***

,[ 3

• • • PREDECl$10NAL...!NTERNAL USE ONLY ***

+ t I not generally recognized bf their subordinates for:their leadership 7 skills, and are generally lacking in their understanding of how;toirecogniterand I manage change. As a group, the degree of teamwork implied byttheirrsqual j status on.the organization chart is not present, and they appear to-lack a shared vision of'how to proceed from their present situation.to"a: point farther down the road to excellence. They" appear'relatively:naivetabout the regulatory relationship, and suffer from inbreeding and isolationsthat has left them without a perspective on what a first-class nuclear operatien C. w en r" ? 's . x,, a. b...'. really looks like in 1989.

n n:\\

Effectively separated from the managers abcve them!and'the'worktforce below, the GS group would ideally function as a translator of the

• guiding light" into perfomance expectations. The team concluded, however, that:the+GS level of management suffered from undeveloped leadership skills and a poor under-ttanding of the managerial skills peculiar to the matrix structure, and as' j

.such tended to filter the guiding light rather than focus it.. W u. r.tW S. F. s The work force below the G5 level would,, in the organizational hierarchy, be j lef t to do the 'real' work required to keep the plant operating':usir.g'then afi tools and resources made available to them from management. ThF team con J O cluded that they do surprisingly well considering how'little of'th'etguiding'esi light actually shines through.. To paraphrase several persons @ orker:1"wish

• they (management) would just tell us,what they want'v. Faced withiantoperatd ing philosophy that tells them to' de whatever is necessarylto.k'eepithe plantuM operating and little guidance in the fem of prioritiration and: planning',eth&,

work force has long operated from 14 posture of'not pemittingiprocedures',4 4 quality control, regulations, technical requirements,7 or-aeninist'rative. ; r?.w controls to impede their support of production. The' workers 2 have)kept> th'e nob plant running in spite of inadequate and uncontrolled)procedurah%fdahceWan** anemic quality control oriaMzation,'ahd limited retourc6s iintthelfom'ofdvPb - ~ manpower, qualified parts, or technical infomation.m Much o'fethe (succ~ess icarf.T: be attributed to the apparent high skill levels, strong work ethic,randepride'h; t .b" in the station. .'.G > h "' t: m ar.1: %.n m m q y# The organizational relationship of the Vice Presidenti' Georjie4Cmeil Ntostheinh. G'.- site managers, and his perception of his role and responsib 11tiestin return Wx;,.. ing CCNPP to an excellent perfomeri 1s of particular ton'cernitoltheWeast.s47W^ ~

N When questioned, Mr. Creel stated that his organizatiorial'rrelitionship'iisiin%

line with the traditional 86&E role of the VP as a corporate;officebwho Me represents corporate management 'and has an office on' site,c HeVdoes'inotd v.d ' i perceive himself as the senior manager on site,"noridoes he'.fsiel'Ntfappropf-w ate to interject'himself into operational decisions'ortsitue'tional/eventsr4x He stated his intention to pursue a hands-off style *of managemeittthat'? #$NM" allowed his managers the freedom to make mistakes'.and'1 earn framithosemq br.r/ He down plays the perception held by many atttheisitetthat herwill:: mistakes. be a take-charge professional manager who will be fim but'fairlandeleadethed plant back to its former respected place in the. industry, notingathatcitrist x the three managers who must come to be perceived as leaders. The team..is p. concerned that while the VP may have a sense of mission he does not: appear to grasp the extent of the change that will be requireduto'returneCCNPPitoran 4 excellent performer. 'The team is ' concerned that;while'the;YP'rpreferredg S evolutionary, pace for proposed change may be appropriate for,,a?fosstl facil19 ty it is not adequate for 's nuclear plant with~ thesrange'andiseverityroftnmA 4 ' 3 T f ; cs..w w c.: TN' deficiencies identified at tCNPP. ~ g 8 a

• • • PREDE'CESIONAL.'.. INTERNAL USE ONLYL*** r n

. M.s. J r* . ;c :..y v, . t,

_~ - - i

• PREDECl$10NAL...!NTERNAL USE ONLY.0** s v.

J 3 i The team is concerned that the hands-off, approach,to,managementbwhichg'h'r,., appears to have its roots in BG & E management' culture..* extends' t6fthe'id(nt t ee i managers as well. The site. functions as though. he,' jas 'BGJ s VP c th'fi r'. I if a;'in,'s, p6nTi.*;V for. nuclear power and each;,0f the,three Eanage,,va's 'i 1 a re a.~ With the entire executive team taking a ands pp th

• i bility for. traditional unagement functions is being pushed 9667.

organtzational structure.by default. pg 2.1.3 Culthal Considerafions Within the Orga'nirat'io((., During'iiterviews CCNPP personnel regularly pointed.'td,40uf,M i N rE N h '

• i explanation ~of why certain attitudes and practices prev' ailed,' ' hd,' regular 1l a

offered it as'en excuse for slipped performance. Few among'the'manageinenyor staff were.able to definal. culture, but most were able to.deset16e1ultur characteristics of the' organization,which impacted 'directlylon,,the"W j' business is. conducted'at.'the plant. 'To aid in.its!aYsessment,of',t iimpact.3f. l s the' following working definition to the term culture:" Values'a{assignend' ide l of culture on operating philosophy 'and practice', the'tesm on strated by management's operating philosophy that drive how work,is, planned.. s prioritized, organized, completed and evaluated." ],}.p ]( g ' {,,*,.Q.,,

• J Beyond being'lture affects perfonnance, which cultura11ylbased grasp how cu pWeating

\\' philosophies are current 1 in place in the plant, or..how mana ement can., a- 'I - 1 change prevailing culturaf trends throughout the facility.7' T I licensee's simplistic approach to change management,', attempts to#re'defins' Plant's operating philosophy to one that emphasizes safety and.q'u'ality','ahyad "' l of production (and in the process redefine the cultural environment)'are:*"' # largelylimitedtoputtingupp.osters'underthethemeMCha11enge;'8g,*P'Wh'ile" l the posters do portray an. operating philosophy which assigns a high' priority NV tosafetyand. quality,theplantworkersremain'skepticalaboutmanagement's,l. l l sincerity based on the worker's past experience with' management's actionsnot l being contistent with the philosophy being promoted.. ;' } ] Management does not appear to grasp the need for demonstrating.a new' phi.los'o

• phy rather than merely describing it, and continues to send conflicting messages to the work force. For example,' workers thought it ~ con's'e'rvative 'to"[

shut the plant down on March 8 for feedwater regulating valve"repa'ir and test,butthetraditionalproductionbiaswasreinforcedwhen"6nMa'r'ch:g$ 1 management elected to start the plant up with an unisolable pinhole" leak in 'a4, i Having missed an' opportunity,ts?dem6'n'stFate' ~' steam generator blowdown line. to plant staff and the NRC their new, safety oriented'op'erating? philosophy ( i managers also succumbed to comunication disconnects"and a detachedFhands'- off management approach and did not describe to the work force their? ration " ale for ordering startup. ,..,,,,,,,g,, 3,,. The team found the prevailing cultural values and ide..als to include:p w 4e Mg r a "get it done' attitude that supports product 16n30'.WdetNNenFof 3 l o l procedural. adherence:or appropriate administrative ~controlsWs' A'% +

o. m uti M

.w.3 a message that says " don't spend too much to geRit"doh the5 o tendency to cut corner,s N' ^ ; n^'* m *.* h,m: d l m, N 1 l 9 _ L _. _ *** PREDECESIONAL... INTERNAL USE_0NLYd** g q,_______ u ~~

• • • PREDEC15!0NAL...!NTERNAL USE ONLY
• a message that says ' don't cause troub?t b' questic'n'ing'"m'a gNt
• Ii' o

your career will suffer". Beinga"teampayer"meansjiing man", and even the plant manager was able' reco ~ inst neei"W unc'oo r'a'tive d Ed ' i d'l}*g'{lj where individuals were roassigned because they were not team players. -l In addition to these prevailing values, the team.identifieFoNiakpMNsM l was filtering through. The control room staff..for exa groups in an environment in which very little of management'sfgilidin light-operating philosophy in which licensed operators assumed 'pers'onal]' spons pd'" j bility for plant safety without regard for the prevailing lphilds'op bein k. ' promoted by management. Sufficient unto themselves and accu's't'ouied o'ha9lig'N tobalancetheirperception.cfplantsafetyagainstthe[produtti6n emintis'; and resource constraints' imposed on them, operators _,.came,t'o*think" f;thim ment,. maintenance QC, systems, design, and fuels enginee selves as being successful:in spite of, rather than7becausekQ4i nt'.mniage i ,r e.... Peanwhile, in response to the production emphasis. int'nt$r@Ni5nhe1Y 7, responded to austerity programs by doing more with~ less and, in'th'eir'percep-tien, were so successful in doing so that any administrative.. technical, or quality control that impeded their effectiveness was viewed with ' disdain.. ,. o., In the Quality Control organization, no operating "bilosophy"e'xMs'.Yo'r* * practical purposes. QC until recently was never ta en' seriously land.,hWd nh', defined mission. Written instructions for contiollini QC activities he'r'e.J. absent, inspectors heve been and continue to be' con'sidered by.the' work' force. i

• second set of to be technically incompetent, and the whole ccncept'of a,f

$ }','y {']; eyes" is considered an insult t,o craf tspersons. In the engineeffn'g organization no cohesive opera' ting' philosNhy?cInu'1d b'e " f identified because that four distinct engineering groups #on site '(system,' % project, design, and fuels engineers) function as separate entities. Cultir' ", al considerations which impact the engineer's effectiver.ess include a lack of.. respect among operators for the technical skills of many of the relative 1y' Y' young and inexperienced system engineers, an opinion which is 'inip' roving-over:'M time, and the lack of respect for fuels engineers..an opinion %hich'is not k improving over time. Design engineering continues to be considered a ?blac hole' by those in need of its services; this negative perception persHts int ' spite of substantial prvgress by the Design Engineering GS in the categoriza-tion, prioritiration, and control of his work. In *short, 'consnunications barriers within the engineering department and between the engineers and their customers impede the effectiveness of the group. 2.1.4 Procedure Problems In light of the significant operating events in which inadequat'e" procedures' and procedural noncompliance has been a root or contributing cause the team was particularly concerned about the low regard all'. groups he'1d for:,p'roce-7 dures. Problems associated with procedure misuse,' Controls"and $iilii!y' pose a serious threat to operational safety at CCMPP. s'he following quotes T i gleaned from management and plant staff interview efferfinsijht*intorthe cultural aspects underlying, the plant's disdain foi proc'edures?f"m l 10 4

• • • pornrcrdf*AL... INTERNAL USE ONLY%#"

• • • PREDECISIONAL...!NTERNAL USE ONLY
• j

( o "We considered procedures to be guidelines and not hard ano fast rules " "We ~had a' htitory'e'f'taking' liberties with'proce'dures;,Tt%aDa o.

n.q,.coussm se

.~%. ctilt*uYa1 o m m "- ' 'M

• V

• s.N mf @gg 9tQ-f(l80W -,

problem.'" -2" M ' 'd v' t,. -! :.. at t.i 8,% i;,, 3 j,5* b M iq "Our' p'rocedures here'not'very' good and ih order ib TetPth'e*2jo W To'n i t 4.. ^ o had to ignore procedure steps; this led to a complacent attitude /t'odrd procedure adherence.".m .:. n.m.m francitom &. o ~ "We didn't always thirik we 'needed proc'edures;'sbme ofdsM6ughY$ 'e7 f t interfeted with our workers thinking things out."4 "'M '" M*h o > fi ~ ;, VW 'd up's ti.#5 I C without procedures because we had a highly skille'd staff. esfncelf'ien i "We were able to run the' plant safely and effectivily'in" theta'r o 'tt " ' " ' 03 N *^"d l our skill. level has been diluted."

• We took pride in doing the job with the resou'rces'avii;1 stile
• arid dofnj 0

o it on schedule. Schedules were more important"than'qualitf.'* e 883'. i i w c:n. m n y n e nn i The team noted that the plant staff tended to speak of procedure problems in the past tense, as illustratt'd by the quotes' abo'e. Iri ' fact',rthUffifw'aF 0 v unable to 1dentify any receht's1gnif1 cant improvement'inVro'cidiirdf(ddlitf for i compliance,#even after managementdissued edicts that)~ pro'cedu'reMille tie' tun; ] followed without' exceptions Forliiamples on Ma'rch 20 aSc'ontro170dFdpefstor in the process of returning an Emergency Safety Features Safety' Actuation ~ ' i through the pro.to service skipped..two steps 'in the procedvM?b'adktr System cabinet' D ~ cedure to reinitiate the seqdencel and initiated'fdepar'tialk i i safety injection system actuation., Management's approach to the procedure i problem so;farrhas consisted 'of orders to comply with sprocedurestknoirnite be v riddled with: deficiencies and a'hastil) conceived Procedbre.UpgradetAttion' Plan (PUAP)twhich-has nohe'en'well' implemented. :This approach:wasteorisid-ered by the' team'to be a representitive case study of management'secoverlys simplistic " quick,fix" view of how to effect change in the organization land their unrealistic perceptiori of.ths extent.of the probleWind'itgepotehtial 9 for reducing

• safety. The problem is exacerbated.by'the lackPof twnderstanding among plant staff and management of shot a cus11tytprocedure"100ksflikePhow it is modified in a manner to preserve its safety /tatogrityphowtit4sem administrative 1y controlled, and how thoroughly it must be performed.-

.. ' n..m p n e r e tr3 o + 9' amp a 2.2 Managemeht Processes m m w wi m h 2.2.1 Organizational Climate . f.N... > u t.,y gy s a. The team identified characteristics which are representative of the climate in which work is performed throughout the plant.- . m w 3 6 m. a FM .v. m1 0 1.rd l .s Dnployees appear secure in their employment with this paternalistic, sent r' l 0 passive organization, BG & C is nonunionized throughout',-and manages is proactive in keeping' employees too content:to 'considw turningato ' organized. labor. W T- ':.0 ' o a m, en .., ni n t. a o With the production orientation pervasive through'ou't'/ ' teamwork'.*is'We perceived as doing whatever is necessary to support operationsYrether than working together'toward'a shared objectivet ; mmoN v# tow u- .m ra# a% krantur n,. e l 11 W.:

• • • PREDECES!0NAL...!NTERNAL'USE ONLY ***

c,.. .a,- W.' Lp.. 3 a,_. m . s,....

000 PREDECISIONAL...!NTERNAL USE ONLY *** I The organization apse [rs to'hhe no oNariltai10nN." vim $n ofh nt or o future. As such, tie facility is managed in 4. reactive rathe than,a i. g proactive mode. Presently, the reactive management resp 6n's'e; being' f placed on the problem plant list has resulted in emotional. con usion k.? i ^ throughout the organiration, as candidly.and,, forceful,y exp,ig,ss,ed;1,n p S % 1 interviews. ,.g. y p on g y - TheemotionalreactiontobeingplacedontheprobO@anI[11Yh'as o perceived as a good operator.lef t many yearning to go backwards.to.the 1 CC m-Many deny perfoma'nce,h'a 1 speds others blame regulators, but the majority appear t6 have acceptEd)tiat.thVir" perforinance was not as good as they had thought. They.can,igotjelcar.lyy identify how, when,'or wh ly should do to improve. y. perforinance declined,,or,yt:4,t]th,eyfindi,vj,dua,1- .g :,,,ag g; r,4pf.gi., / The work force demonstrates a willingness to do whatever,feedsfdoirignto o t return to excellence.. but can not identiff the ;mariagementjl,e'aderjship;;, necessary to constructively channel that energy. ' rat m on n 4,: Nonde reed members of the work force are frustrated by tlitir per,ceptk.;.3 e H ~.... o on nities for earning degrees. lateral assignments..and advanceme of a imited career. path. The team found some indicationythat. t are,;;qru available but are not ft:11y accepted as. options by the, wor,ker).':M,4',yg t g ~ ......, e,. m.., n - There is an undercurrent of a military ca'ste sy' stem. lwith a disc J o 3 offiter/enli*,ted relationship scattered,throughout. theforganii:atio,'ny,,, There is no sense N., urgency However., for prob ens affecti(ng" p o once identified. such as,a. Technical Specificattori" action statenienti;thsrhesiit's un of purpos~e and spirit of cooperation that borders:on & combiymen} g , i,ty,.,*s j l The fatality in 19'88 wNs and continues to'be Msh$1ft tktkoh h o event at all 16vels of the work force..Unlike,l,the,other 'opeFatichfl 3 events that cencerned regulators, the fatality.was theiing%eVen'tI 3 forced many workers to grudgingly admit that problems.3inaf eitis,t.',7Q,'.if, t...., 7..... t.,, There is a general lack of understanding of how'to deal With r......,,.egulators', ' s o an apparent lack of sophistication indicative of the. extent to which,,the, plant has been, isolated from the mainstream of, the industry." ' i sd :.. ',, w ls n num

,s,*

2.2.2 Lack of State-of-the-Art Management Processes Many state of the art managerial and administratNe' t6o'1 and Eon't'r d S rY ].' found to be conspicuously absent at CCNPP. ~ identified and ev'ery copy. is considered a co[ Control copies,,a. m re notl., Procedure control-is virtually nonexistent. o ntro11e'd copydal.th, sod

,no mechanism exists for ensuring tiee current a pproved revision is';1ln se.

Copies in use in the field or staged at wortstations are"ndt siwa 'N complete or explicitly 1dentified as being, controlled.,,,g g g .,n....... y. maintenance department? Once a procedural deficiency has 'be,en,1y Temporary procedure change is a cumbersome process,fparticular in .o 4 ~ - [-; 12

J

• PREDECISIONAL...!NTERNAL USE ONLY ***

) identified, it regularly takes months to correct;.a?delaylwhichN dmpli E - ) cates workers attempts at verbatim compliance. 2 In'the case'ofesome u v '. monthly surveillances, for instance, a technician who identified a ' procedural deficiency in the first month would obtain4pprovalqf6rtaP. 0; 1 one-time change to creplete that perfdmance.mWhen1the" procedure 6s,9. used in the second month the defect would still be'in'the proceduf eUbut not flagged in any way. If;the technician identified the defectanother one time change could be processed, but not s' pemanen't change'.dnThis cycle appears Ostined to continue with no end.in' sight.'3Before the' emphasis was placed on verbatim compliance these defects 1wnre11ghored or bypassed, but the new emphasis on cor@liance has1 created aWeber,before identified need for a~ mechanism to promptly and pemane'ntly? correct" 4 procedural deficiencies. w a um.m v. e. o The procurement of safety grade spare parts' hav,ings theTapliro~p'r'ia'te 7'- documentation from the vendor or certification resulting:fror0'aniengi-neering evaluation complicates the efforts of technicians. There is no effective procurement engineering function and support froln eng'in'eeringi S. t is often too little and too late. For example, after a fire occurred In a switch in the' Unit 2 control panel, repairs;were' delayed'b'ecaus'eTpartsM were not available so that to start up on sched'le:wouldfhaveHreutred rd, u q the use of the switch from the shutdown Unit 1' p'a~n'e1.h0neneidayiof thE3 l inspection there were no documented safety l grade"fus'esnin'tsto'ckiandsthe':n failure of any installed fuse would have~ meant 'tha't' compon' ntecould;'n(t'b, e i l be repaired. u

• m, bar.vern.Wt;r.,.

r.). M. n o't o n.i u w.; % 3 o There exists no administrative mechanism to handle minor inodification's'.T.0 The smallest change receives a full engineering evaluation and formal 10 CFR 50.5g processing, resulting.in extensive delays 'to raccdaplisheminor.5T modifications. This1dministrative hurdle is'. thought;to'fc'ontribute rto:ad tendency rsadily acknowledged throughout the workt force toamodify:the snsb l plant without processing the change as a modificatiori. 6Severali. workers 6c offered enmples of how they' had added loads to' busse's '6r: modified.+. h pipingsystemsorcompenentswithoutobtaining'antengineerinpevaluationb or approval, and without documenting the alterationtin manua,s; tor.w.indy drawings. The team concluded, based on infomatio'n'providedsbyl plant.y staff during interviews, that the actual plant cdnfigura' tion.fmafenow:be:t. indeterminate. Because a verification of plantfe'onfigurationtorgiirimasy assessment of the extent to which it may have beentmodifiedtwithoutff r';' L approval or documentation was outside thesscoperoftthetspecia.1 steam h,tn I ' inspection, the team recommends future regionibas'edsoriNRReinspectionfIw i ' activity in this area." d & ntovt m3r w (At h e i , Ytr-c, The absence of computerized, networked data bases was conspicuous. One innovative G5 was developing an infoni.ation bcse"and.had. ordered wnrk.r.,: stations. He anticipated carrying the data disk from one workstation to C ' 'T f k V ic. W the~next. L pi Mnm o Vendor man'ual control essent'1411y doesn't existiat CChPPha. finding ii: 4 4 l which has' become rare in plants inspected byrRSIBM tm.Jef.d2N t'W m.,. :L, r . p., t, Attisto W y.!dm t'f@9 Prcksdures'us' d to' implement or perform maintena'nc'eioks'urvWil.lancesNare: o e representative of these found"in plants'a'decaderor.2more.igo.*d,Cautionsq are few, acceptance cri.terth 'and the uss of QC holdipointPandrsignef.fsn i a. -l ,, _2 g

..V i.

..ew ,'.e ... i '?,A, +. 9 g( 'h

• • • PREDECISIONAL...!NTERNAL USE ONLY ***

q.. is rare, and there.is no mechanism to incorporate;the.,as-foundscondi. ] tions or repairs,into machinery history.or, trending! Programs.u h.

• (v msnm '

Maintenance procedures are not. sufficient 1ysdet'ai,1e'ety, Hued totensure qua,1 L ....r. o t Por example, a procedure.tosinspect and: replace 2as necessary,4 ejinjec-

tors on the emergency diesel generator, simplyr

referred the technic.ian'to 3

a technical manual,which..is.four inches thick and,.uncon.tro edytT,hei ' technician is free.to 1 adhere.to any portioniof the/nanuale one at. d all. The team briefly examined two new maintenance. proc'eduresfpr' epa'r)ed / by contractors which appeared to contain; state of-the:ar,th ni,tructi,6nal l i i procedures and the. hundreds of procedures in,use:at.CChPPa{the text, visual aids,;and requirements. The contrast.5 etween, l b wast str,1, king. l i The programmatic controls normally asscciated with 12 of the..u!wm

M is l '

u-18 criteria o of 10 CFR 50, Appendix B, was absent, illustrating the'extentsto which n the. plant has remained isolated from industry advances.,;. ump'.., i na. ml.h H,n ynhen i 2.2.3 Leadership .w n.t.m3.u g.my i i k~s.w t c,.: Demonstrated effective leadership is considered by.the team,to be a. crucial i i ingredient.in the licensee's efforts to return to. excellence.,gleadership, t skills must.be distributed throughout the organization intthe.matr1x3struc-s I ture, where functional authority is dispersed and people,must rely,gon ability to negotiate, their ability to effectively, communicate,1 dea.s,.,xtheir t and n., 3 expectations, and on their interpersonal skills. Dynamic leader; ship i the executive team members is particularly important if the needed'ck.amongang'es at CCNPP are going to proceed at an urgent, rather than.an evolutionary.s pace, y, i a interviews with plant' staff ati,'all levefs,it Throughout hundreds of hours of,few rec 6gnized leaders at'CCNPP.',.V1'c'e,,Presi u ( became apparent that there are dent George Creel is almost universally recognizedsand respected as.acleader,. i and the plant staff is looking to him for leadership and. direction.. 0utside of Mr. Creel and Richard Heibel, the former operations GS and.'nos GS.~forTQA, only isolated examples of effective leaders were offered., Likewise, the' I plant employees were rarely able to name anyone the'y respected forhtheir., supervisory skills, although tradesmen occasionally indicated.they; respected the technical skills of individual first-line supervisors. Mr.aHeibel generally respected for his decisiveness and for.being-a rar,ejr,is_k,tak,was .r er" in t his willingness to question management.. The.militarysleadershiptstyle.of Naval Acadenty graduates who comprise 50 percent of;the;.GS. ranks has..notabeen c well received by the work force. The executive team profiles in Appendix A c offer a perspective on the leadership characteristics of the.,four keyimsnag-y ers.

% wnu n. c' 2.2.4 Staffing and Personnel Qualifications,

4 .e 3,3 %, %. Since going on line in 1g77 with a staff of less thak 100,TCNPPM$iehdily increased in staffing to beyond 1000. Corporate management has indidated a willingness to fund additional positions in response.to,beingsp, laced,on,the e NRC's watch list, and mid-level managers in maintenance,and QC<a'resnow.ia. eagerly searching for qualified persons. Theteamconclude$tha' tith'el'p nt staff is sufficiently large to safely operate the,;facil,ityn,f management i provided the existing staff.with the appropriate systems.,procesWs',pa'nd: 3 e controls to effectively plan, prioritire, and perform. work.y.gQ y;;' ~ 14

• • • PREDECESIONAL... INTERNAL USE.;0NLY,.*,** u, 7

t

• • • PREDECISIONAL...!NTERNAL USE ONLY,*y

{ lover; N Q M 1. $

• The ability of the work force to operate and maintain.the,facil efe'ceYt several ~ productive and relatively event; free' years.cff n

some the technicalfcompetence tf the: p1' nt staff..isf.edequat

T

^ ocu, sed) q J.f.:/' a t members and the 12 General Supervisors."'As' indicate'd'liits cencerns more on th ,i 1V Wam .' Wff16T. e,hFee "; - 4 .%t -c.: 3 of the four executive team members have very limited exposureito,quelearJ '^[y plant operation and show evidence fof not' having'

• nuclear l're,11'gion.dri'd' fdi,1 Manager since.1988, Leon Russell,has, supervised appreciation.for the machine.' 'The fourth executive l i

ations;,f of 'the**1 y I ,e $same',g,ro,( of individuals for a decade,; corps.has consisted of. essen'tial 13 years.. Likewise, the.GS. 1 although,several of them;ha' 'e d,;iss,t.gn ments. A detailed review of,the, history of,l job ~ assignments;/'.ex v fot' ' Plint' j-Manager.and'all of the members of.the GS gro i p team to conclude that essentially the'same:individualsTave';occupidiThey.3 convinced 'that the same grou,of. declining performanceiherw,team positions during the period The" p the decline.cf CCNPP and who havs a limited 'pe, General.,,$ p of, managers and tics of a quality nuclear' operation has the insights'or,Lon',the;ch rspective manaierf alikillsi. i necessary to effect the degree of change necessary to reverse the declining trend lon in evidence at the plant. Of particular concern.,to h te the inabi ity of most middle managers to, articulate management ph ios'am is l'.',' op6yr' seebeyondsymptomstodefinetheproblems.besettinfethe; plant.)r consnuni .f.. cate how they personally intend'to improve their ef ctiveness',in n the plant's difficulties..The teani does not advocate,the ' wholesale"replie-c i l ment of. managers and general supervisors; however, it would;,aheay,aliproprid" ' and.P l ate for the licensee to seek opporturvities to inject;competentimanabers'IdintP; advisors who were familiarTwith current industry'standa~rdstof'eReellenc L i"q, ; ' O,?f ',1 the fiber of. the organization'. ~ a 2.2.5 Training and Development' [.I 'l.'; ' [,[.g, l}, " ~ ~ ' I ,g, The team det'e'r$1ned that formal training in ma$gement" skills.jn Few1ra M appointed supervisors is not provided, nor have'seniorfmana'iers%uh'+eli1Mdk. z i to attend classes for the, strengthening of their ma' agerial,:sk111stl',lThe s n of emphasis on training in managerial and leadership' skills supp' orts;thef-Q' team's conclusion that the licensee does not recognize " managementas'an ** academic discipline apart from engineering, with a separate set of skills to be learned. g t 2.3 Management Application and Practice g g. 2.3.1 Change Managesent [ ' fl ,] @$ As a separate issue from the isolationism that has kept. management i'g'n'o'rarIt' of changes in nuclear industry, an underlying ' contributor to many problems affecting CCNPP ts the demonstrated inability of management to effectively manage change occurring within or imposed upon the organitation.J"Their past approach to change management has been reactive and overly simplistic.f. i proceeding directly from identification of a problem to implement 4 tion of *a solution with a lack of appreciation for the' intermediate steps'asY6ciated 4 > l with the process. The problem has been exacerbated by the,1.icens s tenden, a cy to limit,the proposed s'olution to simply adding 'the"p'drrect tidrig,'*W roblem' ive change.stritej(. i'.n %y h t'o'c tha

s list of things.to work,o'n,' 'resulting ignores,.the development lof$. o,mprehens,in an approac N

fa / ne e r. h sk e,- v.., w. ,,m % ; ; ~. p.. W.,...o

• ~

4 $ h. h,h,? h N 'b t 15 s. W l '. M h W/, L

• • • PREDECESIONAL... ! NTERNAL USE, ONLL*JpMi.; 84,.y ggg.pg

?,, . w.r

c'* PREDECISIONAL...!NTERNAL USE ONLY ***~ l lt generation.of uncoordinated, unprioritized 11sts of, actio'N:ite'asi.kAy$ cts' #.:: change management generally absent.from,the process the',' team' observedlinclu 9.. s ' owner,shfp"f6tWesG1t's' ed comprehensive issue identification, ' assignment' of.ick,[and'f,o"l'1/ [. - - [ resource comitments, implementation planning, feedb Successful change management is an organized procis's by whicM6 }tgg b l organtrations are effected with little disruption to,perso 'ordt t Examples of unsuccessful. change ~manajenint t*CC organization's mission. include (1) the way in which QC activities were absorbed by' mainteN d dsisf'., E i the peer evaluation concept and then transferrediout' U h,..W a series of transitions that contributed.to a weak,'u,to'. he'Q y n's'truebredppoVr&Wsn i and subsequent development of the System En 4 E uost,17 oung,, inexperiencedengineerslackingfamiliaritywithilan'tisystems r bil.i I./ k,. ty among the plant staff...Both of these.in,itiative's7suffe'rnd ~ h I' W(uit b(.y J alii planning, a simp.1,isticlview of the change' process,'andal fail the impact the change'would have 'on the facilityf.and..the,"indi 'Is [M-y^ >. l ~ ~ " ' volved. y n M :uo % s$ p t,".r. M n One other example of an unsuccessful attempt at charde[mah0$AM may%'"'"eM potential safety significance. In interviews' the former~ operations G described the simplistic approach taken to implement;the sympt'omYbble'S'd3 ] r change,. the GS failed to consider the cultural' aspects:.o(und,Pe Emergency Operating Procedures (EOPs) in 1985. Facing gren't. oing',' e'ers of y cperating under event-driven emergenc.v response procedures, lAlthough: opera,i. tors helped develop the E0Ps they were not pre-sold on,the. c,o. acknowledged portraying the new E0Ps as a ' guide",~ thereby','dimini,shin ncept'.J The net effect was poor perforwance in' the simulator.'and o,the g. J pera ~ T importance. tor's reluctance to accept the procedures which continued..according,,to the,,., r GS, well into 1988. The t'eim is concefned, on the' basis *'of'tha'th nterview W

• symptom-basedconceptmaynotactuallybeacceptedin that operator performance of E0Ps may actually still be weak and that team referred the concern to Region I management during the:

period. The integrated team irjspection schedule' indicates an E0Pfinspect' ion y,, is scheduled for May 15, 1989. Q,' ~

y. C',l'"y'., 3 r m.a.d. h:.,,

DU ' ' 2.3.2 Performance Management The licensee currently relies heavily on management-by objeYt'iv'e'(MBO)'"a f k L process that is more difficult to effectively implement in the matrix organ-1:ation than in the traditional structure because of the 'di'ffusion of'ac, - countabiMty and ownership of projects throughout the organization. Managers have diff kult" objectively measuring a subordinate's success when that ' subordinate seldom has the authority needed tp satisfy the objective ' Fo r, - .the concept that all site activities are projects, no matter:how sm,a;to" ac MBO to be more effective in this organization management would,have + ll; and' ' establish objectives that evaluated an individual's, contribution, to projects {. lY which the individual leads or supports. g Indicative of the limited effectiveness of MB0 as rfow applied is'th'e coNsis ' tent theme heard in nearly all interviews with individuals','from'thrp'ughout' ,s. the organization that management essentially leaves workersfto'their;own ' M '

• 6 devices to channel their own' energy, to plan and prioritire theiFoin'workN 4

e' 36 1], ] "i

• • • PREDECESIONAL...!NTERNALUSE 0NLY***[

M n

• • • PP.EDEC1510RAL...!NTERNAL USE DNLY ***

  s

. w:ra:: m i and to make personal interpretations of how each can make a contribution.- The work force gave a clear message.to the.. team.that; managements.ist. net 4Nf

g.. c l '.. i l

4 effective at conveying clearly defined perfonnance expectationst.Walib6\\. MDE'g

s t wpas.m.eid #S m

t.' n.u m n.nl 2til2u:! 2.3.3 Management's Demonstrated Emphasis.. en io.In a 21,1 fit,,. ~. / It is clear th'at management holds and continues to demonstrate'a'n>operatNo o philosophy that emphasizes production over quality and safety.1 Management, ..i however, conveys through their actions several other important messagestto the work force. 7.. i-

, ze.ef W'

,3 n Phota o Although it sponsors regular self-assessments, management's poor'. record en followup to correct identified deficiencies leaves the work force-coubting management's sincerity. c.w:m ,. m :..F,o m. The team reviewed the licensee sponsored SSFI, the Duke Engineering. Assessment, the 1987 CSART report, and several, internal:.studiesvarid QA C4 audits, and generally found them to be comprehensive. The QA audits in particular were of high quality, reflecting depth of tinvestiga'tionland a0 willingness to. raise tough questions. Plant staff was : frustrated!withW t - i the lack of management aggressiveness to correct deficienciesJgrowingr n l out of the SSFI, particularly one finding related.to checkMya'1veItesting^;- in the auxiliary feedwater system, which remain'unresolvedts'incer'earlyrm 10S8. m v. w s pf w ot p h.t.E: - r A . :.: n m 9 hb:dur. b NU The team noted that in.the case of the. Duke. assessments:the repo~rth re.n contained 28 findings, 27 of which were provided!totthe: Duke evaluation W team by CCNPP as self identified deficiencies. The! twenty-eighth: item. w l was identified by the' Duke' team'ahd rejected f6r action by CCNPP. To date the correctiverastions for the 27.have not,beenrachighsprioritytf 80 and demonstrates the licensee misconception that* adding a+ problem >to arf 4 list constitutes a corrective action. ". 9n s.c bm :ew.0 G m M m ni bem In the case of the 0SART, the findings associated withsmaintenance were'n found to have their roots in the edministrative control; processes rathere than the quality of the maintenance work itself. The licensee. expects e to address many of the administrative control issues with the new Nuclear Information Planning and Support-(NIPS); project;.;Tondates.thereu have been no other significant licensee efforts to aodress the 0SART comentsb a a c ...:.. Sw e wolvas a trH . vt m tg.r. u. n y y): & w.; c Management.' demonstrated their' lack of comitment to2QC when;theyiabe ne o sorbed QC into the. maintenance separtment under.thespeer evaluationup:w 0 concept and then assigned inspectors responsibility for the successful completion of the job, an assignment that shouldirest with thes.f.irst I,l..t line supervisor. Personnel policies which create a climate where af 4., qualified tradesman's transfer to QC is regarded as;ailoss?offstatusiandT. ' pay also diminishes the importance of the QC organizationgsnm tc y,b. :, o a MN palf ftnirm bna.- M,- By.considering the hours during which managers tour. in;..theaplant,andgthe. o activities? that managers: respond to and emphasize.ingtheit tours,ythe in work force holds'a perception,that managers are more, concerned withnthe. w 4 3 ' superficial.appearancetand cleanliness of the plant 8(particular,1ydin;thea ....p aq.4 xf.: :g4. unn.m.ry 4,y a a +a .vww , n m.. +, z.,. a ^ 17 ?

• • • PREDECESIONAL.. INTERNAL USE ONLY ***nf g g Ql$ g% '

.a .u... q i g ns m 1.. L .u.x - = +

• • • PREDECISIONAL...!NTERNAL USE ONLY ***

?

..x . ~..a.o ;w n..:ulatw.mersim of)nk. 4 well. traveled areas)'than.with the:actualaneterial.conditiont.of4theids4t4 facility. One tradesman recounted how:.thhonly:commentehelfver$.rece1Wd%W.I' from his managers was not earned through the quality ofj hisfworkmanship? l but was in response to an experiment in which he cleaned and;11nediup i.4j. i 7. all his tools on new herculite and perforined no:workeat F1homeganao..G,7 wp..s,. .3. h... ' l o In spite of the deficiencies in procedures now'impedinm.verbat1mscinp11--!! ance, the plant staff is confused about the workingfde'initiont'off.:"MWe " intent" as it relates to procedure changes and4 temporary modi.ficationswoi y The team understood the plant staff's confusion and lack of;ma ' ' ntre('t 2 ! clarification when, in an interview, the Plant Manager acknowle ed he.I could not define intent and did not have a functional?vnders'tandin('o'fF r. i how to address the concept.' This. example.1scillustrative' ofthostheo ' guiding light' fails to provide guidance beca'use 'it neverspetshturned on at the manager level. . ! t. i:. bwn!yki crs3.r:lT. 2.3.4 Planning, Scheduling, and Prioritization C '?C ' M J N U.3ns m e n A ....a y ' i nw,r.t. bnt,.n ibus i Currently, planning and tscheduling are fragmented..throughout'.the*opgatiirav, tion, and:the organization. suffers from the. lack,of.a site-wideninteg'r'a'ted, l accessible planning and scheduling system. Operations :and<maintena'nce' to coordination (OMC) is the. dominant scheduling group.on siteFandiduringJuo outages the role of the.0MC supervisor 1s expanded:to-include tdverall::respon-sibility for outage management. The team observed confusion in'the distr.ibu - tion of authority.and responsibility in the OMC function as well as in the roles of the project and system engineers during. outages.Mithoutt:inforina-tion exchange between departments, prioritization'of efforts 5within work n groupr..is uncoordinatedr: . W Nr v, MAD yd ne,d

• < M n;;: f hettj3M bi ara u

The licensee has employid as a consuit' int the firm'6frArthurrAridersen,elnc., which has pt'epared a comprehensive plan to devist and implement /arsite wide integrated nuclear information planning system.(LPS)r.nowescheduled;toebe phased in over 18 to 60 months. The site staff has done a thorough job of salesmanship.among the system users. The developmentrat,dnimplementationrof, the NIPS program is the only example of successful 4 change: management ddenti; a u v !! m.Ntt w tt fied by the team. e cer:W i.Tt a .c,, -

MI not.3 ii 2.4 Summary Analysis of Activities and Events i

.+ - w u, n.nl in% The team reviewed several major programs and initiatives to assestraanagement effectiveness as applied in the operation of the fa'cility. In addition, the team reviewed significant operating events from theJall of 1988;to evaluate.n management effectiveness before, during, and.after.the event.: e a,s 5k) m " ; h 9t

• tm. $gs-w 2.4.1 Procedure Upgrade Action Plan (PUAP) Rgview = <

i ' a e.:; e ... v w tw '. u. The team's findings from its review of the PUAP is a representative case-study of management effectiveness in planning, organizing staffing, direct-ing, and controlling site activities. Additionally, it is illustrative of management deficiencies in the arees of planning, staffing,, change: manage-n ment, project management and control, priority setting, decision; making.:.. or anizational dynamics in the matrix structurer and. reactionary.,yquickafix' so utions 'for regulatory concerns. In. every> respect,> management 5perforinance 1 on the PUAP is at the opposite end of the performance :,pectrumiftom:th .u p. i.. rmmr$firfidirmt udN b'

6 -

• PREDECISIONAL=... INTERNAL USE ONLY ***

3,,, 7: x f which management' effectiveness,could'be considered a stre.n 0... - aJ + c. u.

4. h m The PUAP r'e,v'b.* identified [>the,,fMl.hing.Lde'ficT. ebch.s'UN 'W N D 1

w. uk pu etTtrMeu

.~ Th'e PUAP. is a quic'k[,'fix",1n.dspon's'e t'c EgulaToYsk [toYal.(plNNNnd o for' the ' program was t'wo' weeks.' By comparison 7 the1 NIPS"progrl%"w"as>"*"' ' -

' M planned for over a year.

Typically. the licensee has underestimated the magnitudeYfftMMec'th," o in part because it has,little concept of how. poor.pr;esent ypcedures.are or'what quality procedures look like. }, ", 'd..,., y;,g,QL, No strategic chang'e management has been ahplied tI'PUA'P.2Wan'aY$iOt? If o-simply, perceived a need for a change and ordered thejstafgto 'quickly1' ',1 improve' procedures, g y,, {. j ', *,, yl ll,",',' { j,; There' has beer; litfliconsideration given' to.N to'dpieiErit*t'heI!*Ed^e o required changes if the cultural 'aspccts of' the"pla'nt' staff'Y att'it toward procedure quality, adherence, or, control,.g 3 . g,.g, g,.,,., 3,. There has been no manpower planning to ensure sufficient-numbers of" o gets;behindschedule]he'. persons.will "just' throw more]od,igsj; , g!. appropriately qualified ,The project manager A sense of ownership fbhe project of'theff'idi'sde'd[pNdu*ck.,j's #nii's"sTng ' ^ o-with little influence over any of them. JThe one)a'ge memd'ganiiation-The project manager has. workers scattered throughout,'the; or' ,from ' the'"; Plant Manager establishing'the effort directed the' project / managerto 4 " direct", ". control", Land " support"line m'anageri".; ' ' The involvement of tiiose.in ope' rations mainienatic'e, engin'e'er'ihg,!fn'd. QC o who will have to rewrite'the procedures and be the. eventual'e'nd userlis investment, and no priority has been assigned,ensureitheirfc'onsiitme unspecified. No selling job'has been done to' for' completing,the task. s.. ......ri The quality of the finished product is in question. The aut6oYs s'ssigned i o to rewrite the procedures are generally first or second line supervisors - who have never seen an example of a quality,prodsdure"aWd whFfeeF2 heir t C existing procedures.Jalretdy range in cauty frasi excell'ent"tdista't'eiof' the art.E Management.,has.not;establitheo 'c'riferia or'conveye'd extiec'ti-tions about the quality of. the.: finished pro, duct;".:'w'"M r wilpc 2.v

• d' "Y ' M'"

r The decision onMidh'proceIdures.'to rewrit(andinWhoFdeYl'EaWthe o team to' speculate that, additional: rewrites"will~be[reqiiired.$Theffirsts tier administrative procedures ~ that describe'how'to write" procedures tand the second tier,that defines programs are ' scheduled for rewritetafter the third tier implement,ing, procedures.,,,, y,,j.y,Q'{ Q 'The. inned's codlet$n',s~che'dule has un'reali'sticE1IyTehdeM'8 fiBis T L o 1 few identified schedule mileston'e's were' unre'alisti'c' and' hivf*a'Iresdy, u " ' O" ' " 'A been extended. 7, 4 v' ages.t cemt.; &.J. 1 19

• • • PREDECESIONAL...INTERNALUSEONLY,**Wm.gj Q,. g.

} p.N. g. s.

. _. _ ~ -.. .e :

• PREDECISIONAL... INTERNAL USE ONLi *
• 1There 1s a general lack of underst'andi6g about"hd[fi regT1stId'rs'W$i'd yTe'd

~ The liciinse 'seeined 's'u'rl ri's'eld o-the program in terms of its adequacy. i during the early phase of the, inspection that the team wa#s ab.le,,he Y to i identify so riany glaring deficiencies, and' volunteered to st6 pit _ program and'"take a harder, look at it*. By the close. of,the. inspection periodthelicenseehademployedoutsideconsultahts;to;, eval'uateith'eh program. T ' ' Q,f.g,', lq v 2.4.2 Event Review

W 'I t e.1 aM t' #!.

A The team reviewed in detail two major events from 1981iIt't' hit'hY$TrpYs%o',f[ evaluating management effectiveness before, during',"and:afteF'e'ach' event. The two events were the July delta T-power mismatch event,in.which gMaf, g ' limitin safety system setpoint for high power trip and axial"f1M of.fse't' p exceeded when' operators ' responded to an apparent power mismat'ch dWering delta T power to match NI power, and the September fatalitf'in'I ihert'ed condensate storage. tank. Like the PVAP review, the event roviews were *,l i illustrative of the deficiencies described througho'ut.this 're'p'or.t.'4.. w.... a.7-Managemer.t effectiveness deficiencies identified througfeie'nt'reViewF # include: a u a-J i g e.:.ni n e! tioYplieYeNnT The demonstrated operating philosophy that crea't' d a$'ctor'in"botW ;. o which procedure adherence was downplayed was'a major fa events..The lack,cf. respect for procedure quality, the technical and administrative deficiencies that' were allowed t'o c,o6' tin'ueunTddr'eYs'ed. 0 and.the attitude of.. plant staff that procedures just $ don'[t'have'Ito'b'e followedbecauseth'ey'retoomuchtroubleandlimpedetthe"effe'ctiveEes's of the ' thinking operator..or tech.ni.cian all contr,ibuted'to'.thei.,s'ce'n.arios. ,., o,,,c , g, o s The plant' staff's disdain for procedure use created an atmosphere in.. o 1 which verbal comunications, verbal agreements'betwde'nfoperat6rfs.j"' C technicians, and other key players, and' unverified'assumpti6ns.'.wcreD ~ adherence to any one of at least three procedures may well'ha'v'e1,ti;',$ typicalf of the way business ns done. In the; case"of the* fatal prevent-ed the, event. . m... r,u m i l Signif.icant comu'ritcations birriers betweer, elements 'of ttie'mnHk i - o o organization. played a major role. Fuels engineers > ire presentiin the control room during the power mismatch. event but did' riot;interjestb d themselves into the mismatch issue, n Likewise',bpenfors"did not*coYsult the engineers because of la'ck of respect for"ttieir"expertiseP*Likewise, the system engineer,and instrument maintenance. supervisor verbally agreed to perform a critical surveillance at 30,perdint'!pBWerFbut'...I failed to ' involve operations or fuels engineers' { g,g,Q The production bias that has been the major element'$f'the.diiisnstNed o operating philosophy dampened the questioning attitude ' safety'cbnscious A operators should have had when power indications were inconsistent:'eil to complacent willingness to grasp at unverified 'asiump'ti'ons coht'rlibut 3 the scenarios. yy 2.5 Licensee Response .a i 20 e.mytypaggitg ....a

• • o PREDECISIONAL.o. INTERNAL USE ONLY 0*0 Licensee management readily ackr.owledged the deficiencies identifiec byithe,.

operations and maintenance group anJ promptly began corrective,acti.on'., tog. " ; '~ resolve problems with Ouality Control (OC) and maintenance proceduretous,1,ity. ' u The licensee was more reserved in its acceptance of the concerns expressed,by the management effectiveness group..but did state to;,the, team.that;;each of ggf' 3 the group's findings had previously been identified,as,,part;of,their compr$ejm. a hensive corrective action program, which was under development,at,theytime3cfni the inspection and was not reviewed by the team. Licensee senior, management expressed an understanding of perceived deficiencies in communication.effecy,e,m tiveness, leadership skills at all levels of supervision, and the,irgbi,li;tydno}:. s to manage change. The VP resisted the team's suggestion that the nature of the,' Ofindings indi-cated the need for prompt and forceful leadership on his part, stating his intention to allow change,to. occur at a gradual pace and permit his managers to learn from their errors. Likewise, the VP recognized that',he i,shiewed.as x y a strong leader, but stated his intention not to pursue an,' aggressive \\ leader-ship role in favor of permittin his managers to display leadership and_ develop reputations among the p ant staff as leaders., ,j @ f . W.-- M. The team found the VP to be a manager who demonstrated.hijh' persona'(and professional standards and demanded the same of his sub6rdinates. He h'a3 been' ' astudentofmanagementandisrecognizedfortheadvancesmadeinBGSgEss; fossil operation while under his direction. The team detemined his"inajor weakness to be a lack of nuclear orientation or a vision of how a well. --i managed and safety conscious nuclear plant is mana'ged; he does not have the hands-on experience that would give him an effective nuclear conscience. The team concluded that the VP (as well as much of his management staff) does not have sufficient time or experience in the nuclear environment to,be proactive in management of operations or 'recognite the warning sighs of declining ~ perfonnance that.would likely be obvious to an experienced nuclear manager. Of particular concern to the team was the VP's stated philosophy that as VP he is a corporate officer with an office on site, rather than an on-site VP who interjects himself into daily operational events or cirects the site's response to situational events. The team understood the VP's philosophy of proceeding slowly with the intention of institutionalizing the improvements he hopes to make and building an effective management foundation. However, the team continues to be concerned that the VP does not fully grasp the extent of the change necessary to return the plant to excellence, and.that while his preferred pace for that change may be appropriate for a' fossil plant, it is not adequate for a nuclear plant with the range and severity of deficiencies identified at CCNPP. 2.6 Summary To sumarize, management demonstrated the following operating philosophy, with key elements arranged in declining order of management emphasis. money schedule productivity minimum investment regulatory relationship. .o 21 PREDECESIONAL... INTERNAL USE ONLY *** . !;g .j.

g.,

w ..u

'M PREDECISIONAL...lNTERNAL USE ONLY 0" 'l ' ' ' ' ' " * * ** ' " *; safety 'f-D'tD'" '"M *n' conservatism toc- ' rU hfa? I M"tf4 ot'I"tpt. gjgg g.cin e n t :r..ss!; eth. celfenc...{f,...gg;g.gg g[' Kanagement's current one-ditr.ensional approach to.. restoring 'ex. 46 4 ..s e at CCNPP is overly siinplistic and emphasizes reversingthe order'df.'this.'11'ft'.'? W. The team considered this strategy to be only a:startin'g"pla'ce.(izationai;. 8[l tm'6fe J" appropriate balancing of priorities in.the complex' matrix. organ sional, project management model represented by f structure in place at CCNPP can be visualized'as'the lynamic thrge' dimen,-. Qualityandsafety.are.at.theNdrder,fincedk.7 . of..y every management;dec'isi6n,,1 "thi be Ces approach,which, establishes'kh'e 'e 'a' rid'*"N

• take. relation' ship #ofc'6st's' ers chidt11e and giyes' a,ful,1,ande'q'd.il.,,tre;a'p Qbatty

'ri th'e g Safety fa c i l i ty by ; re g;u l a'tcWs,[a nd fhje]p;ub'.1,i,c',' y' hj", y 68* N A;)* g..',4 S,..,*3 ' .t. : (,'- .. [ i - b 'n., b f rabr.:.J.* l v t. ? ' ' *s q FIGURE A ?"'E'

• l '",i t 'l 6io; ?

2' - 16 s.Myr m .,*) 9. M. D} :=--~*'.'<* oe 1 (t, #+ :. dw A

• t

.7'- 15 't 3 3 p ', 9.. .g 4 ' '.; f t S f.,d

• L,

' ' ** ; -.W Mt I3 ' 4' P, * ' \\ ;.' 'J ' O l / 1 p,"; Nihe. lI*: LG(..l f'. ' 5, Y ')",5. C f T Id '*"?^ LI-y '. i. > 'h.i. Tiff *,* ~,,,.. .i: r.. du:,nnt..: o.n...er n :,., c' r< [*I' f) [,71l'.,l' h I' 8 N ~ . ?l1.;;$ o '. t) :%.1f L'e') c. M ;. n,t.s.s.nq' c.

, i.. ;,

S., g h

• t - g.

".d . v., . t..:,....; ~ , v. u ..s. ...)

u..

y. . a r c,,. u-:,.. :. w u, . - 5.,,; , 1. : n

Ti t: M : y.

e 22.

• • • PREDECESIONAL... INTERNAL USE ONLY ***-

• • • PREDECISIONAL... INTERNAL USE ONLY. 9*?.m
• n 3

i'- 1-c. a. . t at i:.q uwtisu nt, rd : + ,.,<,.;\\, w.y n w ne y -n 1e n.2 APPENDIX Ar n.,:.. r enligeu m ~ .e y,%. ,.. :. a..: . EXECUTIVE TEAM PROFILES. .., e 1, I ( m3 t.p X,...

- n t.3

.fctf-Vice President George. Creel, with many years as a corporate officer on the fossil side of BG & E, does not have the hands-on nuclear. plant experiencei r3 that would give him an effective nuclear. conscience.J h'e team. considered u T that he did not yet fully grasp the. complexity of.the change required atm.. t Calvert Cliffs, nor the importance of his leadership role in effecting that n.., w r.r,e ( 1,, m.c; a change. . fe..,1 a.; t > Although Creel knows many of the plant people, he.is stil.hlle t-rg, i" arning,the o issues..His method seems to.be. *managementsby. walking'around"cotandihe, often calls people in for impromptu interviews.n n

w. eM.g..nontg1

. ;.t

r. : "olone du m es o

In keeping with BG & E tradition Creel perceives himself-as a corporate VP with an office on site rather<than an on-siterVE.withidirecttmanage-t, ment involvement in daily operations or control. ling'situationahtev' nts. e

1. :mti:.~ roittnb %et: nt

'f o Employees. expect him to emphasize accountability. and:.cteditthim{w.ith the phrase iny waytor;the. highway".. Creelssaysathatt.he, prefer;s,inot tto .be viewed as the plant's salvation, and. feels thelplant staf,f may,r.be. e,., incorrectly perceiving him as a site. manager. - w ;.;.t w ra 5.tte s u m wt '.i: mea y$notusn, o Unlike the VP who preceded him. Creel issperceived:by:.the plantrstaff as a manager willing to make tough decisions quickly and fairly.; He.is f b well versed in management principles and organizational design! utg c. appears naive about-how to apply that knowledgs.in the,nuc'leartenv1ron-a m tal.q:.v3 ment. n + t.t:, M es; inohunft Creel is well known to the plant staff and almost universa11ysrespected o. 2 ees. For 4xample*, he received high praise for traveling fron B: employ. for his leadership style and direct, personal invo,1vement with t 3 altimore

• to-offer comfort to family:and employees during 3thef.funerah.{o110wjng g

the fatality. +* m ni v N d m.n !. W.o c. f.< .w:,.i He of

• 9.

det : sam, : o Creel has worked extensively with one member of the. executive 1 team (engineering manager Cruse), and is aware thats truseg a been;identi.fiEd h as successor to the VP in event of emergency'.:' Thepteam ~'rmin'eKtha.t.p' n ,,irigj CruseNis.a favorite of senior' corporate management 6and4 assignm,g,r,oomed yp 1 for a senior management position (including a,rotationa en,ty.as / PlantManager). e de '. + .r. rl pv n o, d,m.jp fi y,g n,q e e wte:, no - ,y. .un i Plant' Ma' nager > Leon Russell uses a low key, hands-of,f managementr. that s u often gives subordinates the misleading impression that he is unwi,ngj.to address difficult problems and situations. He projected to the team an who had notvyet< met Russell observed an.on-site'tcons impression of: organizational:noninvolvement and ambivalence.g.A.t eet'in er j. identify Russell as the plant manager and ccamittee'etiairaana Z,$,.' ga* ~ W,- i .c o 23 M

• • • PREDECESIONAL... INTERNAL.USE 0NLY ** h %. g. g.gf,,,./.g y y' L

't

- bpj.d N

• • • 'PREDECISIONAL... INTERNAL USE ONLY ***. :.

l

ag

+ Russell'seemsphysicallyandmentallyburnedoutfromover$h$a'veragi, o ing 90-100 hours / week since December 1988. As a result hdIappears' to bel,M M ' struggling to keep up with his duties of! operations s'n'd]lma'intinne;ept, ~ manager for a dual unit site plus acting as site manager 3 orith'e?niajorFSl f T get-well effort underway at the site since:be'in'gplaced onsthe(witch f.N ~ ~ w. list. 4 " i' 3.. .;..:c':.mc5D Jt&t 2c i9 hYl Rather than displaying a take charge attitude..hisprefe'rreUstylelis'ltot o use questions in response to situationseor problems,to)he'1pfas'sociates W a and subordinates identify the correct decision or a~c'tfon'n ton;btb W.~tMr . d <.*nis m im,a 11.tl 3 t w W ;i o Russell has been in 9 supervisory role in operations for 11 of:the:last* 13 years, with two years out to be in charge of maintenanco.' He moved into the Plant Manager position during the 1988 reorganization'?o(He lis 'o politically aligned within the BG & E organizationtwith*former.VP.10od Tiernan. The team speculates he is aware of' Cruse's 'statusWithithh i c current senior managers. ? I ha sura en%, ssi.nl y ll~ u Despite his involvement:in. operations for manyiyears,*:Rdsselh denionM o o strates skill deficiencies.in application of overall-technit'tivkndwledge! in~ timely decision making when faced with plant operational lpr'ob1ces; He does not seem to understand the 4need for.rancunderstoodfoperatidnal"' ' c l L " language" for the; site, or his responsibilityltocdevelopfone'.mrEor& ' example, with regard to temporary modificationstandepro'ceduritchinges','a 7, the site clearly had no definition 'of the : tem ".intint*4candrin9 direct ~ questioning Russell was unable to define or discuss the concept'of an " intent". tor "nonintent" procedure change.

m o'

h' snt o D M n 1 -i c.t f i h: wt;wa.. Russell is not considered,to.be an effective or.rexamplary leader by:;the o plant staff or, the-team feels,"bihis: peer:managerimhLik'dwiserihist managerial' skills.are generally held in low regard. Many of the'. site functions he has managed are experiencing major concerns, including' procedural-adherence,-quality control, maintenance 7 procedure inadequacy, e p Sa d r.: v.mi W vM l_ and documentation compliance. 1 A

5. n, +. m o ~,oh x Russell was described by BG &'E President.Crooke'ast"not'veryi(ynamic".

[ o Mr. Crooke stated his intention to rotate Cruse into Russell.'stplantt manager job "at the earliest opportunity". u :.. /w-eK bec o Russell locks sophistication in dealing with regulators, doesnitt.seem to. o outwardly demonstrate that he understands the gravity oftthespresent situation, and overlooks opportunities to demonstrate tofregulatorsiand his staff his comitment to quality and safety. w.7 r.,M ,0.9 w,'.w M Russell's approach to problem solving is analytical, but he often fails - o to verify or validate information inputs. He trusts' subordinates and i O often doesn't recognize or question the quality 'or completeness;.off the.?. j: n. 0-n: input. .s ! +.. b,'.* '; v;. Russell's strength is his extensive Calvert Cliffs. corporate memory. rHe,, o should not be tarred and feathered and driven into:BG 8tE's1 fossil be.' c.w purgatory; however, he is in urgent need of rest and assistance b T % g W,t C fbqj M t V M rd it y 4.,.f,.J me i 2 v-

1. k.'

j h[ h* 'T i s' ,pp M f. h-l-

• • • PREDECESIONAL... INT RNAL-USE ONLYT*** M

_ 1. %... #. n g w p e' s 1

f. -

.f

• • • PREDECISIONAL... INTERNAL USE ONLY ***.

QA Manager Robert Denton has a limited nuclear background.andgh.is onlyupc s

c previous exposure to Calvert. Cliffs was in;the late.1970s.nUrit,11 h.is trans-73

g" ;

fer with the'1988 reorganization, he was.on.the:BG;&Ericorporate) taf.fdfie involved with strategic planning and subsidiary development.f eThe. team;had, c.M 6 difficulty arriving at a consensus regarding,.Denton'.s operating (phi,losophyh $ '- management skills and leadership style, and the. extent.,to which:,hepwas iter r personally invested in the licensee's recovery.< . u. %13 MN e7u:m o Denton is bright, knowledgeable about the BG3 EgorganizationMnd % _ 3 q politically astute. His first. impression to;most of thehteamjwasioneiof i 0 arrogance. based on insecurity, and he tends' to ;projecta asdemeaningi d ' standoffish: posture.:.. ith continued probing they. team.foundrsone ev.i.-i W dence of warmth and. caring -

e cnon.eut(

. me iN n:.ild ? u, -Denton avoids decisions and situations that carry high political. risks.- o If his involvement. is unavoidable, he attempts to;prov.i.de a logical:,o -n-nn systematic-method of dealing with the problem thatysubletsurespons.ib,i.11 i ty and involves others in the problem or process.,d.The3onlytexamplerto counter this generalization is when he backed upihis: new-QA.: General.i Supervisor when-that GS issued a stop work order, involving parts,quali-fications.- 2 M w w... %f w. dt:st.1c:. m o Denton's preferred style is to remain detached from..the; organization,' to the extent that he gave the team the initial strong,l impression of,inot s wanting to be on-site at all but rather back in the relative'ly ' plush --- ' ' world of corporate headquarters. When directly pressed,on this issue g n1 r Denton strongly voiced his personal desire,to be4a_, key.rpar;tji Calvert,m. Cliffs'. improvements over the next several years.m;..n.,n p.n.n4 .e .snrmn ./ m.ylim eteo bas Denton uses a " third. party" management style that gets a positive.M6fod o response only from strong,-self-directed subordinates whodapp'reciateithe i a freedom.- The majority of his subordinates.do:not(seem to,goutini,1ydock n ~a l to him for guidance or direction. ' vd 4 Denton war r.ot perceived by his subordinates as.a risk-taking.. dynamic o leader. e-d,. : w t e n w.: o Denton gave the team the strong impression that he did not want personal responsibility for get-well. efforts..even though many3cfsthe eajog c. nate activities of others to whom he has, in his mind,'spitfted c initiatives fall under his department. He.seems,5to:prefergto i-res6ohsi-bility for developing and implementing. corrective; action, initiatives. Denton is results oriented, organized, aiid 1sid)dhNohdkthe o extreme.:

a. % y.,

np k nt n.n . s id b \\-( sn r ..w. .s.e r Engineering Manager Charles Cruse is a favored associate of, Geor,ge; Creel)ith. an extensive fossil background as the consunnate professional engineer.gHe is still on the nuclear learning curve. 39 e,1 s.9 i W : s.& 7., ..A

v. s.y cow.: nr.

.e ^ t 25

• • • PREDECESIONAL... INTERNAL USE ONLY ***

y,; 0" PREDEc!SIONAL...!NTERNAL USE ONLY "* y o Cruse is analytical and carries a reputation for being willinptoupre R confront problems and make decisions. He prefers *an< an&lytical<and.ete o + systematic style in his7 subordinates.

• W M?'m MiedtMi'd.?W w..&,

.m er dm bsyl'orn);, Cruse is polished and professional, a sharp dresser who prbjkcts 'athigh"rth o self-image and a sense of control. He appears to understand his sp'ecials stature with Creel and other senior managers,'but does not: flaunt (it F w. Subordinates generally regard Cruse as a comunicative','effect'ivecnM 'o .o manager, but withhold judgement on his leadership ~ attributes'(AH1's" style. 'e is not charismatic or-emotionti, but he is regarded as YohtistWnt?a'nd'., fair. Cruse was receptive to the team's observationsthhtlh'efpirio' dical y ly shift from Brooks Brothers tc blue jeans and'make:himsk1fhdorennc W visible to his direct subordinates and others in the' plant.

, :ncM.rs:.utors;.nMov3 o

~, =. The team considered that because Cruse is 's'til1Jo'n tNewikidliWJeYrning 17 k '" o curve, he may not yet fully understand 'nuclea'rdel'igionW(<The7simYtG He seems to isckVs'c'phift1Wtib'n generalization can be made of Creel.) m + in understanding the regulator's perspective an'd.incorporat'iWgetKa't* " regulatory influence into his: decision making'proce'ss'esMBe'calise hWhas; y v not seen for himself what a quality nuclear organization'look's%1'ikeWe-does not at this point seem to recognize the ' warning bell's":that ring _ in a nuclear manager's mind when evaluating and 'r'esponditigrtogepidifi o developing situations. en.nta 2n:rj a op 2 N. r.0: e of.gWe ~ ' In tems of team interpersonal dynamics, the executivelteam.'ista" mix' of m strong 'and weak managers, most of whom lack experie' ce11n"the'fnuc1' ear.ce'nvi'- n ronment. The only manager with nuclear experience-is' consideredroversorke~d, isolated, and outwardly weak. ..g.,. eng z ~ ~ s., The three managers 'each seem to bring a personal ' agenda tothe teamin o which impedes team building and effective management off the' facility'as a team. ,, re w hq vt M cc Thethree'ranagershaveonlyalimitedunderstandingfof?how?to'workiC o effectively in the project management matrix organization foundaattthe, site. V?.? ' V ::t;.M;*: s' Outside of VP Creel, the team has had little management orileidership o >.. : :, rsv' w d e,i skill development training. ..uW W.Mtvih ohn The role of VP Creel as a leader and manager needs!toibeidefi'nedim6he o precisely, with an emphasis on greater direct involvement in site management. Concurrently, the role of Plant Manager' Russell:needs to be defined in terms of site manager, since he clearly has that responsibil-ity by default. o The role of QA manager Denton as a change agent is not well defined among,the executive team, nor has Denton outwardly 1and forcefully.e. ' acknowledged and demonstrated his key responsibility for.beingia change

• I

"'a 1,. ia liv agent. The prevailing historical BG & E corporate philosophy emphasizes hands-o off management at the. VP *ievel, and some of that filters down to the N 26

l.

• • • PREDECESIONAL... INTERNAL USE ONLY ***i a m V

4 g: m c. 4 "- * ~ * ' o** PREDECISIONAL... INTERNAL USE ONLY **o 3 t t - y r .three managers; indeed, they function as.though Creel was.BG.& E _i President for nuclear-power, and each of the three managers were a VP"in-charge of his e.sn area. ;With the entire executive teamseffactively-p= taking a handsoff approach. responsibility is pushed down int'o'/the, s.-.s.%ji. %., ,3 organizatioh. r '; = te.ieISYi>b' ca.N ed. N :: '.L i? vs i_ t,f 41 : M. l r . t; u. - . e-.1 , r 2 s '%nj yt(3nc6f l -Tf,: 1- ,;;j r 23,u r, 's a ^ s! 14 / fi.Vt i-11g 20 ~ t,n // i 4; im4n F.1 . Et W." %'\\"i ~ r

• .idi

-r. ii.u 'i - .a E i i -a.. . s v.o - ) e v..v,.rt::

• er c,.

v ': ..res.1. - .a e-c.vp 3.~ ./ r:,? f41.

• u.w.1

....b i e a. q 'l n..ce, m.: m * . M % W..**.:'to*.*R 6 .>p.. o.~e.m m * .,/ .r :: 'yv c - ..s r.s. ..%. tier.:.m! NO g druer - :: w-iclJd.r,fii s't.t

• . s, 9

27

• • • PREDECESIONAL... INTERNAL USE ONLY.***.... m.

N *,; u9.1. 4 Scpa. w- .n f.. .. c,..,.. r .v *. - 1.u t

. i'-

• • • PREDECISIONAL...lNTERNAL USE ONLY OM, a "'

i. APPENDIX B r,.y, s n i p A y;q:.h'>F A eP W... 7 aw M . y ' MANAGEMENT EFFECTIVENESS GROUP METH000LOGM nw o, tpW.3 ; .w,,a..n cqs Yio m l -.r:dts::ingvid,'. The team developed a management effectiveness model designed.to (1)l systema't--; .S.- ically review and evaluate the licenste's organizational structure and identify the attributes necess6ry to succeed in that structure.- (2)* inventory and assess the management and leadership skills of managers and supervisors at all levels of the organization, and (3) objectively evaluete'the effeca tiveness of managers in applying those skills within the organizational fran.awork. The team first developed a management effectiveness model (Figure 1) with which to focus their evaluation of CCNPP.

• $e%q*uest P

l o,g,,g,,,gg,,,g ute ems

• Leadership Managerial Requirements
• Expertence Support Interfaces
• Job Know-ledge MANAGEMENT EFFECTIVENESS MODEL

. Auessa.ent of Management Effectiveness . g E

• State of art mana'g ent" k
• Decision making
• Problem solving I ggw
• Safety Ucadon Escenesce
• M ty -
• Resource mgt.

praetgee

• Assessment of orgin.
• Change mgt.

Isauonal potential FIGURE 1

• covernmental compliance The team then developed an evaluative method (Figure 2) designed to support the analytical model described above.

t t. s a.. v.g

~

e6 ,-N, .28 . x:;, 6

• • • PREDECESIONAL..., INTERNAL USE-ONLY **,*" "g..,.g4~..j,. f;,,,.g... g.....,-

yse. ."* PREDECISIONAL...lNTERNAL USE ONLY *. t>- ,1 DOIM.', y %;... MANAGEMENT STUDY METHODOLOGY "1 ' k Mil

I c e..m n g.3 %,V at m e.]L'.

i Jer.,N Ae..<!nunf.0 ..i,,,^N. ' . f.... w ::.. 1,:a rege.=; ;,,,m.rdM e.. a' r+

• ri<sim. eicae 4 6.tr.>o

.s. [ Orgarsatiorial Requirements

• I 9

c + w an.',;;;o'..* h 9 -.1* *

• el O

'.\\ ms m v sr..syt.. Appropeisseness D . ; g. d.* pin " Fadrgs e 3,..., .., w.,c.. . t 41 * ?+ +5-4 Practice . i e t'

• t 0

t.. Mv. l tesoseg,,w '~~;;;;';t,,;-

• t J.....,...
• l;*t fi
• M1. t. Inf in.

l 6 3 E Weenase hu+ -a, eva fe m.t t ' srpt' * - ' ! g e ioM t b :t.d' -e fleslee I'd'95 4 App 6C390ft & i 9tectice.. ~ a .1 r.! ? ' tir,. , y l l f ft P s;. :.. ! (.... ? *. + e69 u g.n se s. Ensesesses "'Eiiii" rasrgs

• n M

y o....,

• .r.... 1

... s 3 1 y..

r y,i.s..

* '.+w,

y te.aw Yes n.asi 2 a emess ~M-I Recogrnon i l Recommendators l W i.o.'r!93 f.f4E g. ci a htie' :'F,'.U.Mfi: ? * "h'. 9,, g, %y.,.. p,e

ra wb

, ia.' h tli) c., M T';. ; ? HD

• tif mt: y isr:tm FIGURE 2

,:e Mr.v:Rn of

t..m n c.. :

q Evaluative criteria (FIGURE 3) were then developed based on the modeleto-n l i further focus the team's inspection activities.

Wt

' /.s j g ..w 29

• • • PREDECESIONAL... INTERNAL USE ONLY,***-;- g M - [

' Qi.T-Y. 1..? ~ Mf v

L,L i

• • • PREDECISIONAL...!NTERNAL USE ONLY "o MANAGEhENT EFFECTIVENESS CRITERIA 4;

!.", E TJ l hl Id Orfanizetional Requirements Q"$ Management Appilcation OrTanizationalExecue'nos (Structure & Daign) & Practice (Actions) (Results & Image) )

• Structural design and
• Management knowledge
• Quality soeurance and
• Management performance semmunication interfene and operience control history
• - Culture (monagement
• organisationel climate
• Change management
• cuennt management philosophies) and human relations performance
• Reguletory eemplieue
• Strategic and businne
• Personnel pregums and and nview
• state 4f.the en snelysie planning administrative support
• $ hared communicaden
• Serievenen, urgency
• Manpowet planning and
• operational knowledge and and commitment and gnwth of concerne forecuting operience
• Performones snanagement
• organitettenal quality
• Work planning and
• Leadership and supervisory and safety otheduling effectiven.n
• Planning and scheduling e oevernmental compliance
• Performance monitoring
• Stefnng and penennet
• Rueuru ellecation and reporting quality organisational focue e
• Regulatory review and
• Training and development Priority setting templiance
• Ortenisational image end pubtic relatione FIGURE 3 Finallye the team developed an " effectiveness scale" as an evaluative tool for internal team use. The scale (figure 4) was used to assess the degree to which a given criterion, attribute, or finoing was effectively integrated into management, activities at CCNPP.

EFFECTIVENESS SC ALE E Not commonly recog-Recognized as in. Recognued as im. Organizationalin. Mana0ement prac. nited as imponant to ponent tnd not prac. portart and improve. provements amently lice sW @ echieving org. resuhs ticed offectively. ment $ planned ,being implemented. tradional esco8ence. FIGURE 4 The team relied heavily on the results of extensive interviews revieked e programs and activities with an emphasis on managerial controls and effec-s tiveness, and evaluated in depth recent signif'icant operational events to determine the extent and appropriateness of management involvement before, during, and after the evtsnts. Because of the apparent subjective nature of n the findings in.the management area, with its emphasis on human versus engineering performance, the management effectiveness group stressed the need to substantiate apparently subjective findings with objective perfomance examples from the operations group to the extent possible. Toward this ende the management and operations groups coordinated activities and findings extensively 1 s en 30 p

• • • PREDECESIONAL... INTERNAL USE ONLY ***

l 3,) d'e e,- .p. ,f ~ .4 .r ,,,,,. o. v., f.f. - RECOMMENDATIONS,- PENDIN6 RECE!PT OF LICENSEE'S CORRECT!vE ACTION PL E ...n '.W-W% + l ~;;Q Q ot 1

1.. Encourage the licensee to obtain the services of a' recognized expert in

, d;Q - the'if eld of organizational design and human relations f or consultation and ' ' 'l training on eff ective management skills and their application in the comple'x; .Di satrix structure now in place. 'd . ' ' mpenp ' ~l Encourage th' licensee to bring into the. pla6t"orgasiration,p'r59en"f 2. e .canagement talent f rom outside 96kE, pref erably at,the pl' ant salnageq a6 general. supervisor f or operations (6501 level s. loave the Engineering Manager, who is new to the site and slated to,,ro-j linto the plant manager position, in his present assign, ment.unt11. theeprobless 4 alth engineering perf ormance,- organization,~ and :interf ace notedyint,thenlast. l two SALPs has been remedied. onl y a s si gnment s wi t hin the. exi sti ng organi zation. in, whic'h' an'. 1 could have.suf ficient influence to bring about meaningful change'.VA:.d 'A , ~/> udlla V:m i

• Qi

.. y s

sf placed in either a newly created position directly below

+.- f 'd! canager" or in a newly created position as advisor to the,,VP. ,[ (l ate location f or, the newcoser 's created position 15uld Thegapprgprip. onhty'eje ven,t,u a,1 ,,,, l, resolution of a now unanswered'questient is Mr. Creel 4,,VP ho ync,tionsgass. si t e manager, or i s he a corpor a t e 'of f i cer who s, pends, 'ti'oel@i n t an4 7 r, site? ~ 1 m cv; % !imth 3. Apply immediate regulatory pressure .a .m insic 92 to upgrade..the.0C progr'ast and htW . integrate a healthy, involved ~. quality organization 11nto the:dalTy w'ork routine at CCNPP. N " 9'W6" M? ,c, w;e m;c 4 Display a timely and active regulatory involvement:.in th'e pEdNu3e[' ers, f ragmented responsibility f or completion of specific tas M p ? unrealistic schedule. To ensure a quality product which is accepted by th' plant staf f, the project requires the same high level of consitaent ' frost e f; ' sanagement they have demonstrated with the planning and. scheduling project. un'derway in parallel with the procedure program.

• > a 'm " "

c5. idaily operating decisions to ensure that quality and saf ety d dance over production. The goals of this program of intensive oversicht would " c ' be to convey performance expectations from regulators and demonstrate:tc the u.. licensee what a conservative operational decision really looks like. j'[i M c 9 I ay 5 . j' e

p4 1% F27"e y 1N 15 P01 + f J

\\.

p,k,.,a,. Q e Q 'y'as y& \\l O. j -{ us + +..... n n e.., m * * * * * *. * * *

• n * * + + + * *.. * * * !.. iM * **
• s s i a *N* *)*** * *. =

l PR .u.o....,*n*u ne....u*****CDECISIONAL . 4.h?. '4

• ..***.n u ******..,.*
• g... J.,*g.***.**y:hcEql

.( CALVERT CLIFFS PRELIMINARY ROOT CAUSE'

SUMMARY

,,.,..u nr.;t W m M 3 g e, pg.y b th L 4 1, m r.ser n 9.@ * 't? D P 9 - Acting out~ of a pusture of complacency, isolationismpand ign6F0ic*e',dM/ dei;" management failed to recognize and res send to changes in the nuclear indus-7 m i try, the regulatory environment,.and t1eir own. organization"Whi'chfequire'd*- 1 licensees to develop and, implement.an operatingiphilosophy;that' eiriphasizedt'W "". quality,. a conservative' comitment to, safety.cand..appropr,1aterp(roceduralfiinh "- programatic' controls to ensure safe rea,ctor:operat,ionmByudemonstratin'gunf wp 3 through their actions an operning flillos~ophy,.that managensent created a, cultural'rhvironment in which,i. stressed prpduc'tivity s consetystism, proce'duralmt: ap organization were suppressed !in favor of,'doihg, wha't adherence, programmatic 2 controls, und Lim. pii Lititpistfon asje, cess,ary toike,ep, when the plant was reorganized in 1985 intra c'oinslek'pYdfe'ctb 2# L i matrix without identification or development of tie unique l managerial?skil,1s. M. D '

• f #'{

necessary to function effectively within that"sophi'sticatedTorganTrati6nal Af, structure. v 't f "" d' ( ., r., wt n t m ' '. ' n nla c The relatively safe 'and efficient operation.of the facility. oveMthe11ast 5 m

• decade 'is ample testimony to the technical skil.ls,ofveraf.tspersons - and nthe ;a, >.<. "

operational knowledge and attitude'toward,safetygfound/amongn perators',.;,boths ~ r !- e of whom' satisfied production goals in spite"of'liinitid7es'ources, few'ptdcee.m dura 1 or programmatic safeguards, and minimal management' dire ~ction. Much of the plant staf f denies or fails-to recognize any deterioration.in perfor 'b l r -mance,andnaivelyconsiderstheirprocedure"quaTit'droce'duralidhf6 incl l. y and effectiveness of programatic controls to be 'among'th'elindu'strys;best'. P:'. I Most managers do not now appear to have progressed beyond identific2 tion'!ofy 4%i symptoms and compilation of uncoordinated, unprioritized lists of_ actionzM - i items, and many do not appear.to have a full appreciationtof. thet.magnitud$f6 N;Y the change they must effect in order to approach and exceed" current:1ridustry@7K' r standards and satisfy th'e' ek,pectations of regulators;and:,the4public.',.%,k;W ',a n p .,+ u;p.. ~ ;o rstJm:u:;. j ii . g :; w, W h.s! d" , c, e s.3 <.u 1MO Ad.t ~

• • • ..u.******** o ***.. ******....n..** n...+.~

.. 4. W /*'*~* J.M N** ' ' ......... u..... * * * *

• n n.. * *.........n.. +. n v

.....^ ~ .,,.,. & -[ - p p; PREDECISIONAL ,.h .m 3., m.c.; M. - ,sw

r. i; : 3 l, M.

. r s e,a t c. ; lsn., ' 4,en : t 2.,

{y 4

c'.

• i

' ]A, .3,

4...gy

,e n

J';,,,5y' L'.

. :,o . d.[QS,QOhi ;6 ;'f. .}}