ML20012C092

Forwards Calvert Cliff Special Team Insp Mgt Effectiveness Review,Executive Summary

ML20012C092
Person / Time
Site:	Calvert Cliffs
Issue date:	03/13/1990
From:	Varga S Office of Nuclear Reactor Regulation
To:	Poindexter C BALTIMORE GAS & ELECTRIC CO.
References
NUDOCS 9003200077
Download: ML20012C092 (32)

Text

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Mar.ch 13,1990 -

e I

. Docket Nos. 50-317 and 50-318 i

Mr. Christian H. Poindexter L

Chairman of the Board Baltimore Gas and Electric Company P.O. Box 1535 Lusby, Maryland 20667-

SUBJECT:

TRANSMITTAL OF INTERNAL REPORT EVALUATING MANAGEMENT EFFECTIVENESS AT CALVERT CLIFFS This letter transmits a "Predecisional -- Internal Use Only" report entitled "Calvert Cliffs Special Team Inspection Management Effectiveness Review." The j

Management Effectiveness Review was a predecisional report prepared by the team to brief senior NRR management on management effectiveness and was for internal use only. This predecisional report was never acted on nor does it represent the final agency position.

The Calvert Cliffs Special Team Inspection Report (50-317/89-200 and 50-318/89-200) portrays the final NRC staff view of management effectiveness at 1

Calvert Cliffs.

In accordance with'10 CFR 2.790(a), a copy of this letter and the enclosure l

will be placed in the NRC Public Document Room.

Should you have any questions, please contact me.

Sincerely, Drlginal signed by Steven A Varga, Director Division of Reactor Projects 1/11 Office of Nuclear Reactor Regulation

Enclosure:

Management Effectiveness Review pu.ug cc: see next page Distribution:

Do Tt.Murley, NRR JHSniezek, NRR JGPartlow, NRR FJMiraglia, NRR

$Q@

SAVarga, NRR BKGrimes, NRR WDLanning, NRR SCGuthrie, NRR go EWBrach, NRR PFMcKee, NRR

.RACapra, NRR JEDyer, ED0 o8 MSta11ahan, GPA WTRussell, R1 iContral: Files" DRIS R/F So RSIB R/F PDR M

O

'88 oc 1

N

• see previous concurrence

-Se SC:RSIB:DRIS* C:RSIB:DRIS*

D:DRIS*

D:DRP*

i Of Rfd-

-SCGuthrie:bt WDLanning BKGrimes SAVarga

'03/12/90 03/12/90 03/12/90 03/13/90

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Mr. C. H. Poindexter Baltimore Gas & Electric Company Calvert Cliffs Nuclear Power Plant i

cc:

i Mr. G. C. Creel Mr. Joseph H. Walter Calvert Cliffs Nuclear Power Plant Engineering Division MD Rts 2 8 A P.O. Box 1535 Public Service Comission of Maryland Lusby, Maryland 20657 American Building 231 E. Baltimore Street Baltimore, Maryland 21202-34B6 Mr. William T. Bowen, President l

Calvert County Board Comissioners Ms. Kirsten A. Burger. Esq.

Prince Frederick, Maryland 20678 Maryland People's Counsel American Building, 9th Floor 231 E. Baltimore Street D. A. Brune, Esq.

Baltimore, Maryland 21202 General Counsel Baltimore Gas and Electric Company P.O. Box 1475 Ms. Patricia Birnie Baltimore, Maryland 21203 Co-Director Maryland Safe Energy Coalition P.O. Box 902 Mr. Jay E. S11 berg, Esq.

Columbia, Maryland 21044 Shaw, Pittman, Potts and Trowbridge 2300 N Street, N.W.

Washington, DC 20037 Resident inspector

[

c/o U.S. Nuclear Regulatory Comission P. O. Box 437 Lusby, Maryland 20657 i

Mr. Thomas Megette Administrator - Nuclear Evaluations i

Department of Natural Resources 580 Taylor Avenue i

Tawes State Office Building PPER B3 Annapolis, Maryland 21401 Regional Administrator, Region I U.S. Nuclear Regulatory Comission 3

475 Allendale Road King of Prussia, Pennsylvania 19406

• • • PREDECi$10hAL..1NTERNAL,fISE;0NLY. g.

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CALVERT CLIFFS $PECIAL TEAM INSPECTION l

MANAGEMENT EFFECT!VENE$$. REY!EW.,,,;,,.*dd @@ g j

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I EXECUTIVE stM4A.RY..... v.4 m M.a4 ha,W i

From FNrufry 2f throudMaNh'.3'1.a. ten.of'Iff'r;C 'isi cloN o$ulM **i,[ @.

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'P1 Writ (CCNPP ts', '. ".,

special~ team inspection at/Calvert Clif.fs'Nuclea t~

the*cWVe[f}

ghe.

1 and 2..The intent of. the insp'ection was"to"dete

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l' events du apparent' declining perfomance and a series' of' ops itiThe l

tions and maintenance group which performed, inspections in,the l')n N :? DJ,* r last half of 1988.

operations, maintenance, quality contr61', sur

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management personnel in safely operating the. facility,.'.'*]g,

" Wa d by'YosIp'[tefit The o trations group detemined that the plant waslstafN, feisi knowl dgeable persons who executed their duties,in'a 'proThe operatio J

were capable of operating the plant safely.

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significant deficiencies in the absence of written proced i &le f'tofsiuch quality control activities and in maintenance procedures wh c d

t to the judgement of maintenance personnel and.did not,contain instructions to ensure maintenance activities we documented.

• ', ' ', - -l*,,*, g g '

thoroughly or in a timely manner.

i The four person group evaluating management effectivenes 3

ll lhvels mately 320 person hours of interviews with management and l'

and in all departments, observed limited operations arid ma ties on back shtfts, reviewed programs and events',.knd observe

site review committee meetings.,.d'.presEnt, to 'the". declining *pfr'foi y,,

.In sunmaryi the' team.

"# N *

• Gd' ing causal contributors..past an

..'..':! w..'"h v % w'q.bobereek W

' For the life of the p1 ant up to the prisdrit'[ site

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CCNPP.

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4 ment demonstrated by their budgetary controls allocatio i

and operational decisions an operating philos'ophy'which e

g.,g productionoverqualityandsafety.

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Plant staff has deve1oped a N1ohn Wayne'dhph345'i production goals of the facility,ine. Plant staff"rea'dily'sacrific45.

o to be done to keep the plant on l h

conservatism, procedural adherence, programatic, contr W

involvement of the quality organization to achieve that'ais tm. ara @i I. i$

Management failed to recognize and respond 'to"chan

. industry, the regulatory environment, arpithin'theirjown;or l

' in m -

Management has remained isolated and su6prisingly l

o d in thel.'M

• e programs, procedures, and systems throughout-the in j

in place today at CCNPP are reminiscent,of,' state evolving regulatory arena.

• d ' * *d

• W otlyssgpa g.p years ago..

n r.,p $.%67c'hTn

• dcAtr.itew r

Once the need for change was recognized, the plant's a thes 1

endency%p$' {

management, tended to.be simplistic.and. unrealistic'. This Q<

o cau s e d pl. ant pe rs onne1' to' u. n.dere s.t.imate.,the [,t.a

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.n; The production bias, budget ccinstraint@i$d EEtM"prhgre W'D1.0Y 4 g.4e m %

q' o

C reduced manpower sent the message to the., work. force to do more;sith.h; 1. c.*

worker's disdain for procedure use and adheren L' '

less, and do it faster and cheaper. That'eiiphasisi. set

.s demonstrated that procedures were mere Management's enphasis on ou poor procedure quality.

gnor& Wen 'th'd {#

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plant's culture.

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l Isolated, inbred, 'and somewhat unsophisticate'd; 'thi"p1'aW s'ti'f'f7'e'n'u'inTt*t! n

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ly believed it was among the best in the indust '. :The'o'pfrat'i6n'aW83 -

events and enforcement actions of late 1988 had' ittle, imp'att o'n th'e waf~3 t

V business was done. The fatality was a signific

't' emotion'alrevenYflir'd-the entire staff, and for the first time there was some g dging ac-knowledgement that procedural'" noncompliance 'a'n'd "a' caialle op'eVa'fi 8k le 'tWrs M

style had gone too far., Management, howeveE.9fas bah nize symptoms, much less diagnose root causes'and'begin 1'eh 8%

" "8"8 M.

plant back to health.

" '.'"t al.t h lm !cis nes.g l inp o

I Landing on the NRC's' watch list threw the plarii"'in't'o"i's't'at'e"c* FIN'iv4 anY CI '

o irational and emotional confusion, and placed t6e" plint"in'a'{ react i

mode that substituted the compilation of unco 6rdinated!'c'un'pf,1orit'1xVd lists of symptoms and action items for a comprehensive hange Ytiategy.WI-The former Vice President (VP), Joe Tiernan,'bFa11T &6(idts"nsY6M'T '

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effective plant manager but as a VP did not exercise man'aiepial contr$1T' over the facility. He did not. hold subordinates'iccountable,Rastumed' (often incorrectly)' that his orders had been followed..and was' riot kepttL*

well informed persons'repo.rting,directly to h'ini!^!n alvidiot'apsdm' **h emotional ' address to 'the plant st'aff fo11owing;thedatalit'ffTier6aN OM M'3 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 VP volust6ered that, in? retro-J spect, he should.have been relieved as YP as early"as'81g86F N W8 ir..s, u n. a ve s a.

The remainder of the executive team lacked an uninstandi69%th'e'th...

o managerial and leadership skills necessary for success given the complex e

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' pro,1ect management

• matrix organizational structure shosen during'the o

".' " '! ' C N '

1986 reorganization.

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Middle management was and is ineffective in tr'anslating o'rs' hirsti6nal a

o goals and operating philosophy into defined performance expectations' for.

i the work force. That work force has been accomplishing their assignment

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of supporting plant operations without benefit of adequate pmcedures.

1 systems, or programs, defined work priorities or, performance expecta,-

4' tions, or QC involvement.

v.

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 deservirigM respect.

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Management is inbred,imbre Gas and Electric Company (BG l'E) fly {or' ide with virtually no new infust'ok 'of 'e'ner o

from outside the Balt

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organitation at anylmanagement level. AJEU'ev [i Supervisors (GS) fo'r/examp.le, detersin dithat the(0same vals has been supervising s'ite activities *for*'the.la'st

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in which to disagree with the corporate'emphasisTonSpYo'd M 1 IA branced as uncooperative. often to the detrimentfofiorie;'

K Tosuwartte,managementdeontstedthe*fok g ' pY with key elements arrang'ed in declining order of manag'.me'n't...,..iP.'#6401Ir.*t.. ### P.

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'.'!..'.*W h.C M h., T productivity minimum investa nt t

1. # # # "U N' regulatory relationship

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• conservatism quality

,,,,,,.,,,,3 g,g y Management's current oneidimens'ional ap'pread to 'restofiMcEileSce a't(,

CCNPP is overly simplist'ic;and emphasites'reve'rsirig.'thd'ordeP this'liit The team' considered thfs. strategy to be'o'nly a.startths p.1'a't&$

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.i.P.

appropriate ' balancing' ' f 'giriorities'in the co,mp's the',' yha;m(or,ga o

lex"ma'trix tto Structure.in place at.CCNPP can be visualized a d

it.

sional, project manageme~nt model represented by figureg (thjeW

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IMeDedfD

' ' ' Qualfty.'and s' fe[t*aEaap > roac a

[ ces eveit management desisio ifthil'bd "a'nd ta te relationship of costs versus, schedule., '. ;

Mty and gives a full and equal treatment to g

performance expectations imposed,on the

]Sifety 4 facility by regulators and the public.

sch*Me N N peashn

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FIGURE A

.W;jem.... q y-Licenseemanagementreadilyacknowledgedthedeficienciesidentifiedby.the..,Lf, cperations and maintenance group and promptly began corrective action.to*:9. ' < p.-.

resolve problems with Quality Control (QC) and maintenance procedurejuality. < _d:?

• The licensee was more reserved in its acceptante of the concerns expressed by J !}. :

' the management 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.

t the inspection and was not reviewed by the team. Licensee senior! management

.,.F expressed an understanding of perceived deficiencies in communication effec p'

.g' tiveness, leadership skills at all levels of supervision, and their ability l to manage change.

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The VP resisted the team's suggestion that the 'na'tN.of thelfiNdi5g'sI1"nhi...

l cated the,need for prompt and forceful leadersh'ip',.on', hfsipart., stati.nhh,1.s..

intention to allow change to occur at a gradual. pace.and,pemi is. managers I

to learn from their errors. Likewise, the VP reco nitid that,'."is"viirwed as p..

t-.

di toi, splay g a strong leader,'but stated his intention to.permi,his. manage 1eadership and develop reputations among the pleWt,;s,tWffn 's,(le,. r,s4,9 y.g

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The team found the VP to be a manager who demonstra pe on

.an J-t professional standards and demanded the same of..his.subord nates.1He'3 a bee,n%.

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o BG'8 a student of management and is recognized for the' advan'ce's'.'ma'de' ]! sidor

'ss fossil operation while under his direction. The leasi' determine weakness to be a lack of nuclear orientation or a vision of how a:well run...

l safety conscious nuclear plant is managed; he does not have the'handi',;o;.f,,'.~O.,.

experience that would give'him an effective nuclear conscience.,

eam,. 4 i

i aie A 'i h'

b;d6esi 'p" oa'c'ti fe"i'n....p" concluded that the VP Las well as two of the three manager, l

sufficient time or experience in the nuclear environment.t l

mnagement of operations or recognize the warning signs ' f'dicli (6(Q'e or o

l mance that would Itkely be obvious to an experienced nuclear manager;.f,,,,7 a V l

3 Of particular concern to the team was the VP's stated philosophy misYP i

who interjects himself into daily operational, event' slo ".than.an on-site VP g he is a corporate officer with an office on site.rather dirfcts,th" siti'Yh phil.,Veme,nt '

D '..6phy,of h response to' situational events. The team understodd'.t JP i ' ro proceeding slowly with the' intention of institutional zing,da H

he hopes to make and building an effective mana'gemen.foun o

the team continues to be' concern'ed that the VP doe's hit fdlly pa th'e* *'

extent of the change necessary to return the'plantjo*'e,xellelnceCakdithN c

while his preferred pace for that change'may be appropriate for.a.fossilf f.

n plant, 'it is not adequate for.a. ndcleat plant with the range an8 %e' verity 1f y;. "'

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deficiencies identified at'CCNPP.

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CALVERT CLIFT 5 $PECIAL TEAM INS

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MANAGEMENT EFFECT1YENES$'REVIEWM'el T ". 3. 4...

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.e 4-1.0. INTRODUCTION

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' '"?.'.stes3mi@4Nm u 1.1.

Objectin From February 27 through March 31,-198g, a team' e'f 12 NRClinskec't'o V :. k.;i

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aNu'cIn'rA.

contractors performed a'special team inspection at the CalurSCITffg$tena'dce4I.-

Power Plant.1 The team consisted of two groups,'an'operat'ibWsWndfm'a'i group that inspected in the areas of operationsi maintenance,Qualityt66tfo1% *

(QC), surveillance testing, and corrective action 'and ~a set:on'd'g'fobpie((14:t'N ating management's effectiveness in safely operating the planti/L.TNe.4te1m's'W findings are detailed in Report No. 50-317/89 200 and 50-318/8g; 200)*n #ns;ttd y em 3:r.e1 tycra wClistiops The objective of the mana'gement t'eam was to assess ma'n'a'g'nleh'tT'ffEctiveneYsM e

inplanning, organizing'.. staffing," directing,and'contro111n'g*'the7'opeYatTin~f!30 of the facility. The team emphasized in its evalu'ationtthFident'1%' ft4ti'orrr fet e

management related root causes and contributing factors to recognired funda-mental problems affecting safe reactor operation, af.;ti san) +pmdspohsssFe1/

y rntn bon nhrp}otta+nslrta l.

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~

un bivos bna.pp eHNahtse '""

1.2 Manag'ement Tea's Composition "..

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', wu nt gttubop4;mstg:n.A The management team members were selected specifically to prodde*Ot?alis&edi's1'-

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credible team representing diverse backgrounds. A former;Ndcle'ar}VicekPresi.?'.

dent offered i corporate manager's perspective that bas 4c'oeipidaien't'e'd/bbthe... T i

extensive operating and training manager's~ backgroun'd'!cf)avsecdridettaa..

l-member. A third mes6er, s. recognized expert in organir'atiorfal desigtwith l

nuclear corporate exposure.ybrought an academic influence:to th'evg odp. The

~

p management te'am-leader was'a team leader from Reactor'Special ainspectionso B ranch wi th?an scademic' backgroundin mana gement and.'a ibroad 'rangetdf.'experi-ence in' plant' operations'and NRC inspections; :The.uianagement teamfwasE $^

limited to four persons to facilitate team building,*: productive coemunica-l l

tions, and effective team management.

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1.3 Evaluat16n Method i e d.3 M.*n per {t'IfaQtiv-s e-m.m!N..gesp yo ses a siilT' c-1 The team develo' ped a managese'nt effectiveness Wodel and'methodtddsigne8sto s.r.8:.;/.

X ture and identify the attributes necessary to succeed in that struct'uren (2 (1) systematically review and evaluate the licensee's organizattorklostruckudh.

inventory and assess the management and leadership skillk ofdnanagers'.andM,:....qL objectively >ev'aluate -

i supervisors at all levels of the organization, and'(3)fwithin theibrganiza--t,.

the effectiveness of managers in applying those skills tional framework. A detailed description of the management / effectiveness ^

.y group's approach to the inspection is provided in Appendix 8.

. t.n : w, o f x u.a 2.0 DETAILED INSPECTION FINDINGS

il V '

.:.t a t,hn 2.1 Organizational Structure ar '

Ic : i n is ~

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• k ytv,h.M n 2.1.1 Special Challenges of Matrix Organization

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The team evaluated the licensee's chosen organisational;s WA.3C

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. P W '. structurtry T

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l addressing the question of whether the chosen structure,is,the most pprop'g....I.*

chosen 0

,es3thinph'\\'MP Having no justification for stating that t ate for the facility.

structure was more or less conducive to effective management sc' l

cation.,,.,., ~f any other structural model, the team concentrated instead on 1o I

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I tio'n-The licensee has chosen a complex, project management u,matr,txhorga~

and gunders',tanding.,4 a)Q,ca j 3 3,,,

design known to require a great deal of energy'd organizationalgdes gns i.n: wg.'

levels. Unlike traditional, vertically aligne u

which individuals have functional authority that_ is. gener. ally,.connensur. ate q e,.J i

withtheresponsibilities.thatpersonmustdischarge,tnthe'1,1,cens.ee4si.y a

matrix design there is virtually no one below the.. level of, p,lant, Many persons who do not have the word.

x.-

negotiate and share resources.

• manager" in their job title have management responsibi.11 ties,':for,,.comple,ti,o.n,q of projects, creating a situation in which special,ited p,roject; management ando 3

leadership skills are prerequisites to success.

3..n a ut hg g;bc,,a! h a.

a.

m.a t. r < % ten < st.mpwr The team conc 1'uded that lice'nsee management and staff,. at:,al),11evels,lo,hthe a,m, organization were not aware of the special challenges presented by a complex required.to matrix design, and could not identify or address those attributes, ion'cir? '"j function successfully in that design. Specifically,theorganizat

..,,. n,gm.,,3,f ye, 49,6gg rently lacks:

A shared vision cf clearly coninunicated.and,pn%crine was: cid la

.consi. stent,1y, tinnm s',0 o

demonstrated organizational goals and.,0bjectiyes,q'gg mm,3 Shared information

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.w.c An integrated, site-wide planning and schedulingfsystas u).in..

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Middle management effective at translating for the.sork o

A demonstrated understanding of the interdependence.of for'ce k

broadlystatedpoliciesandgoalsofmanagement..into o

I: :...

o performance expectations,and work practicesos c,m..,,. ] g g M y The licensee appeared to lack an understandiM th}t71nNeNihhk virtually every activity is a project, not just obvious project activ,ities ^r'*^

Although the majority of each person's ivork"cbEtHbbtes like a s.4jor outage.

to a project, the following attributes of successful, project management we,rtg7 g

found to be deficient.

. 3. yp.7% g g.,gyep. g Wisu w v d

. 6-The Project Management Manual for CCNhP,d: oes not prov de a re g.,- l zs

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understood definition of functional responsibilities or,accountTher o

abilities within the organization.

g on ownership.

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g.l..,f-The facility's lack of a site-wide planning and scNedNindyst

~

impedes the distribution of shared infomation.. < Access.to,comput 3,

o While in a' traditiorW erized information is virtually nonexistent.

al vertical structure information is a cosmodity'which maynbe f

selectively distributed to contrs1 people and processei' successful"'

project management requires all par,ticipants.to be. informed, and,

coornunicating.

Conflict management is not recognized as a managemen't skill, nor is o

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it developed. Because conflict is inherent.in.,the.all.ocationiof l

scarte resources, that conflict must be,constructivelyps61vedfy*

1 involved manager,s..i. a

...,,,. a,., g ig,'g fgg decountabilihodrihtcomh'etidnMiNNN uhfMh.

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I organization,-and generally. is not. clearly ldef nedifoM a n,1c,1 g i

l

.,,;.,,.,,. g,.

4Mredushn.1gritsispyr.

pants.

An analytical, systems N iented EpprNach M h "c M YmeT s h.

not in evidence. Comprehensive project management sesi}ho*jbF;*

o generally considered unnecessary..

.._.,.3 m.i bNc W g d sh D The cultural fa[ tors of thist'a0 re akh kfy t,.

I o

v..ra seon hosVga' $asumge.at.nh.k.v. 'z' i

n i

7!D !.shepasm af.!?.rgddedit. w". "

d'*

i

)

n M v4.M.? 'sp: In o?:Mks:s k.,g..LM ~

~

2.1.2 Organizational Dynsinics Q&.g.<.. q,gi@3.;.

1., ;

.c-

.,q T.'

1 w.v

....t y, g.

The team concluded that in the practical sense;.CCNPP was,,d1 ded.organiza-mf%.,Jr,~

/

ing'mosic'r'.h tionally into three separate, operating entities, each.functless independe J '.

philosophy,: attitude, and class. These three, entities.,are,(Qth,ef tWr'e'ei g,",

r Manager) each.of.whos report.directly to:the,Vic.0perations,/Ma

'g c.

Managers of,0uality Assurance, Engineering.f and ant L

f j,*. ' W.

General. Supervisors (GS)-}.and (3) the work. for e,Presidenti tite'l

~'

e General Supervisors (AGS, Supervisors, and worker's.,*,Th'ei Nu' A entity, the Vice President.was too.new to the job at' thenV;his'.'drg'anha's i

fythein l

tion to draw conc 1Lisions about potential barriers af,fecti tion divided vertically with, distinct comunication al relationship. The team also..found. sone evidence;that.:the L

s hfi l

lines.

• These. vertical barriers appear less pronouri,cedjthanthe,,,

,37.,,, 3.'d W bhIud M J3h l.(

disconnects..

..e c u.-

.f.

Profiles of the characteristics and skills of the site's executfv"beYsjgd j

included in Appendix A to this report.

.,g r,g. y, 7,g,9;,gg,4,g,y The teah' ana' lysis of ' he role of the three mana!eM("th'e ffrYt*'w 13e*

t entity) indicated that if they were functioning e fectively.thef be"thf, major architects of policy. would be a sourte of clearly'..understsod efpec'ta >lf

~

I

,and "'

tions broadly statzd in.terins of organizational goals..'andfobjecti "si * ?;.*

would strategically plan iorganize, staff, direct,'and'c'ontYol.;

6Ql.

activities.. More importantly,;they would bi.the 's'ouFcei'o,f,,Ihe;'g di light" that: defined and demonstrated a safety-or.iented' operating philoso and provided leadership examples. The equal sta'tus:.cf,all.;thse.on','th'e

site's. organization chart implies equal respotisibiliticisland atitho however, the licensee knows and the team confirin lant"mana clearlyhadmoreresponsibilityandauthoritythanthefngine 49.m managers.

..,y,. y The team concluded that the three managers seemed corifused'aEIMdNEsf

i Rather than demonstrating an operating philosophy that. emphasizes l safety and -

quality, the managers are and have been a.. major source.of. mixed'messag'es that",

g., ;g.,,,*

demonstrate a production bias, an emphasis thatshas'bcen ge(;t,-

y

'l

'.d. j Q:.

f..

z.

• • • PREDECES!ONAL.. INTERNAL USE,0N,LYi',* h.

3

.t

• PREDECISIONAL...!NTERNAL USE 0NLY *.

l

25. Le not generally recognized ~by their subordin&tes for!their leadershiphkills, and are generally lacking in their ~ understanding of how toirecognishran'd..

o manage change. As a group, the degree of teamwork impliedibybth41rt' equal status on the organization chart is not present, and they appear. to lack a shared vision of'how to proceed from their present situationitona: point i

9 farther down the' road to excellence.' They" appear'relatively.!nalvetabout the regulatory relationship, and suffer from inbreeding and isolation 3that has left them without a perspective on what a first-class nuclear operation

' w &. w> / s.m t r.t.

o really looks like in 1989.

?.

.i u.?c:1.entM., t -

nr o

v Effectively separated from the managers'above thein'an'd'the'worktforce below, the GS group would ideally function as a translator of the ' guiding, light" into performance expectations. The team concluded, however, that':the*GS level.

of management suffered from undeveloped leadership skills and a poor under.-

I standing of the managerial skills peculiar to the matrix structure, and as

.such tended to filter the guiding light rather than. focus it.

M'

<..it.a..j, i, o ts a fr:t: % S. h r.

The work force below the GS level would, in the organizational hierarchy, be ?

lef t to do the 'real' work required to keep the plant' operating)using)the's #4 tools and resources made available to them from management. Th& team' con'/ dols -

cluded that they do surprisingly well considering how'little of'.th'etpuidthgdoi.

light actually shines through., -To paraphrase several persons;4orker:1'wish %

they (management) would'just tell'us what they want*AFaced.withlinloperataa9 operating and little guidance in the fors of prioritization endt)$1the p'la ing philosophy that tells them to' do whatever is nehessaryf to+k'ee

~

annihg,tefhe work force has long operated from a posture of'not permittingtprocedures',%4 quality control, regulations, technical requirements,7er achinist'rative.c r3e controls to. impede their support of production..Thet workers 2 have>kepta th'e nots '

plant running in spite of inadequate and uncontrollediprocedurahhfdahce',+anV ".a

,s anemic quality control criahira' tion,"and limited resources iinith'ei.fors'of4t.vm O..

manpower, qualified parts, or technical information01Much 'o~f'the tsuc

?. *:,

in the station.

. '9 %

'.t"A "

i.d.W r..c Ms M.e mcM. 7 The organizational relationship of the Vice President," GeorghCreeT.T site managers, and his perception of his role and responsibilities *in:

p s

When questioned, Mr. Creel st'ated that his organizationallrelationshipiisjin.!C.I'd '.

line with the traditicaal BG8E role of the VP as~a corporateloffice'r4who sett$'.! N.

represents corporate management and has an office onfsite.c;HeVd6es'inottar.@ -

perceive himself as the senior manager on site,"nor doet hetfe'el'Nte*appYopf 48 0;':

ate to interject'himself into operational decisions'or situa'tional/events r

He stated his intention to pursue a hands-off:stfle of managemesttthat allowed his managers the freedom to make mistakesvand>1earrfromfthosevem br.si mistakes. He down plays the perception held by many a't*the: site:.that herwillt be a take-charge professional manager who will be firm butefairlind+:leadethe /.

plant back to its former respected place in the. industry.. noting':thattitfisp's the three managers who must come to be perceived as leaders. The teamds g :r 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 requiredrtoireturnyCCNPPatoran,ect excellent performer. 'The team is ' concerted'that:while'the1VP'.s prefer'redgfd evolutionary, pace for proposed change'may;be appropriate forgap,fossi.1 facil.1 ';

ty it is.not adequate for's nuclear plantairith the<rangef andiseveritytofenca4 d

%Wchrt tim >wM -

deficiencies identified at tCNPP. '

. )..

y

• • • PREbECES!dNAL.'..!NTERNAL USE 0NLY

• M,

,..j

.a c'* PREDECI$10 MAL...!hTERNAL-USE ONLY c**.,,p.; 6,

..:.. i.'.

... G' "O,f; C-

,i The teem is concerned.that the hands-off. approach,to'managementhwhic appears to have its roots inLBG & E management' cult'u i.* extends' t i

J

~ ddt. i*

The site functions as though,wa,s, managers.as.well.

{was' he ff..d for. nuclear: power and each;cIf the.'three Een'ager,s,3nds th'e'ir.g M.*

VP o

i o'n'si.,

area. With' the entire executive team taking"ah ap bility for traditional management functions is being pushed' 6 W

• ,'; N,

organizational structure;b4 default.

,y,. d t t r.mg.ea'EIfNtYdot

. r.M."

[

2.1.31ulthal ConsideraEI5ns;WithIn 'the 0%izjt'io[,]

explanation 'of why certain attitudes and practices prevaile,d,$ d,', regular 1 Duringl'iNrviews CCNPP personnel regularly'pofntid.'to,M hTiNhk ou offered it as'en excuse for slipped performance.

Few:among'the manapaineny characteristics of.the' organization,which impacted,'dir:ecily,'on,1 e"i:u

.tu,tlal"," *";

staff were 'able to define?. culture, but most.were able,.to desci he%a) Met [9,.

d' business.is; conducted'at'the plant; 'To aid in.its:a's'sessment'o,*t 1

of eviture on operating philosophy, nd practice',~"the' team @sYigry,e hG

a following working definitio'n'to the tern cultur'et Va16es'and ides Bemond'*.

strated by management's operating philosophy that drive how wo a

,,.;,,.;j y..,[,

'g'fy prioritized,,organtred, completed and evaluated.*

Beyond beinh unable to read 11[ define cultuts.MgNnektTes M ll grasp how culture affects performance, which cultura11y' based'%5 ophrating v' philosophies.are currently,in place in the plant, or how management-c.an

.*3-change prevailing cultural trends throughout"the fad 11ty.X' Typical,hfl'thF8Ed.j.,,..r licensee's simplistic approach.to change management,! attempts to[ndeftns'tfiP[' 5 and,qualith"ahiad',M plant's operating philosophy to one that emphasizes safety'v

'a re* *"

of production (and in the process redefine.the, cultural.en largely limited to putting up posters' under the thems'*Cha11en'g'e g'8g the posters do portray an. operating philosophy which assigns'a h1 hhi'ority'W t's to safety and. quality, the plant workers remain' skeptical about managemen#nbtN sincerity based on the worker's past experience with'mana'gement's actions being conristent with the philosophy being promoted..;',,,'

,, ,,' ' f,,'.,''(

Management does not appear to grasp the need for demonstrating,;a phy rather than merely describing it, and continues to send conflicting.lo w phi t

' ~ ~ "

messages to the work forte. For example,' workers tho'ughtiit.'c'oh'sVr' atiVe't'o".

v shut the plant down on March 8 for feedwater regulating valve';r, epa'ir' and'.'"#-

test, but the traditional production bias was reinforce.1 when'on Ma'r'ch'*g'lV!

't.f management elected to start the plant up with an,unisolable pinhole

.a Having missed an oppor' unity M'de'moh'stFate'?,..

~ t steam generator blowdown line.

to plant staff a'nd the NRC their new, safety oriented' operating?philessp'h managers also succumbed to comunication dis' onnects[and'a' li' c

off rianagement approach and did not describe to the work ' force their! ration ale for ordering startup.

l

.., g,,,g,

,3 The team found the prevailing cultural values and,1de..als to include:.w.w toJhni s

a 'get it done' attitude that supports productionldWdetNNW6f M o

. procedural. adherence:or appropriate administrativ[cj6nt,jdlsgg.].

A 4dMnMcNHek.;..-

a sessage that says ' don't spend too much.'t 'g'ehif*'8olie*{W' ###'P W.

• o

'"'"*l'"

-' r%4 - %..'!*"ng. f ews Tw q,.

tendency to cut cornir.s*

i-(-

m e

v.a..,

t.,

9

• • • PREDECES!0NAL... INTERNAL USE 0NLY.

. - 6e

%'-]...:4"'.

t

.l

s.,

s

\\

• • • PREDEC!$10NAL..'.1NTERNAL.U$E 6NLY M '

~

.i., f,...,

. t Y h'..,Y. * '

i t

amessagethatsays' don'tcausetroublebf.5ediTn'in o

LE. S.S '

your career will suffer *. Seing a ** team. player'. nee'ns' e'ing~

• yes'.f6M man', and even the plant manager was~ able:recovit.'severa1 in kes'8Pt.$ '.,

where individuals were reassigned because they]w T

not team pliyers.

,/,j y,*gy g

In addition to these prevailing values, the team identiffeNperkbh65$sM t

ophies, with their attendant cultural aspects, that had, evolved.among various was filtering through. The control room staff.,for,,exangle..had,de groups in an environment in which very little of management's!'gVidin l

'd

.bility for plant safety'without regard for.the preva111n'gl phi.16s'6p

' pons'D operating philosophy in.which licensed operators.' assumed lp'ers'oriall IEin

• promoted by management. '. Sufficient unto themselves adaccust'omid

hay n

to balance ntf

• D l

and resourc.their perceptioniof plant _ safety against,the,pr;;oduEt16 ment,. maintenance. QC, systans, design, an e constraints' imposed on them ' operatorsMme f;t s

,thM Meanwhile, in response toihe production enpha' sis',jsfntNU@'Oson'nft1N,7. ' '

responded to austerity programs by doing more with less and, in'theWpercep.'

l tion, were so successful in doing 50 that any administrative.. technical, or E quality control that impeded their effectiveness.was viewed with'disda.in..'.

l

... w 6 0, 6 w... 4 In the Quality Control organization, no operating 'pi1Nsbph [ex*GisNO M\\

taken'serio sly lahd' fi4dinNo*I i

practical purposes. QC until.recently was never'rollin[de QCactivititisbeVe i

defined mission. Written instructions for cont absent, inspectors have been and continue to be ' con'si to be technically incompetent, and the whole' concept'of,4,'selond set of "" k eyes" is considered an insult t,o craf.tspersons..

,',,[g *, [.

i In tN enginee6n'g organization no cohesive opeWting'. philosophy?c*o^u identified because the four distinct engineering groups!on.sitefsys$

P C3 project, design, and fuels engineers) function as separate entities." Cult $*d al considerations which impact the engineer's effectiveness include a lack of respect among operators for the technical skills of pany of the relatiVely".A.

young and inexperienced system engineers, an opinion which is'isip'r'oving-overM time, and the lack of respect for fuels engineers..an opinion % hic'h;is not'9 hole" by those in need of its services; this-negative perconsidered,a improving over time. Design engineering continues to'be spite of substantial progress by the Design Engineering GS11n :the 'categorita#

tion, prioritization, and control of his work.

In 'short. communikations " " T' their customers impede the effectiveness of the group.

', ' 4,

,'y barriers within the engineering department and between the engineers and M"

• • U 2.1.4 Procedure Problems In light of the significant o erating events in which inadequit'e%Medures' and procedural noncompliance aas been a root or contributing pause, the team

,e, was particularly concerned about the low regard all" groups %1d for,,proce-dures. Problems associated with procedure misuse. ' control;"'andQuility'.' pose ' '.

a serious threat to operational safety at CCNPP. The following" quotes.

0 cultural aspects underlying, the plant's disdain foi"pr;oc4duresf gleaned from management and plant staff interviews" offer' insight *.

'[,, "

• 4

]j

?{h?l.,

[

~

l l

J'

.I

}g

(

• • • oernir.Fdf*AC.1NTERNAL U

rb

[W ' 7 PREDECI510NAL...!NTERNAL USE ONLY, g,

,,3

.y'

[

"We considered procedures. to be guidelines and not hard and Yas't' rulesd

U.;;

o i, a,wn e, n. ;,%.

.. c., a..

. u,.g s nous eg.pnt. je....

'We h'ai a' hiVt'or of"tYkin f11bertidisithMee'dures;d 2dit* deal.)-75s -

1 pro,blem '" M" *y' * ^W""g* k '-

t o

' m SaJ e U w m 't e aammre..

,...Tm,..f r. v. ;

• cmo t; 't.rt I:n :. 4 M ' r.6. Q.anid o @ 9 h d, y ria tg X ;^

16'orderf Offit1'tWWP. idn~i0%Ai E,). M -

?

• 0up Weeddres 'seM'n6t vir' > go'od 'an'd o

p y

had to ignore procedure steps; this led to a complacant attit'udeYtWar'd n procedure adherence.",r.:

'1 n., 03 nM 7 m Tanc.c'" "Nora ec J'

• .o i

"We didn't' always thihk'wi' heeded proc'edure's';'s'oine'4fMMh*6ughT th'e7I..

o

• MN interfered with our workers" thinking' things'.out..f 4 #4 '.'5 6 I upa*4

. j. if t et.ti f C

.i 3

'e f.

it without procedures bacause'we' had a highly skillid staff. +'Sfnce;Iy%y "We were ^able to run the' plant hfely and effectiv~ely'lin'theVdWi o

• theh r

our skill, level has been diluted."

• "*8

'J N Di d"0 TI o

• We 160k pride in doing the'jobnwith' the resou' ices'7aVi11stifi4 fd do1/g

. 9.

1 ar Schidules Wers' more' important"thari',qua'fity? o3 M8J0 8. *N '

it on schedule.

. c.. *

.a

.o < e s:,vu ;otos as t w anoon.

The team noted that the plant staff tended to speak of procedure problems in' p

the past tense,'as' illustrate'd by the quotis' abo'e.' Irbfac't? th'e(fiam%iii*.: 4 v

una bl e to i de nti fy ' a ny ree'e'rit ? si gni fi cant : 1mp rovement' <i n Vfo'cidirFiddl i rl. :.;.

.P compliance,#ey'en after ma'nagementdissued edicts that)pfo'cid# emf 114d't followed without'eiception? 'Forliiamples on Mirch !!0 aMc'oritfc1Todefdpe W_

System cabinet',to service skip' ped two steps 'ih the p'rd(e'd in the process of returning 'an Emergency Safety Features Safety? Actuation 6 P'

a 8 through the' procedure to seinitia(e the seg enc'eFandtiriitiated1drpiftTaMe safety injection. system actuation, kanagement's approach to the procedure problem soffarkhas consisted *'of orders to comply'with sproceduristkndirneto'6e o

i riddled with; deficiencies,,a'6dda'*histi19 c6nceived.Ptoced(ire UpgYadecAdtiono Plan'(PUAP)r'which-has~ not'beinNe11< implemented.' ;This appioach!was corisid-e ered by the team't6 be a ripressntitive ' case study df sidnagement'secover:1fo simplistic." quick,fix" view of how to effect change in'the.organizationland V :

their unrealistic"perceptie6 of,theiektentfofcthe p?the.;1ick90'ititpotehtial robleFande o

forreducir@.sa'fety. The problem'is exacerbated,by f8 understanding'.

among plant staff and management ofdrhat'a quality'.proceddre91ooks111kMehow ;

l it is modified in 'a manner to' preserve its' safety.'intdgritfphoWtit1.isrMo1 N administratively controlled, and how thoroughly it must be performed.2.

saenac6e ytid'c o3..

.a.....

s..

st. a..,.... e c..

e 2.2' Manageme"nt Processef

M k NI nomiU N

~

't

.n. 6,. ts ' >; i nnd ewi4ns TV,,,. v,;{. ;,.y' -

2.2.1 Organizational Climate

.'?,

.14 me? io.x:u.! s',v.s

.N l

The team identified characteristics which are representative of the climate I

u

"# W - a t> il) io eM0 $W '

in which work is perfonned througho' t the plant.".1 o.. W w 4 m rd.'cJ 1,rxM '

L

..a. n. -

Employees appear secure.in their employment with this paternalistic,., t e o

BG & E is nonunioni'ed throligh'out',tand'managemen passive organization (

z is proactive in keepin'g' employees too ' content:to ' consider turningSto" W '. '.. f XS di.o*' n organi, zed, labor.

A

• '" A.et h d a

  • w nt zDttG With the production ' orientation' pervaiive through'ou't',l'teamwort,*is'va' 1

c perceived as doing whatever is necessary to support operationsYrather,

. J';i,

than working?together toward'.s shared objectivet'e SM8vt4@".AioWefi <.u.3;..

- ;,r.)

s./m mh$

.pfsp' ' ',.

.<...s

,.e. : :y...

e Q-f g3

'. MW:m L

PREDECESIONAL...!NTERNAL'USE ONLY *W.tTi!& A$N.W[e.'v M a.:

.;e'

~ *"

2

,..i...

J

't i.'

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

The organization apieaEs to'h' ire no MaIithionN."vtEn N n't or a

-o future. As such, tie, facility. is managed.in a;., react,tve ra,t,he then,af~.4 g

b'e t n.g /

'J f6 rib,.c <

Presently, the reactive management response, proactive mode.

placed on the problem plant list has resulted in emotional 9 p

.. g yn.,p g.y y.

interviews.

3..

The emotional reaction to being placed on the probk'eIiT s

o l

CNPP was;g.g left many. yearning to go backwards.to,the 1984 era.,when f

l'tNa'tTth'eff '-ippedsothe perceived as a good operator..Many deny.perfomance.,h'a 4

blame regulators, but the majority appear ti ha've"acEept l

perfomance was not as. good as they had thought...They.can no,tyc

~a identify how, when~, 'or,why, performance, dec, lined,6r,,wh,at,'

fg.y p l ly shou!d do to improve.

.. g,,,;,a g,.g u.... ".

o The work force demonstrates.a willingness to.,do twhatever;ndshs' hte. 'f5

• rtturn to excellence..,but can not identify thec,maha~g'emenfile'a'd

.pg necessary to constructively channel that energy.

' ' 7.* QL l-Nondegreed members Nf the work force arehrust[atei b e$

r#c p b ((1' o

of a limited career. path..Theteamfoundsome!indi,cationfth oppottWdz5 nities for earning degrees, Ir.teral assignments..and a~dvancement are,ggnagp g

available but are not; fully.. accepted as,opti,onls byethe.,p r;ker).M 7 Q m..

There.1's an undercurreYef a military.caN [sk$1h k~ dfNNrI1bh officer / enlisted relationship scattered,throu'ghdut,'the,oggarypa;tio[nyM o

There is no sense of. urgency. or ag ressiv. asu.e a.;.v.nvt Ant W >ms:g,%

enessb n.addressjngs F6 bis vs n.

a<.

us-i

.j o

l of purpos and spirit of cooperation.that bor j

However,. for prob ems affectindlantl l

once identified.

~

ef g

b,ay meg 1

.p,.

in '198$ w'as and continuss to'tI syr$lffcNtktko

^

The fatalitk levels of, the work force.'r tilike the@thedI

~

o ther'o Thti' re

'O -

o 4

u event.at:al n

events that concerned regulators, the fatality was.i forced many workers to grudgingly admit that' prob 1,emy.paj ',ji',t.j'h y y; s

l There is a general' lack of undrstanding of Sw'NabtNIda'tfoM an apparent lack of sophistication indicative of the. extent to bic o

I plant has been, isolated from the mainstream of, the industry. '"' ' "

~

.Mralt.1 unrisssir,q10.ns.'i 2.2.2 Lack of State-of-the-Art Management Processes

-l ManystIteoftheartmanagerialandadministratiYe[*todsIid.To'n'tNs',""'".?

~ ~ '

found to be conspicuously absent at CCNPP.

ktm;c r,

.~ u Procedure control is virtually nonexistent.- [CoS.....+, 't"p ot,,

trol c are identified, and ev'ery copy.is considered a con'trolle,d,,op o

cdp 1.'th

no,

'isli se. c uP,..-

mechanism exists for ensuring the current approved revisi Copies in use in the field or staged at workstations arie"n~dtish complete or explicitlyj identified as. being(c,ontrolled.,

g Temporary proced'ure Narige 'is a cumbersome'prNels,'pa$1c71a$1 o

maintenance department? Once a procedural deficiency h'as 'b'een i

h :'.. u.

s.

y_

J4 :*.**,,*,[*.,*P m

12. -

! i;:<.

W

. a *:

v

• " PREDECISIONAL... INTERNAL USE ONLY *** f '".,7,.

.i;,'

n a.

.' r.

.v. u...... y. -

cates workers attempts at verbatim ~ compliance. 8 In'the' cas identified, it regularly takes months to.correcti a? delay Mhic ktdnhii-M'.

l monthly surveillances, for instance, a technician who identifisd a E

. /fD ' '

procedural deficiency in'the firstimonth'would obtain4pprbtalitf6rtat 49 +

• one-time change to complete that performance.S*:When'lthenprotedn'et Ws 3 3,'1,'

used in the second month the~ defect would still beiin'the procedufMfbut

• not flagged in any way. If;the' technician identifiedithe defe'et'apother one time change could be processed, but not s'permanerit changeFnThis cycle appears destined to continue with no end.in'sightiU.Before the-emphasis was placed on verbatim compliance these defects 4tre11ghored or bypassed, but the new emphasis on compliance he's' created W ekersb' fore e

identified need for a' mechanism to promptly and permane'ntly."ciopriect19 I-procedural deficiencies.

'.7:m.!wncvplatC r;

The procurement of safety grade spare parts' havin'gtth'eispTro'prVte V-

';N c

documentation from the vendor or certification 'resultingyfromVahlengi-1,." J neering evaluation complicates the efforts of technicians. There is no effective procurement engineering function and support fpolnTengih'eef i

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'etausF'p'artsd D were not available ~so that to' start.up on; scheduleNould.thhe4euiredy!.

q the use of the switch" from the shutdown Unit.1' p'an'elW0n'%netda'yroff.thei,e.'

inspection there were no documented' safetyg'rade'!fus'esuivf' stock andsthe'#1' u

failure of any installed fuse would have meant'tha't' compon'entecould:Mt%,.,

v

+

, v m: 4te:lt ne, bas 4esotttswgm -

'be repaired.

.. D ev;Ku:. not tytfuaq self '

o There exists no administrative mechanism to h'andle'ainor40di'fication's7@. -

The smallest change receives a full engineering evaluation and formal 10 T' CFR 50.59 processing, resulting;1rr extensive delays 'to raccdeplishizinor$T modifications. This~idministrative hurdle is. thought:to'.' contribute:torad tendency readily acknowledged throughout the~ worktforce teamo'difyathe*nsb

~

L

' plant without processing the change as a modificatifori.1Severali.vorkersse ;

l offered examples of how they' had added loads to' busse's 'o'Hmodified.W h-piping systems or components without obtainirig anrengineerince'valuat16n'a l

,or approval, and without documenting the alteration'.in mand s, tor,e sn.)T<;

-drawings.' The team concluded. based on informati6n'providedibylplantvm staff during interviews; that the 'actua11planttednfigufa'tionJmafrriow:be33-?

indeterminate. Because a verification of plantic'onfigurationtoryarimaff.

assessment of the' extent to which it may have beentmodifiedtwithoutti c'd

" approval.or documentation was outside thesscopefofttheapecia,1$ team 5

4 inspection, the team recommends future regiontbas'edwor/NRRdinsp nfidw-r

': er el PA #W cyts,:rtleims,</ rem (

],

' i' activity in~this area..

e- >-

.t%

o The absence of computerized, networked data bases was conspicuous. One~

innovative GS was developing an information base"and.ha'd. ordered: work.S.!

stations..He anticipated carrying the data disk from one workstation to O

k U.L n' "Mfdw W op &

• the; next. '

'.p W n et hm~ >:n o

'Yendo'r' makual control essent'f ally doesn't:existiat CCNPPpa>findingiiH N

~

• i..i al as' become rare in plants inspected byrRSIBt,w tmsattyNtato.t tMW.

which h

. b-sf ttTats ini 7:f(Ling thsp*

,s

.t.

,m Pro'Ee'dur~ei' us' d to" implement or perform maintena' ride.;o*rDsurvW1.1.lancesfarg e

o rWpresentative of :those found-in plants'a' deca'det'or.2ndre.1ago.wi,Cautionstg ?

,,.g.:

are few, acceptance ' criteriaknd the?use~of QC5 hold'fpoihttaridrsigho

~

g

.,, y

.v_.,.-o.r

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NAL USE ONLY'*,**.8 W :,%.,

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• • • PREDECESIONAL... INT 1

-,,. -. - - - - -U

(*

• PREDECISlot:AL...!NTERNAL USE ONLY 0%g..

..L is rare, and.there.,is.no mechanism to incorporate the3as-foundtcondi.

F.

.c

- tions. or repairs,into machinery. history;or,trendin;giprogreas4w 3aYO'NE e not,suffic'ientlysdetai,Ie.xM.tpMe?

<t

., : >.9 n,,-

.c :.e v.1 ^, b-nm ' N '

Maintenance procedures ar%,;

L o

d.to}ensuge

,1,.ity Wy t

For example, a procedure.to. inspect and; replace 2as.necessar,yj nj ec-ferred theitec ni#1a'n..*to s

, otors on:the emergency diesel generator.. simply 3

a technical manual which..is.four inches thick an 1ediff Th'e,f '

technician is free,.to, adhere.to any portion;ofdthe manualso s

all. The team briefly. examined two new maintenance p'eha,r,,tynroc by contractors which appeared to contain; state-of th

$nal-text,. visual aids. and requirements. The contrast.sbe.tweendt 3,wo n'ew-procedures and the hundreds of procedures.in.susetatsCChPPawasystr1,,ing.

.., A M.Tcsu% w.:

o The programatic controls nomally associated with 12 of the 18 criteria of 10.CFR 50, Appendix B, was absent, illustrating thetextent.sto;which a

the. plant has remained isolated from industry advances. r.4&nv2.w.o a.:H axo: elh.Jsvegnhohn 2.2.h. Lea'dership

,,. r n,w an.,xm,yq eyuh,,

.a

.J u ben MMM en nMN i.)

Demonstrated effective leadership is considered by.the. team,,to be.a. crucial ingredient.in the licensee's efforts to return to.. excellence.,pleadership, skills must be distributed throughout the. organization.

x3struc-ture, where functional. authority is dispersed and peopling.the: mat esmusttre heir' ability to negotiate, their ability to effectively coneunicateit easgandM.p.,,

l expectations, and on their interpersonal skills. Dynamic leader'shfpj,among r W i

the executive team members is particularly important if the.needed.'ch'ang~es at CCNPP are going to proceed at an urgent, rather than,an: evolutionary.i. pace. Io Throughout hundreds of hour $ of, interviews with plan't's'taff$t alkkvekit became apparent that.there~ are few rec'6gnized leaders at?CCNPP?., #fc'e,,Presi-dent George Creel is almost universally recognizedsand.;respecte( as.4,.. leader.

and the plant staff is looking to him for. leadership and, direction.. 0utside.

of Mr. Creel and Richard Heibel, the former operations GS,ahd.~n'os GS.~fo'rlt)A, only isolated examples of effective leaders were offered.x Likewise, the plant employees were rarely able to name anyone the'y respected f64their,j supervisory skills, although tradesmen occasionally.. indicated:they-respected the technical skills of individual first-1ine supervisors.w.,Mr.. He'ib'el 'was generally respected for his decisiveness and for be'ing airare.?'

tder in his willingness to question management. The, military.,1eadershi y1eiof well received by the work force. The executive team profiles i c >p,en,t,,been.

Naval Academy graduates who comprise 50 percent of;the.GS. ranks as.no l

r offer a perspective on the leadership characteristics cf the,fou'r gy;'

A di l

g nag-ers.

g, l

2.2.4 Staffing and Personnel Qualifications.,,,...., v.. b n:>nat.it. cr:

l 9.

e

.,a M wuh;

.-%na yu s..n e narm.

Since going on line in 1977 with a staff of less than 100. CCNPP increased in staffing to beyond 1000. Corporate management has willingness to fund additional positions in response;to,.beingsp,la,ced;on.the,

NRC's watch list, and mid-level managers in maintenance.an'd.QC;arNe now eagerly searching for qualified persons. The team concluded tha^t h'e'. 'p staff is sufficiently.large to safely operate.the,;fac.il,ityn y provided the existing staff.with the appropr.iate sys i

rocesses.yahd

, p.y controls to effectively plan, prioritize, and perform. work.

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• • • PREDECESIONAL... INTERNAL USE.0NLY p,f.r..s...,-a Az...

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The ability,of the work force to operate and maintain.the act 8'over

-- several productive and. rela'tively event"frie'y'e'ts,cf ehtfe JOC-N.%.

a the technica1l competence o,f thelp1hnt 'sIsff,l1s 'adeque its concerns more on the' questionable competence level 1)fgsam Pfs p W of the four executive team members have very limited expos members and the 12 General' Su'pervisors.""As 'in'd1Est'e'd' n'

.O L

.. q.

plant operation and show evidence lof not'havingnuclearf' eli idE l

Vnd'la.iful it appreciation.,for the machine; '.The (fourth"executivi* team nti" 1 of he';1Est*

Mana'ger sincel1988, Leon ~ Russell,has su'pe'rvised bpefation's3f of individuals for a decade,; corps.has: consisted of is' en'tial h;e/samiig,$vpf','I 13 years.' ' Likewise, the GS s

although.several of..them

/

ments. A detailed review of the; history of,l job rassignm,ha'v'e"f'.eients Manager andiall of the' members o'f,the~ GS' group"6ver ths'glast, 1 int L

team to conclude that essentia11y'the'same individuals 1ake* occ'upidhkebD convinced lthat the saperiod,of., declining performance.

positions during the s'n'ot T h me group of managers 'and ' General Sup s6fs l

the decline,of CCNPP,and who havl a.11mited 'perspecti

,ths ch' arac'ter'ist'"".3 necessary to effect the degree of change necessary to reverse the;declin tics of a' quality nuclear'op'eration'has the in' sight's' niperial?,'ikills. "

l trend long in evidence at the plant. Of particular concern.,to the. team is see beyond symptoms to define the, problem, articulate manag'e the inability of most middle managers'to cate how they personally intend to. improve their effectiveness';jof,1:cesnii s, besettingthejplant.

l l

the plant's difficulties.EThe ' team' does'not advoca'te,'the Wholes &1e'reple'c'e ~"

L ment of. managers and general 7 supervisors; howeverfit,,'wo'uld'a$eagalipropri.d*** '

ate for' the licensee to: seek'opportuntties;to inject;conipetsntiminsberW'.anit advisors who were familiar with, current 'indety itecsst',orsukQncP.inl3" the fiber of the organization'.

' ' v '. " J. * ':" 3. -' ' ' '.' 'p' ' ^.' ~M *

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.w %d

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• M'.'"

".. u~.;l! sm.;N,' #'?$.

2.2.5. T'raili.hg and D.evelo'peerd 7""" l 2.a :..

The team dife' reined that'forinkl. training'in.madgemEnt"iEills!NHiewF @6 appointed supervisors is not provided, nor have* senior!mana'gerstliebTn re~qif6d C

to attend classes for the.st'rengthening of, their mahagerial'sk111sM's'i he'*MThe;1a of emphasis on training in managerial and leader' hip 1 skills support t s

team's conclusion that the licensee does not recognize "mansgement'4s"aN * '

academic discipline apart from engineering, with a separate set of skills to.

be learned.

g.,.g g g g,,.4,,

2.3 Management Application and Practice

,,y,

[ [[0. ns..Y '# ', se an.M 2.3.1 Change Managesent c,

's.'.

~.D t.

fihb C.

As a separate issue from the isolationism that has kept'. management i gnoran't.~.

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 organizhtibn.Y"Their!past,,

approach to change management has been reactive and' overly simpliiticG,f a

,3 solution with a lack of appreciation for the' problem to implement:a'tlon ointerm proceeding directly from identification of a 5

a a

with the process. The problem has.been exacerbated by the,1.icens s.tenden.'. " :.

tf 16ri 'f'M % }?..

cy to ifmit,the proposed s'olution to simply adding 'the" problem.

list of th16gs to. work oh,resulting,in an approach to'cy risti t'iW W.W i gn o re s,.the.; de.'v el o pmen't lo fpnompre. hen.sive changi'.s'tr'a'te*%

fa 18

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he' "a'cioE 7 M change mana,of uncoordinated, 'unprioritized ' ists"of,/th generation h':

gement generally absent,from e

ed comprehensive issue.iden,tification,'a,th.,processss gnment"of 'o' ne

&lt, k

4.. m.j,.a tiedm5rp resource comitments, implementation planning,'. fee'db'ac.k,"'hsh s

w L.

B and*fo) l

. e n..v.:

l Successful change management is an org'anized procis's' by whicih $a5 MtUrl D organizations are effected with.little disruption'to,pefs'o'nni [enoq tNe' /***I

,f..,

organization's mission. Examples of unsuc'cessful.cKang'e siana' e t*CC

-l

, N l.

include (1) the way in which QC activities were. absorbed' by ma'isteR tI ds aseriesoftransitions.thatcontributed.toawealout;to,'ru'e;QAJ grizakio$ h'y.?.;:

the peer evaluation concept.and then transferred h

d';

~

k..'unst cture p dlWa'n q:f 6

.f.2 (2) the transfer of the engineerin organizatio'n-from'Baltisidtfe o y,iti "N%.M.'

l and subsequent development of the kystem Engineer; system v' sin'gts'es oifn'.

l ty among the plant st~af.f..,Both of;these.,,ty,itiative'sysuffe',with 'pla'nt yJ,ff inexperienced engineers lacking familiar,1 uJ in 1

p l a nni n g, a '. s imp.1,i s t i cT'vi eC o f, the ' change ' pr'oc'es s', 'a rid "ajf Yu the impact,the change'would.havelon the facilityJand"the'8*'

'J " f

.. F.v,..

m:b uh WMY)6%$ gist 40ssn;W'.,'@*.

volved*

n 1..

n

"'*" 'k[h One other exaaple of an Asuccessful attempt'ai chaMe"inaNMEt,;

N 4

potential' safety significance.

In interviews the'foriner~opepation 3

.,d described the simplistic., approach taken to implement,;thefsympt'aidtbh i

L Emergency Operatin Procedures (EOPs).in 1985., Facing gre ffs'tEnc

'g, change.. the 65 fai ed to consider the ' cultural: aspects,',of;CA1,tho,'yel oing' I

operating under event-driven emergency response procedures ugh' opera-tors helped develop the E0Ps they were not pre-sold 'on;the,concep,t.,4He ""

acknowledged portraying the new E0Ps as a ' guide",'.thereby';dimin.ishings,E',@ g importance. The net effect was poor performance ih"the sisulat6rla' d opera *.,

i the,,;

tor's reluctance to accept the procedures which continued,.according,,to,iew', #'2 GS, well into 1988. The t'eam is con ~ceined, on the' Basis

• bf 'tha't'dinterv symptom-based concept say.not actually be accepted"15;the" cont #nd that operator perforinance of E0Ps may actually still be weak.a rciin.**

dy team referred the concern'to Region I management duringitheLin'sp'^ctiibri.

' "M' e

period. The integrated team inspection schedule' indicates 'an. EOPynspectYein },[

""..T.:.~to : # 1 m. ;" z em.t

+'

is scheduled for May 15, 1989.

.'. r, d u,' n tt' M s. n c 2.3.2 Performance Management

. D,# SS The licensee currently r,elies heavily on management-bgo'bfeYt1'v"e (%idf,5b? U

~

a process that is more difficult to effectively implement in the matrix organ.,,

ization than in the traditional structure because of the 'dfffusion'of'ac,"

countability and ownership of projects throughout the organization. Managers..

have difficulty objectively measuring a subordinate's' success when that; ;

• subordinate seldom has.the authority needed tp satisfy the objective.'"tFor",

M80 to be more effective in this organization management would hav'e to ace'ept '

establish objectives that evaluated an individual.'s contribution to'pr the concept that all site activities are projects, n'o. matter:how s'afal1% a6d'"

which the. individual, leads or. supports.

],,'Q'y"[g';['{'f.f-Indicative of the limited effectiveness of MB0'as n$ippNed isWco5 sis?

the organization that mana'gement' essentially leaves' workers td?t tent theme heard in nearly all interviews with individuals [Vfr6m'throughou 4

44 e i

devices to channel their own' energy, to plan and prioritize thE1Ffoin'woMN 2

e es

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• • • PREECES!0NAL...INTRNALUSEONLf*N I

, ",,7 l

• • • PP.EDECISIONAL...!NTERNAL USE ONLY ***

)

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. u.N... :. :M */ X'J M

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and to make personal interpretations of how each can make a contribution'..'... ',fd r l The work force gave a-clear message..to the.. team.that(managements.1spotM6

.l.M '

effective at conveying clearlyrdefined performance'expectationshM1HhsM 2

d t i w. w.2 -... :.m. c s..: W t u n n a m 3.f d # e h 7 t?.n.;

I'

.:1 t' : :..

v.', ' ct... i.

7.* !satttp.yng? 4a',l)ud, #

yd ' '

2.3.3 Management's Demonstrated. Emphasis i.i r a

t. s i +n no. dons ;tM RA,. he.6 U f:

It is clear th'at management holds and continues to demonstrate'a'n)op'e'ratirig o.

philosophy that emphasizes production over quality and safetyzl Mana'gement E however, conveys through their actions several other important messages'tto i

e the work force.

m..; w t ts. wr. s ms3 'enf 1. a

.n: ;- n <1,.:D tu):n

~s.-

o Although it sponsors regular self-assessments, management's poorirecord on followup to correct identified deficieni:ies leaves the work forcer' doubting management's sincerity.

..,,i i Ni u nt-

.t-1 m.pt.m sM u nc The team reviewed the licensee sponsored $$FI, the Duke Engineering.

Assessment, the 1987 OSART report, and several. interna 1LstudiesWrid QA M '

n audits, and generally found them to be comprehensive. The QA audits ini particular were of high quality, reflecting : depth.ofiinvestiga' tion'landia0 6;M.

willingness to. raise tough questions. Plant. staff. was frustratsdiwithnst.13 1

the lack of management aggressiveness to correctrdeficiencies6growirigmarl%.

out;cf the SSFI, particularly one finding related.to' check'ilv'a'Ive ttestingc3.

. in the auxiliary feedwater system, which. remain ~uriresolvedis'incefearlyt.nd. '

.y:a.,:w ns y)hSMun/ti.tda.e.yp.?

mem pnr.m etvihre. Sol.T

'1988."

c

'~w

. i a cow.'2 m :.

.e The. team noted thattin.the case of the: Duke:assessmentt:the+ rep'o'rtW edoi '

contained 28 findings, 27 of which were providedito!.the Duke'.'evaluationa.':

i team by CCNPP as self-identified deficiencies. Thettwenty-eighth:itam u q.

was-identified by the' Ouke' team ~alid rejected f6r action bf CCNPP. To date the cor.rective actions for the 27.have notrbeentathighsprioritytf-se:T. ;

and demonstrates the licensee misconception that* adding afproblem>to asf 4 list cons'titutes a corrective: action, s - ntn.m%i usin oct:rmsut

. n.. s~ C;, as M tssc ni ks:!.:'.4 In the case of the OSART, the findings. associated with.4 maintenance.were.r6 found to have their roots in the administrative control; processes rather,c.c than the quality of the maintenance work itself. The licensee.expectswa.

to address many of the administrative control issues with the new

.c.

Nuclear Information Planning and Supportt(NIPS);projectWTondateithereu-l have been no other significant licensee efforts to address the OSART-l zcorrnentsa

-.m i.o - '. M E

.m Tr i.e ir.m iwenst ur.o.t piti.

1 ort /.;

- r 1 0.. '

yi cc...... rt W ic.c ?.t inbevl?MW F

Management demonstratsd their lack of commitment to,QC:when theyjab-ing-o sorbed QC into the: maintenance department under.4therpeerrevaluationa:pansf concept and then assigned inspectors responsibility for the successful completion of the job, ansassignmenti that'should', rest withsthes,f.f rst fl line supervisor.

qualified tradesman's transfer:to QC is. regarded asiatlesstoft'statusi:and;T,

' pay &lso diminishes the importance of the-QC organizationgsng: ic ghd M.y c.:.

.~. sac n g W pnt(Wrtemy.knr.,.8,.

By con idering the hours during which managers tournin:.thejplantnandqthed s

o activities that managers respond to and emphasize.ingtheir.: tours,ythe vr.r concerned withathe.a.

3 l' work force holds a perception.that managers are mores 4

" superficial.'appearancesand cleanliness of"the plantn(particular,1ydin;the,g., m.;.

' /t h W Wag. sf.qdg4.U9;$No@g &

• u

W.re w c.,

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s:...., 1:,v.

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f, 'y;.;.:/, 4.y. Q:: w.,

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,m

. o. w a c ; w a s u d 4 n: b. & &.,sas(:fi

.~ G c

well. traveled. areas)athantwith the: actual material.tondi iontof& thel dy.i

". ~.

facility. One tradesman recounted howtthh'on,1ybcommen

. !$ ?.

from his managers was not earned through the quality of,. ebe'verfr;ec but was in response to an experiment in which he' cleaned!andflined

.isfWorkmanshfp'N W.

f all his tools on new herculite and performed;.no:.workyat SL11embganaNf.f(J,,4jl7 8 sqw Mc c.s.,w. y In spite of the deficiencies in procedures.nowt impedin@;verbat1sncolnp11M,.

o-P ance, the plant staff is confused about.the working:de'initWontiof@Hf Mc

" intent" as it relates to procedure changes.anditemporary.sodi.ficationspoei The team understood the plant staff's confusion and lack of man'ag'em' nt Ei clarification when, in an interview, the Plant Manager acknowledged.he e

.M couldnotdefineintentand.didnothaveafunctional!vnders'tahdinWfWr.

how to address the concept; This. example:iscillustrative' ofshewstheW '.

' guiding light" fails to provide guidance beca'use 'it..neveragetst.' turned,c t y

on at the manager level.

.G.

n.: ' I s:U bws t m,.i.., ::ut.s3 :d". {. 7 1..

2.3.4 Planning, Scheduling. and Prioritization M20 T801 edi.%'inesdeM4'/.y, r

+

d, to:no'r y!Iaunsp Edg.;.astbs.s'A 6 currently, planning andtscheduling are fragn.ented.throu'ghout..theforgarH f

i tion, and.the organization. suffers from.the <1acksof.ta site

• wide.vinteg'r'a'te coordination (OMC)g and scheduling system. Operationsqand.<

accessible plannin

.e is the. dominant scheduling group:on si.tel.Wdiduring 3po c.. '.'

outages the role of the.0MC' supervisor.is expanded:torinclude'dVerallnrespon,

1 sibility for outage management. The team observed confusion in'the dis'tr.ibuh tion of authority.and responsibility in the OMC function as well as in the roles ofathe. project and system engineers during. outages.Mithoutdnforma-tion exchange between departments, prioritigation'of effortswithin:workoa groups.is uncoordinatede:.'

4

.,n s. ' m M-1 lrt n W.33 yd ami,

n l M eru y wusuhLgay.

.r. : v:,

i The licensee has. employed.'as a 'consu1Gntithe;fira!6frArthurrAridersen, sinc.,

i which has prepared a comprehensive plan to devise;and. implement arsite Wide integrated nuclear information planning system 4(NIPS)r.nowischeduled:totbd phased in over 18 to 60 monthsk The site staff has done a thorough Job of salesmanship.among the system users. ;The development?anddeplementationrofs,2

. s the NIPS program is' the only example of successfultchange:managementddentiD j

fied by the team.

at cis Tr. p tTappWIN4ti.h.*; *,1

~

e udnhavfiiiQ3%. m

. :.n :a

.c.

2.4 Sunnary Analysis of-Activities and Events >

. u t-

' We :

v..x.omesW'or.trl.r The team reviewed several major programs and initiatives to assessamanagement-effectiveness as applied in the operation of the fa'cility. In addition. the team reviewed significant operating events from the,Fa113cf,.1988;to:evaluateno management effectiveness before, during, and.after;the-event., M bd% '

r:*

o.i w Procedure Upgrade Action Plan (PUAP) Rgview. ph:.. m nr par, :tqs:wo, e -

2.4.1

. '...) r y.my.s

<c w... m. :.

.z:.: v equt onri The team's findings from its review of the PUAP is a representative case;;.

study of management effectiveness in planning, organizing.estaff.ing.: direct-ing and controlling site activities. Additionally, it is illustrative of 1 mana,gement deficiencies in the areas of planning, staffing,, chan ment, project organizational dynamics in the matrix structurer and reactionary..M 3

solutionsLfor regulatory concerns. In. everyi res pect e mana gements performancedi:

l on the PUAP is at the oppos'ite end of the performance'spectrsm'.ftom1'that 'seengps:s -

,' a :,. q q...

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• • • PREDECISIONAL... INTERNAL USE ONLY 3,,y

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during reviews of the N!PS program, which is the only.,acti f2 g2 * " J' g,,

which ma.nageme,nt ef fec.tive.n.ess co.uld be c,on

.~

L 4.

n, a. e. N D

,,..6 The PUAP S.v'M..'i. dentid..e.di, he..

wrwum

(

k ko't pkUnh 4

Th'e' NAP is a quiIk',Yix$Yn rkspois'e 't'oIEgut'a

.s.'.7.,@.,h

?"'? Y o

planned for over a year.

0f Nec,

Typically, the licensee has underestimated the magni orLwhat, quality prycedures,look like.., ;l,.

p f

o 7

L I

' No strategic chang'e inanagenient has bee L

simply, perceiveo a need 'for,'.a change and ordered o

3

~

i improve ' procedures.. g.

There has Seed litdPconider'ation gi$ed',To,k'p'to*.[

l.

^t required changes in"the~ cultural'a'spects of"ths ia,nt sta C

o toward procedure quality, adherence, or. control,.4 g.g,,g 3,,T###

There has been no manpower planning to ensure sufficient num 1

appropriately qualified,p'ersons. 3 he pro

,... M.

T o

.a

... s. m.a

.%s aITs"i'ng.

.s A ser5Ee"of ownershipfM.'the"projeEE EEtheff'1'rii'sh'ed 8

'iaVidh

.4 The project manager has, workers scattered

'h e meino' from'th("*

o Plant Manager establishing'the effort di' rect'ed the 7QC 0 nt of IEose.in ope' rations, m'aint' edin'c'e',[e'n'g'in'

'i

.Theinvo5v who will have to rewrite'the procedures and be'th o

investment, and no priority has.been assigned,forl comple unspecified.

......e.<~...

.~

5 d

The quality of the finished product is in question. The rvisors to rewrite the procedures are generally first or second line su liftheir. e,-

o who have never seitn lan' example of a q'uality,poc'edure"6d lst' ate of'" N, S

existing procedures.lalready range in quality.from' excelle

"' *iit ' 4 (;a the ert.'. Management,his.not; established 'c'riter,f a oPeo'r

. Q.I '. '

?9i'

• d tions about the; qual.ity.cf the: finished product?a":06 tm' Myc sW.

.n.#

M{1'iiMthe4 T u.

The deUsion on2iih"proceIdures 'to,,rewritf$nd~inM%rd team to' speculate that,. additional:rewritesiill,be',resiiired.

ffand..N tier administrative procedures that' describe'how'to write'l p o

fter:i'"

the second tier.that defines programs arel s

' " - N

.b gMtsw TGse';/,..[,

'The pNN cst's"coEkletforY,sNhe' duke fras u'irNal%

4^ ^

few identified sche'dule milestoney, were' unrealistic' and'hav

• F'* '-*.

o

' i Wi'.:hh. 7.:,y,,..

I i

been extended.

/;..

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sp.:, age 5Sd:nchU,,6 j

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19

+e anM5110NAL.._. INTERNAL USE ONLY,**W.O'4*g9q)(@

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• • • PREDECISIONAL... INTERNAL llSE ONLi

• N #' "

There 1's a general lack of ' nderstan'i6 abo 0Fhd7regY1'at'o'rs',ToNdY1'e'% 9-u d

o-the program in terms of its adequacy."

he li'ce'nseh'seeine'd/s'urpris'e? M%'.'.

the. team was 1

t.

during the early phase of the. inspection that 'unteered t'#$able tot'6p'The identify so,many glaririg deficiencies, and'vol i

program and "take a harder, look at it".- By the close.cf the"in's ection d. "< '"

periodthelicenseehademployed.outsideconsul'tahts;'to'ivaTuiti~th'ey C',i.

" +, W'w. ?

n i, */

program.

. 4!q f. TJ'.'u */ol.b(fe,'JS Q 2.4.2 Event Review

' netin.au.. Nt:ihitT et TheteamreviewedindetailtkmajoreventsfrMi98ifwiM evaluating management effectiveness before, durinsi',"and'a'fte'thF *sY of r"e'ah' eh The two events were the July delta T-power mismatch event in,.'sh,1 flimitin exceeded when' operators responded to 'an apparent: pow',figof.fset' p?Ea$...g

<O safety system'setpoint for high power trip and axial" eFaismatch' dWerinD

~

delta T power to match NI power, and the September fatalit/W 1'h'ehted condensate storage tank..Like the PUAP review, the event illustrative of the deficiencies described throughoist 'this' reviews'. sere #'

're' port 0

Lvi,....ti. " "M*! } Ul% i

• i.

Management effectiveness deficiencies identified th' rom"ev'eE"rIv' ins" include:

e.! ;.tm m d tM thsM o

The demonstrated op' rating philosophy that ciea'tiNil'dTtnis*plie*ri e

a W

o which procedure adherence was downplayed was "a' major *fa'ctor"Inb events. The lack of. respect for procedure quality,,the technical and

- administ'rative deficiencies 'that' werer allowed t'o c,on'tinue" uria'ddr'ess'ed.

0 and.the ittitude offplant staff that procedures just',Wnt'.hns,'Ito,* tie -

d followed because they're too much trouble 'and ' impede'"the effictivends's" of the ' thinking operator..or technician all contributid"tF0ie'{s'ce'niriosi

• J

. =;t,.i g O.if.

• 4 4 9.-

which verbal connunication's, verbal agreements betwee'njo'per:aThe o

• + '

technicians', and other key players, and'unv'erifiedlassumptiVns e' net typical.of.the say business was done.

In the; case of-the *fa'ta11tyi3 adherence to any one of at least three procedures may well'haVeFprevent-ed the, event,

, n g, g.

g Sign'ifNant co$nuYications b'a'rriers betweeri elements'of th'e'idFr:6 0 o

control room during the power ' ismatch.' event but did'soi;prese organization. played a major role.

Fuels engineers'.isre'-

d m

themselves into the mismatch, issue

Likewise'f'bpeYators';did not* consult the engineers because of la~ck of 'res:pect for"theiPekpsrtiss?"LikWGise, the system engineer,and instrument maintenance. supervisor verbally',@-

agreed to perforn'a critical surveillance at 30 perdent'lpBWerPb'N.

' 'i ut-failed to involve operations;or fuels ens lineers' "{,.g',Q The production bias that has' been the. najor elehe'n'tNf* lid 'dsiiMi r o

operating philosophy dampened the questioning attitude' safety %nscious i

operators should have had when power indications,were inconsistentyA t.

complacent willingness to grasp at unverified ' ass'umgitt'ons. co*nthibu'ted to the scenarios.

". m' ' s'W '8n n.d.

2.5 Licensee Response

- ],*

g go.

n.

• • • REMNhD@beiNT@RNAL USE ONLt M"

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• • • PREDECISIONAL... INTERNAL USE ONLY 0**

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' 55:MQ t y '

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Licensee management readily acknowledged the deficiencies identified 3yd..he9 'N '

fNl.I.hl c't1o operations and maintenance group and prom $tly began corrective,a',du,r,e ofit ssed,Nk%.jp.

resolveproblemswithQualitycontrol(QC and maintenance proce a

4 The licensee was more reserved in its acceptance of the concerns exp

' y'b.

9 "..

[. ? E the management effectiveness group..but.did state.to.,the team,.thatjeach.('

f the group's findings had previously'been 'identififd.as t

i hensive corrective action program, which'was.under.d 1opment[at expressed an understandin$s at all levels,.of supe management of perceived deficiencies inicomun'ication m

tiveness, leadership skil i[1;t'ym. e g.,.. q to manage change.

~.;

/

TheVPresistedthetea5'ssuggestionthatdhenatureofthe!

ghildk cated the need for prompt and forceful, leadership on his part, it'ati_ng 'his intention to allow change to, occur at.a' gradual pace and permit-hi managersy(

3 ewedias

.h. d-to learn from.'their errors; 'Likewise,'the VP recognized that2ef1 p,y.-..y.dy,, 'd a strong leader, but stated,his intention hot to pursue anvaggress, ender--

A

ship role in favor of pe'rmitting his managers to display 11eadershg.

develop reputations among'the" plant staff as leaders.[,[

'y-The t' am found the VP to be a manager who demonstrate [iligh pMs'enY ft.

I e

professional standards and demanded the same of his sub'6Ydinates.).He a student of management and is recognized for the adv

, bee f;j f

weakness to be a lack of nuclear orientation or a vision of.hoWafwe11M(

fossil operation while under his direction. The team determine'd.histaa WM managed and safety conscious nuclear plant is mana'ged; he:doeslnotcha o

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)cdoesinot have sufficient time or experience in the nuclear environment to,be 'proactive in management of operations.or recogsfie the warning sighs of declining performance that.would likely be obvious to an experienced nuclear manager.;

Of particular concern to the team was the VP's stated philosophy. thati;as.hP,

.c~

he is a corporate officer with an office on site, rather than an _on-site VPd.:

who interjects himself into daily operati' nal events or directs the site's>.

3,

~

o response to situational events. The team understood the VP's philosophy"of. f.

~.

proceeding slowly with the intention of institutionalizing the, improvements. 7j.N.

he hopes to make and building an effective management foundation.? However,'4:

the team continues to be concerned that the VP does not fully grasp.theyl,y;s. ?

extent of the change necessary to return the plant to excellence' cand!that&';.' 4.

1 while his preferred pace for that change may be appropriate for affos~s11;$M.. b.

s.

plant, it is not adequate for a nuclear plant with the range and s'everitypof.s ',y deficiencies identified at CCNPP.

2.6 Sumary To sumarize, management demonstrated the following operating philosophy, with key elements arranged in declining order of management emphasis.

.f J.c

^

money schedule productivity minimum investment t'd.

J" 4 ( %.;. 2 i '-

1,.:

regulatory relationship.

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

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

' ' ?-

""'." M.Y* * 'M "M E M ""b m p

'M safety

~

• • -'i'**-

A"

iu conservatism

' " ' ' " " ' ' #I" I"'N'"9 '"I"'B'-

quality an'+..r..rne tar astr.us! E stit.

s-

.., i V,anagement's current one-dimensional approach'to vistfrfsg eIcMfenfat"4 N.

i f

CCNPP is overly siniplistic and emphasizes reversingthi ordefd*fittii The team considered this strategy to be only a<startin'gpla'ce.* Au u

. appropriate balancing of priorities in the complex Mtrix' ors'aMiatTo(e.f#"I #:,3 na structure in place at CCNPP can be visualized as'the'dynesis sional, project management model represented by figure'A"'

g; y$.

f'i:y,'

v, Quality and safety, ar,e at:,th.,pa;;...

.. - x

?.. o f.' " -

e' center,fa'nNdkg.

Ces every managemen't;defisl6n,,1 ihTs'be approach', which estabitshe - 'e

'e*a'nd """?

takeirelaiton' ship #of'c'esYs' r;s c.hafdd Y'.'.T 2 '

Qhabty and gives a ful,1)nD.'q'u,'s1.Epos'e'd'oWIttie

,l,c-rea'tme'n'titjo' n

4 performance expectations 1 Safety facility.by; reg]ula, tors}ndg'qpju'b,*11,$hg,y.

3 3

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,.nf Y :. chunos s t's @

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s e :.?.v.2 APPENDIX Ar.

.. gr.w;]. W #t I ann, l 'j '

t

... : a. mms:($w.iIWa /

.m u :r.s ',M oi 7

et.

i

- 4 c

. EXECUTIVE TEAM PROFILES...

Vice President George. Creel, with many years as a corporate officIr on,ht :p i.

.the:i %

fnssil side of BG & E, does not have.the hands-on nuclearJp'lantsexperiencei a

that would give him an effective nuclear, conscience.iTh'e team. considered o that he did not yet fully grasp the. complexity.cf.the changetrequiredtats.

l Calvert Cliffs, nor the importance of his leadership role in effecting that

..u..:

nt.asd.ast! fistai4:

c l

change..

.t ev s,> rij t=,t :1M E!

L o

Although Creel knows many of the plant people, he,.'is:stil.13llearningathe..

issues.. His method seems to.be. " management:by. walking!around"v,yandihe 4 c often. calls people in for. impromptu interv.iews.wt r.m.i/eM g.nsensWE.%i..

m y a.~. sot.hek duVr W.*

W n

In keeping with BG & E tradition, Creel perceives himselflasfa@orporat'ei ' '.

o VP with an office.on. site rather <than an;on-site,Vihwithidi. rect (manage. '(.-

ment involvement in daily operations.or control.1.ing:situat'jonaly.ev'eists.;..... l '

. w.. i:..

..r

, 3,3.....,.

,g. eat h m nota beb 3<ftt W F*.*.

Employees expect:him..to. emphasize accountability and credit 1.m]w.i th..i.,l:i:

the phrase " sty waytor;the ; highway".. Creelssayssthatt.he, prefers linot.ito o

'^

,be. viewed as the plant's : salvation,- and, feels thelplant;staf,f mafgbes,.%

4 y

incorrectly. perceiving him.as a site. managers s wi.;rsty.Wr si!

c.n wt.$ isu y Anot':zss.r, r.-

o Unlike the VP who preceded him. Creel:is#. perceived:by,st p antr: staff:as-a manager willing to make tough decisions quickly and fair.ly.i..He.is.

well versed in management prjnciples and organizationa1 design {but;.c g:

3 appears naive about-how to apply that knowledgd.ingthe,nucleaheny1.ron-

.g.4rith r tw g, ment. ;

~'

.p a

. s w ;...u r.t:.' wi M Anonmnet.??; ?

o

' Creel is well known to the plant staff and almo'stzuniversally., respected? ~ -

ees. For example', he received high praise for traveling.from Baltim.loy for his leadership style and direct, personal invo,1vement wi,theemp i

ore &

' to offer comfort to. family >and. employees.;during jthe,.;funira),

110wgg'p;;.g'.l the fatality.

d eo

a. Meen Nttl betzmo C.C J,

c....7..,.. m1% oh 28"%tasbsssa# C.

o Creel has worked extensively with one member of the. executive: team M r/F e

as successor to the VP in event of emergency':yCruse.ha bee, denti 1 j ir.,

(engineeringmanager. Cruse),and1s-awar%that a

J+ Cruse'.is.a favorite of senior corporate, management (.and The) team' rm 'n'e'd oomedj:J i

for a senior management position (including a >r;otat.iona assig, men,tps.9, 7-n PlantManager).

J.# M.:.u WF.,

1 eig.sv:q n's Qgs Qy'Q' %:.

.r.h i

y.

. : ;. t.e e gr e...,6

'F wri e

.4 Plant Ma' nager' Leon Russell uses a low key, hands-of.f.managementy

.,t, often gives subordinates the misleading impression that he is unw

,,nggo address difficult problems and situations. He projected to the. team.an impression: of : organizational :noninvolvement,and amb.t yalence ite'am' member g who had notvyet ' met' Russell observed an.on-siteicomnitteQ h'

N-Russell chairedrand.was. unable' tot.tell.who was tintchargegoffth'eSme' fing er.$,

e

.,iyf identify. Russell as the plant manager and 'cocenitteeicha n '.

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• • • PREDECESIONAL'...I_NTERNAL;USE;0NLY b.

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• • • PREDEC1510NAL..oINTERNAL USE ONLL ***..

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Russellseemsphysicallyandmental'yburnedout.from'ofr$

$eha

.t )

1 o

ing 90-100 hours / week since December 1988. As:a? result $-

V4 O

~ ~ '

struggling to keep up with his dutie' effo'p'eratioris 'a'n'd!

M U.fN'$ -

s manager for a dual unit site plus acting as site managerfforXt 16alor?

K.4. l get-well effort underway at the site 'sincerbe'in'gTplaced,onYthe.

teht*

list.

I d;f4 S.0:g-T K -

....:. 3:. O.q1c60 Jae.btas19 # Y "

i Rather than displaying a take charge' attitude hisi! re'fe'rrellity.lehis1tM P

o use questions in response to situations or proble'ms.toihe'1p fas'socfates 3t.itt and subordinates identify the corract decision or a~c'tfon'.4yften. bib 'eff.tt/tr '

u

.....<. W s e rtin'..a1.1.t W 79 HJin.-

o Russell has been in a supervisory role in operations for 11 of.ithe.las.tdr 13 years,-with two years out to be in charge of maintenance.:* He moved

'.L into the Plant Manager position during the 1988'reorganizatfon'.pHe'lis,. ~o politically aligned within the BG & E organization!withtforWier #P;idser 'M -

Tiernan. The team speculates he is aware of Cruse's fstatucWithtthe'cM9 "

Despite his inyolvement:in. operations.for manylyearsp:Rdfsd. sief%1[3.!:.. :

current senior managers.

f.N 2.: -

M

.t.

..i !! t !: 3 A ES ff hf 2

• ViRT o

.strates skill deficiencies;in application of overal.1 technit'tlackndwledge"O .

He does'not seem to understand theineed:forsan.tnderstoodfoperatidnal"'ti@.T i

in timely decision making when faced with plant operational. problems. w.

" language" for the siteror his responsibilityltocdevelop'one'm/EoratiF S-example, with regard;to temporary modifica'tionnand'preicedurkchinge the site clearly.had no definition 'of the: term *. intent".tfandritradiredtT

.c.

questioning Russell was unable to define or discuss the concept-of an

• intent".ror "nonintent" procedure change.-

1 ow n0..? W sett sPM5 o

h b. e..li t h.' assem.n t Russell is not' considered.to.be an effective or.texemplary ' leader by the o

plant staff or, the-team feels 'by/his > peer:managersehtikdwited. hist, managerial' skills are generally held in low regard. Many of the site..

functions he has managed,are experiencing major concerns. includingt '.

proceduraladherence..qualitycontrol,maintenancetprocedure; inadequacy!:

,e and documentation compliance.

• O v;a a tri" :.md ~ a M ini

. er.1 e4 ;O.g o o sot ae3 J

Russell was described by'BG 8'E President Crooke'rast"not'veryi@hamic'...

o Mr. Crooke stated his intention to rotate Cruse into Russell l$tp'la'n'tt:.f).?

manager job "at the earliest opportunity".

N:Of.' '. :

.s-

'. u -

.e a.: :,..n a:,s.w wt&tW toe.y %'^ i,.' -

~

Russell lacks sophisidication in dealing with regulators; doW5n%seettin,?.

o situation, and overlooks opportunities to demonstrate.to.'regulato outwardly demonstrate that he understands the gravity ofithe>present. 7 V

his staff his comitment to quality and safety.'.iw...+ m nea. r. ist

.bytne %sM. X. -

Russell's approach to problem solving is analytical, but he often, fails y o

He trusts subordinates and to verify or validate information inputs'.often doesn't recognize or question the quality 9

u. M w+y c:n input.

9. ; #r.:.d. 3 h rd :em tu.

Russell's strength is his extensive Calvert Cliffs: corporate

• memory.vHe,.

o should not be tarred and feathered and driven into;BG 8tE?sdoss11tw ce -

purgatory; however, he ~is in urgent need of rest:and. assistance.b Pin 4...

m.

' ::. m M i.q s.M M,.

WR;g,Y1gnt,Qlp',

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• • • PREDECESIONAL... INTERNAL.USE ONLN*G (--

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• • • PREDECISIDNAL... INTERNAL USE DNLY,C** ;,

y QA Manager Rotert Denton has a limited nuclear. background and(h.is onlynye n'

3 s

previous exposure to Calvert. Cliffs was in.the,1ste.197,DsmUnt.11qh,isatrans GW.

fer with the 1988 reorganization, he was.onithe:BG:&rEdcorporateistaf.f#eW U.W '

difficulty arriving at.a consensus regarding.Denton's operatin,Thee. team had M involved with strategic planning and subsidiary development.N

'fphilosophyG, N '?

L g

L management skills and leadership style, and.the extentytorwhichthejwas.'trf.or* 7 L;

personally invested in the licensee's recovery.

1 ; U.. feed.h. tw Mus m

.4 Denton is bright, knowledgeable about the BG;& Egorganiz' d. ok*ghIds c'

o a

politically astute. His first. impression to;most of,;.thehteamjwasionesof.

i arrogance based on insecurity, and he tendsito project;aidemeanin~gs er stancoffish: posture.p..With continued probing that. team.foundrsome,ev.1.-)

dence of wamth and. caring..

Hovr3ryyW'stMt.(

.mth ild M MHtte.

Denton avoids decisions abd situations that carry.high political. risks....

L o

If his involvement is: unavoidable..he attempts;.torpr.ov.1.deringlogical,w.e.o systematic method of dealing with the probleer thatysubletswrespons.ib,1;11-y..

ty and involves others,in the problem or process.g Thetonlynexamp.lexto

.l '.

counter this generalization is when he backed upihisi new.iQAfGeneral d i

l.

Supervisor when that GS issued a stop work order, involv.ing par.tsquali '

fications,.

c

.. m. t u. rM Sci nee ha n..,

. ~ s.

. ?ntca rMt :!z scr. tot o

Denton's preferred, style is.to remain detached from,ithe; organization.' to the extent that he gave the team the initial strong,, impression (ofunot.... -

wanting to be on-site at all but rather back in the relative'ly ' plush., ".*

world of. corporate. headquarters. When directly pressed,.on"this 1ssue?.it nl Denton.strongly voiced his personal desire,to befa, key par;tjin,,Calyettm.i3.,

y Cliffs'. improvements over the next several.yearsocpu.m dao r.F.inae:rs,

Denton uses a ' third party" management style that gets a posi. bas ibetafos)

Jrnt.yIta wido-tive 2:..

y o

l response only"from strong, self-directed subordinates who,tapp'reciat',ithe n.

a s

I freedoms The majority of his subordinates.do:not,.[seenjtogoutindjff ook l

t'o him for guidance or direction.

',.7,,, j sar,sMP i'

...c.

Denton war not perceived by his subordinates as,a risk-taking.. dynamic o

a

. v. t.,..I ::t p vtt:g %

leader..

Denton gave the team the strong impression that he did not wakt p.wt ersonal o

responsibility for get-well. efforts,,even though many,,,ofqthetaajogo... e initiatives fall under his department. He.seems,3 o: prefer nate activities of others to whom he has, in his sind, stiif,to;coor,e,1,- 7ted respon,s t

bility for developing and. implementing,correctiv.eraction;in,itiativesy.,,

d vf +cu Denton.is results oriented crganized, and is,an;m ne rtW;advocateoffMB0y,n,the o

g

-extreme.i j-3:t/. 'to ame nt:b niiA-t

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Y,

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c an extensive fossil background.as the consunmate. pro.fessiona,1 engi.;, Cr Engineering Manager Charles Cruse is a favored associate.of, George tth neer,.g is still on the nuclear learning curve.

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Cruse is anal tical and. carries a reputation for.being willin (toisps O.1 alvand 4 h.

confront prob ems and make< decisions. He prefers *anhanil o

wWpwn ked:stbe.,w1:

4" s

systematic style in his' subordinates, huuh;. ipw.st. Mw tpsvJoyn) 4 Cruse is polished and professional, a sharp dresser who prb$

He appears to understahd his tptc141m o

self-image and a sense of control. stature with Creel-and other sen Jo Subordinates generally regard Cruse as a comunicative',e'ffect'iveonM manager, but withhold judgement on his leadership o

Cruse was receptive to the team's observ'ationtthht io'dtc'al-g,

ly shift from Brooks Brothers to blue jeans 'andinskeih mod; ". 7 fair.

visible to his direct subordinates and others in the plant. %

4.,

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... nas wot st.os;p ast Theteamconsidered.thatbecauseCruseis's'till>o'n'tkeh

l1 ' a[.. J

.. Ej.b, curve, he may not yet fully understand 'nuclea'rde1Y fo~nW(TH'e' o

4 w EckVs'6hhift 1Fn' : 't.,UC.

generalization can be made of Creel.) ' He <seems :toin unde P 7' regulatory influence' into' his' decision making' p'r' cVs's'esPSB o

not seen for himself what a quality nuclear organizationlookTCITkPJhe'*i J_?

does not' at this point seem to recognize the ' warning bells":.that. ring'. >.'

la'spidif o

in ~a nuclear manager's mind when evaluating and :r'e'spondi r ce en sa nsMighs.

developing situations.i-

. u <.T %no?M at.ptsinw -~' ' i.

.w.

In terus of team interpersonal dynamics, the executiveiteami'ista"mir 6f1N strong 'and week managers, most of whom lack expe ronment.

isolated, and outwardly weak.

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.a The three managers each seem to bring a persona o

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a team.

The three' managers have only a limited understanding of bl effectively in the project management matrix organization foundiatsthe,

o site.

" M bn}*MG *:u1OC O

Outside of VP Creel, the team has had little managementich' leadership u m t'br tsymretni o

skill development training.

wtre % aoistythr. esan The role of VP Creel'as a leader and manager:needs?toibeidefiheddi s -

precisely, with an emphasis on greater direct involveme o

defined in terms of site manager, since he clearly has that responsib management.

ity by default.

l The role of QA manager Denton as a change a

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for:beingia change c.c acknowledged and demonstrated his key responsibility,dm.:..cC:

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agent.

The prevailing historical SG & E corporate philosophy emphasiz off management at the.VP level, and some of that filters down'to thel o

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26 i

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

1 three managers.

Indeed, they function'asuthough Creel was BG.8,E President for nuclear power, and each of the three managers were a.YP;'.ini m

charge of his own area... With the entire executive..teamseffectively &.'i,7.,,,

E.

taking a handsoff approach, responsibility is pushed down.1.nt'o$the,.J/,;';.;j,,!:A.;,:.z,f..

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organi2etich.

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APPENDIX 8

.n.; 3

,.w3.w. w.fr.fryf MT; A',11?sererGTEl'-ln'. ' ':

4 L

. MANAGEMENT EFFECTIVENESS GROUP.NETHODOLOGYu nMefd"tsftyW:;:;j!.7.Q:l Te '

c-1.mm,a:,rngqs Moabesid:2q$$ aim.' y ilN -

2 The team developed a management effectiveness model designed.to (1)

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ically review and evaluate the licensee's organizational structure and identify the attributes necessary to succeed in that structure.- (2) inysntcry and assess the management and leadership skills of managers and supervisors at all levels of the organization, and (3) objectively evaluate'the effec.

tiveness of managers in applying those skills within the organizational framework.

The team first developed a management effectiveness model (Figure.1) with which to focus their evaluation of CCNPP.

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• LeadershJp Managerial Requirements

• Experience Support

'. interfaces

• Job Know-ledge MANAGEMENT EFFECTIVENESS MODEL o

A86*O. eat of Management Efreeuweness

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• State of art managemente - s;;

s..

• Decision. making

• Problem solving g !cadon Organizational

• Safey

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at i

Eseellcace

• MT

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• Resource mgt.

. Assessment of organ W-Pr*ttlC*

• Change mgt.

traconal potenual.: '...

g,3 g.

compliance :,,,., s.

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

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MANAGEMENT STUDY METHODOLObY/.'.

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FIGURE 2

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Evaluative.. criteria (FIGURE.3) were there developed based on the model.nto t..v;.

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j further focus the team's inspection activities.

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Management AppUcation OrfanlantionalEzeenence ornalzadonal mquin.ments

& Practice Metions)

Otasults & Image 6tructum & Design)

)

Y suvetorei duign and

• w.n.g....t kn..).dge e e elity ese. ranee and

• mnegement perf.rmann u o m onio u. insu r...

and operienn sentrei nietery

• c iton (menage.n.nt

• ort.niati..i etim.ie e ch.n p m nsp oent

. cornnt unegement phit. phi.i>

ens hum.n nieti.

- perf.rinenes

• Regulatory esepliance str.iegie and busin...

• per....I precome.nd and uvie.

• stais.t.she. ort ensiyeie l

e planning admini.tratin suppent I

• shared eemmenication

• Serievenees, orpney

• Manpower planning and

• operational kne lede end and sommitment and emeth of eseeern forecenting esperienu

• Performance monspment

• Orgenleeuenal goality

• W.ek plenning and

• 14eder. hip and supervisory and safety otheduling etTectiveneu o Planning and scheduling

• oewrnmental eempliance

• Perf.rmance monitoring

• stamng and permanel

• Rueene ellecaties and reporting quaisty

• orgenleetional twee Regulatory nyiew and

• Training and denlopment

, sempliance

• Priority setting

• organisational imp and puhue reisti.no FIGURE 3 Finally, 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 finding was effectively integrated e

into management, activities at CCNPP.

l l.

l.

EFFECTIVENESS SCALE NW commony recog-Recogsod as in.

Recognited as in.

Oganuafend in.

WaneGened pac.

nited as knpona io pom na nas pac.

porta and kaprwe.

p<evements cunenry tica swor* P

/.

.cr. % ort ee u t uc.d on.se9. -

enat planned t ino implesw.d.

tesions neeame j

FIGURE 4 s

The team relied heavily on the results of extensive interviewse revieked l

programs and activities with an emphasis on managerial controls and effec-q l

tiveness, and evaluated in depth recent signif'icant operational events to i,

detennine the extent and appropriateness of management involvement before,

?

duringe and after the events. Because of the apparent subjective nature of

..,6 the findings in.the management area, with its emphasis on human versus engineering performance the management effectiveness group stressed the need

.c e

to substantiate apparently subjective findings with objective performance examples from the operations group to the extent possible. Toward this ende the management and operations groups coordinated activities ar.d findings extensively ea 30 4

- _ muneracecaremrm-_ _MRmcnus fgm1***