ML20059J798
| ML20059J798 | |
| Person / Time | |
|---|---|
| Site: | Seabrook  |
| Issue date: | 11/03/1993 |
| From: | Feigenbaum T NORTH ATLANTIC ENERGY SERVICE CORP. (NAESCO) |
| To: | NRC OFFICE OF INFORMATION RESOURCES MANAGEMENT (IRM) |
| References | |
| NYN-93153, NUDOCS 9311150053 | |
| Download: ML20059J798 (7) | |
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' P.O' Box 300 '
Seabrook, N H 03874 ~
Teltsphone (603)474-9521 Facsimile ' (603)474 2987 Energy Service Corporation Ted C. Felgenbaum -
Senior Vice President and Chief Nuclear Officer NYN-93153 November 3,1993 United States Nuclear Regulatory Commission Washington, D.C. 20555 Attention:
Document Control Desk
References:
(a)
Facility Operating License No. NPF-86, Docket No. 50443 (b)
North Atlantic Letter NYN-93132 dated September 30,1993, " Reply to a Notice of Violation," T. C. Feigenbaum to USNRC (c)
USNRC Letter dated August 31,1993, " Inspection Report No. 50-443/93-13," A.
R. Blough to T. C. Feigenbaum
Subject:
Supplement to a Reply to a Notice of Violation Gentlemen:
In a letter dated September 30,1993 [ Reference (b)], North Atlantic Energy Service Corporation (Nonh Atlantic) transmitted a reply to a Notice of Violation identified in NRC Inspection Report No.
50-443/93-13 [ Reference (c)]. This response described the root causes and corrective actions for two separate occurrences where personnel did not implement station procedures as required..In addition to.
the correuive actions taken to address the specific individual occurrences cited in the violation, the sesponse also described the methodology utilized by Nonh Atlantic's Personnel Error Response Team.
(PERT) for evaluating and developing recommendations to address the reduction of personnel errors on a generic basis.
The PERT evaluation applied both quantitative and qualitative analysis in considering incidents involving personnel error. The quantitative approach consisted of using North Atlantic's Methodology for Event Reduction Evaluation to analyze five incidents involving personnel error. The analysi, led to the identification of eight issues. Each issue was identified as belonging to one of three categories established as cultural, programmatic, and management oversight. The team developed a total of twenty.
recommendations relative to these eight issues.
At the time the Peply to the Notice of Violation was submitted, North Atlantic was in the process -
of reviewing and fina!aing the PERT report.' Subsequently, on October 7,1993, I fully endorsed the recommendations espoused in the PERT report, disseminated copies of the report to all North Atlantic management personnel, and requested that they review it with their respective staffs.. I further requested.
the Station Manager to ensure aggressive implementation of corrective actions to address the PERTc recommendations.
110030-WE 9311150053 931103
{. a member of the Northeast Utilities system jr
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PDR :ADOCK 05000443 I
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United States Nuclear Regulatory Commission November 3,1993 Attention:
Document Control Desk Page two Accordingly Enclosure 1 contains the recommendations described in the PERT report. Nonh Atlantic is currently developing specific corrective actions and completion schedules to address these recommendations. The Station Manager is specifically reviewing all corrective actions to ensure a coordinated effort with those actions also being taken by North Atlantic to address trip reduction, procedure compliance, and procedure quality. North Atlantic will continue to keep the NRC Resident inspectors apprised of our progress in implementing these actions. Additionally, North Atlantic will be prepared to discuss the PERT recommendations, their corrective actions, and completion schedules for ~
these actions, during the upcoming meeting between NRC and North Atlantic management.
Should you have any questions concerning this response, please contact Mr. James M. Peschel, Regulatory Compliance Manager, at (603) 474-9521, extension 377')
VervIt ly yours, AFv N
Te C. Feigehmm TCF:JES/jes Enclosure cc:
Mr. Thomas T. Martin Regional Administrator U.S. Nuclear Regulatory Commission Region I 475 Allendale Road i
s King of Prussia, PA 19406 l
Mr. Albert W. De Agazio, Sr. Project Manager Project Directorate I-4 Division of Reactor Projects I
U.S. Nuclear Regulatory Commission Washington, DC 20555 l
Mr. Noel Dudley NRC Senior Resident inspector P.O. Ilox 1149 l
Seabrook, Nil 03874 9
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North Atlantic L
November 3,1993.
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ENCLOSUIE 1 TO NYN-93153 l
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i SUPPLEMENTTO A REPLY TO A NOTICE OF VIOLATION In response to an unacceptably high frequency of personnel error during 1993, the Station Manager l
requested a special committee to determine the root cause of the errors and to develop recommendations to address the causes. In response to this request, a five member Personnel Error ResponseTeam (PERT) was formed. The team members represented various depanments, which provided a cross disciplinary approach to ensure a broad perspective in defining issues.
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The team applied both quantitative and qualitative analysis in considering incidents' involving personnel error. The quantitative approach consisted of using Nonh Atlantic's Methodology for Event Reduction i
Evaluation to analyze five incidents involving personnel error. The analyses led to the ideraification of eight issues. Each issue was identified as belonging to one of three categories established as cultural, programmatic, and management oversight. The team developed a total of twenty recommendations relative to the eight issues. The issues and the recommendations are described below. North Atlantic is l
currently in the process of developing corrective actions to address these recommendations.
Cultural Issues and Recommendations Issue IC:
Personnel errors are tolerated and rationalized as being acceptable. They are shielded from.
scrutiny by overemphasis on confidentiality, with resultant lack of accountability.
Note: Management must provide a reaffirmation of Nonh Atlantic's policy on discipline.
.I The reaffirmation should delineate the distinction between non-disciplinary activities, such t
as performance coaching and counseling, and disciplinary actions, such as verbal / written reprimand and suspension / termination.
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Recommendations:
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Management's expectations should be verbally communicated frequently and visibly.
Establish accountability and promote open communication.
j Personnel involved in an incident related to human error should prepare a presentation on the incident to be delivered at a depanment meeting or during a session of requalification or continuing training.
Develop a basic outline, or agenda, for the presentatian which is based on answermg Who?, What?, Where?, When?, and providing action recommendations designed to prevent i
recurrence.
The manager, department head, or supervisor responsible for personnel involved in an i
incident related to human error should deliver a presentation on the incident to the Station.-
i Manager's daily meeting or the weekly Group Managers' mecting.
i Interdepartmental communication on ' operating experiences should be improved by
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implementing the following action.
q Make operating experience, including specific incidents in the industry or at Seabrook, a topic for presentation and discussion at each weekly Group Managers' meeting. The first 4
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l presentation should include a general discussion on preparing and interpreting trend chans, l
with following presentations using trend chans to support interpretations of current -
1 operating experience. Publish the content of the presentations in the Station Manager's i
Messenger.
i Issue 2C:
Absence of management's attention and priority for incidents leads to lack of ownership and responsiveness to activities, with inability to effectively institute corrective actions.
Recommendations:
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Proceduralize a post event evaluation in accord with Methodology-Event Reduction Evaluation.'
l Develop and implement a process to assess the effectiveness of corrective actions taken in
.j response to post event recommendations.
i Management's expectation message needs to include content, priority, ownership, and i
responsiveness to incidents, particularly those involving personnel error.
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Evaluate the effectiveness of the Maintenance improvement Plan (MIP) as related to the reduction j
of personnel error.
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The Station Manager needs to more frequently require a Human Perfonnance Enhancement f
System (ilPES) evaluation of incidents.
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'i Issue 3C:
Upper management is sometime insulated from the exact details of an event due to incomplete documentation of event information.
I Recommendations:
Include nonconfidential portions of the HPES report in Operational Information Reports (OIRs) 1
.t and/or Station Information Reports (SIRS).
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Include the Stop, Think, Act, and Review (STAR) Worksheet in repons.
(Note: References to people identified by name could be removed from HPES and STAR infumation that is included in other reports.) '
Managements's expectation message should address the issue of open and candid communication.
Management should adopt a "Tell it like it is policy.
Revise the Station Operating Experience Manual (SSOEM) to require a Cause and Failure i
Analysis for events.
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t Procrammatic Issues and Recommendations
.i Issue I P:
The STAR Program is ineffective.
i Recommendations:
Develop and implement a site-wide (not limited to just the Station) program on self verification to achieve the following objectives:
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- improvement in awareness,
- direct linkage with OIRs and SIRS,
- timely development of STAR worksheets, and
- worksheet distribution identified.
Issue 2P:
The $upt rwory Walk-Down Program is ineffective.
Recommendations:
1 Revise the Supervisory Walk-Down Program to include r.eeded structure and appropriate portions of the Northeast Utilities program.
t Define program objectives that encompass more than housekeeping and safety. For example, define objectives for:
Procedure Adequacy Procedure Compliance Job Performance Personnel and Equipment Concerns Programmatic Issues j
issue 3P:
Overly complex processes, programs, and procedures.
Recommendations:
l The work control program should be improved through communication and feedback among the key applicable organizations. The Work Control Interface Committee (WCIC) should be the focal point for this efTmt and use specific examples of problems, or enhancement ideas, to improve work package quality by designating appropriate level of instruction, documentation, program' guidance, format, and package size.
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Implement Procedures Task Force recommendations.
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Complete implementation of the recommendations of Configuration Control Task Force II.
Evaluate results of Northeast Utilities' Performance Enhancement Program (PEP) as they relate to Work Control.
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Manncement Ovenicht Issues and Recommendations j
Issue IM: Lack of follow-up on Corrective Actions (CAs).
Hecommendations I
Develop a system of priority for responding to events and for reviewing the efTect of corrective '
actions. The highest level of priority should be designated for safety related events. The lowest level of priority should be designated for housekeeping-related problems.
Develop and implement a review process for OIRs and SIRS which requires that the responsible j
manager assigned to an OIR or SIR must prepare to meet with the Station Manager to discuss the resolution of the issues involved, if requested.
PERT must ensure that the actions implemented by the Station manager in response to the PERT j
recommendations are efTective. Three to four months after a majority of the actions have been
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1 implemented, PERT will:
evaluate trie effectiveness of each action, 3
evaluate the effectiveness for the combined impact of all the actions, and make suggestions to the Station Manager for any changes needed to improve the actions.
l Issue 2M: Too many conflicting trend reports.
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Recommendations:
t Develop specific performance measurement indicators having a statistically significant correlation
-l to work activity, e.g., the number of personnel errors per RTS completed as computed by the-followmg ratio-Number of nersonnel errors in RTS work performance Number of RTSs completed (Note: "RTS" signifies " Repetitive Task Sheet.")
Evaluate and implement recommendations made by the Trend Task Force documented in report
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SS 56655.
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