ML20112C547

Public Version of Allegations Root Cause Task Group, Final Rept Aug 1991

ML20112C547
Person / Time
Site:	Millstone
Issue date:	08/09/1991
From:	Bouchard G, Dietz W, Laudenat R NORTHEAST UTILITIES SERVICE CO.
To:
References
NUDOCS 9605290166
Download: ML20112C547 (19)

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ALLEGATIONS ROOT CAUSE TASK GROUP FINAL REPORT August 1991 G. it. BOUCHARD ,b A' -

W.1 DIETZ , BMf &4 '

R. T. LAUDENAT b M d ei J w t ?-i-il G. ft. PITMAN Mf_% t/y/9f 290030 P. .i. PRZEKOP M V.', M z u #

?. .'. SCHMIDT, Chairman d//MM 9/9/9/ d 9 ~. L. VARNEY // h //f M /f I

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EXECUTIVE

SUMMARY

l l A task group was chartered by E. J. Mroc ka to assess NRC SALP Board recommendations relative to on-going employee allegations within NE&O. The task group was  ;

! comprised of seven (7) NU management personnel from within hT&O.

The task group evaluated the chaner aquest, developed an interview guide as part of a survey process of NE&O employees, conducted interviews, evaluated interview results, l analyzed NRC letter allegations and responses, and prepared this Report which summarizes the

! asults of the task group activities.

l De Task Group has concluded that a number of complex factors may be operative ing,as I of NFA O where allerations are scrivelv beine cursued and has determined that two root causes 1

contributed to this situation. Hey are:

• Relationships between employees and their management (first line and above) that are significantly lacking respect and trust.

• Insufficient management sensitivity to routine employee issues which results in a failure to provide timely and objective msolutions. l This Report discusses these root causes and provides both conclusions and acommendations for consideration. De analysis of recent NRCletter allegations validates these  !

root causes. Recommendations address the resolution of on-going allegations as well as

=ial= Mag the potential for future allegations. 1 l

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1.0 INTRODUCTION

l The Allegations Root Cause Task Group (ARCTG) provides this report in nsponse to its chaner, which is included as Appendix A.

The ARCTG recognizes that the handling of concems (a term which includes i allegations) is crucial to nuclear safety. While a concern generally involves a technical issue, emotional, managerial, legal, and financial is,tues can complicate its handling and

! nsolution; and escalate itsimpact.

Notwithstanding the limitations that exist due to confidentiality of concemees, the ARCTG was able to collect much information on these topics. This information i consists of fact, perception, opinion and observation. The ARCTG compiled and evaluated this information to develop the basis for its conclusions and ,

neommendations. Due to the nature of the information and the ARCTG's commitme to protect the confidentiality ofits sources, factualjustification for its conclusions and recommendations is not always available. I The ARCTG obtained considerable relevant information, except in those areas where investigations were being conducted by the NRC Office of Investigations.

l Although most employees prefer to work within the Chain-Of-Command (COC) to resolve concerns, the emphasis of this evaluation has been focused on situations where this option is not productive.

In its attempt to identify problem areas and root causes, the ARCTG focused on the '

areas needing improvement within NE&O, and made no attempt to identify the many strengths of the organization and its people. This critical approach is necessary to meet our charter and the high standards expected in our industry. hT remains as one of the

,s premier nuclear utilities in the United States.

This repon represents the ARCTG's beliefs and is presented without bias or influence from others extemal to the ARCTG.

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2.0 EVALUATION OF VEHICLES AVAILABLE TO ASSIST EMPLOYEES J l1 j IN THE RESOLUTION OF CONCERNS 2.1 METHODOLOGY i .

'Ihe task group recognized the shortage and unavailability (due to confidentiality) of

information relating to employee perceptions of the vehicles available for their use in the resolution of concems. For this reason, the group decided to conduct interviews of a major cross section of the employee base including several levels of management.

Interviewee selection was generally random, but individuals believed to have valuable l insights to this issue were invited to participate.

l I The task group was instructed not to make direct contact with NU employees known ;o I have filed allegations. The task group did have responsibility for the issuance of two i memoranda which invited any party within NE&O to talk with or be interviewed by the 4

task group. The first of these was an E. J. Mroczka to NE&O employees memo of i May 29 and the second was a June 17 memo to all employees from the task group i inviting users of the Nuclear Safety Concerns Program and the Nuclear Review Team 9 to discuss their experiences and observations. Several interviewees were accessed via this " invitation" process, and these included some who had submitted allegations to the NRC.

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The task group compiled an interview guide for the purpose of gathering consistent

- information. NU human factors experts and an outside consultant assisted in developing the guide and conducted training ofinterviewers.

Four interview teams were formed, with each being assigned specific interviewees.

Teams were selected so the interviewer was not in the line organization of the interviewees. Team selection also considered potential bias that would compromise an objective and factualinterview. Selection was also based on maximizing the potential

' ' for open and frank input. Information not substantiated by other interviewees or other sources was evaluated and generally discarded. Interview notes were destroyed upon repon preparation, since they had contributed to our general understanding of the

matter, had no remaining value and represented a risk to confidentiality.

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i Over 75 employees were interviewed on a voluntary and confidential basis. .

Additionally, there were several significant discussions with others on related topics j that contributed to the data used in this report.  !

1 2.2 INTERNAL VEHICLES TO EXPRESS CONCERNS I

i The task group was charged to evaluate the three internal means for resolution of employee concerns relative to nuclear safety,: These are the normal Chain-of-Command (COC), the Nuclear Safety Concerns Program (NSCP), and the Nuclear 4

Review Team (NRT). The objective of the evaluation was the identification of reasons l l why the internal resolution vehicles a being bypassed and why the NRC is viewed by some as being the preferred vehicle for addressing concems.

l The previously described employee interview process was used as a means for the collection of information. Most interviewees did identify all three methods as being workable and expressed a strong preference for resolving issues within their own  ;

COC. In fact, most employees do not feel a personal need for the NSCP or NRT. In evaluating the NSCP and the NRT, the views of those individuals who lacked confidence in the COC were considered most important as those who are in this situation a most likely to need an altemate to the COC.

2.2.1 THE CHAIN OF COMMAND The task group found that the COC was the preferred vehicle for identification and resolution of issues. Since these issues never become concems, they are generally heard only at the local level. It is clear from the interview pmcess that the vast majority of NE&O employees are able to work with the COC in resolving issues. Even employees who do not trust or respect their supervisor m likely to take concems to the COC. However, the probability for employees in this situation to eventually go to the

, . NRC may be high if they do not receive responses they feel m acceptable.

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De OOC is not an effective option for a small number of employees, who have chosen to deal directly with the NRC. There are also a few othen at Millstone who provide -

information that is used to make allegations. And there are people throughout the NE&O organization who sympathize with allegers.

Interview results indicate that the number of sympathizers is increasing and this leads us to believe that the number of people providing information may also be increasing.

CONCLUSIONS

1. The dynamics ofinterpersonal mlations between the Unit Directors of Millstone Station and personnel within their units are strained. The natum and degree of these relations vary among the units. Personnel specific sensitive information and recommendations on this situation have been communicated with senior management.

2. "Too full a plate" is a common concern among supervisors, as this detracts from the time available for interpersonal m1ations. The messages from senior management to "do more with less", and the lack of resources to improve cumbersome programs or to address additional responsibilities further demoralizes supervisors as well as their employees.

3. It is widely perceived by people within NE&O that the present management chain is staffed with some personnel who have progressed because of personal relationships with NE&O management, or via a line of appannt " automatic" prognssion. This has the potential to cause problems, including a lack of accountability and diminished  !

respect and trust from within the organization.

4. There is a concem on the part of a small number of employees to avoid raising sensitive issues to their local management. His feeling exists within Millstone Unit I and Unit ,

2, and to some degme in other areas of the station. We were unable to discern if this )

concern was due to individual employee insecurity or the result of management styles.

If the issue was a clear safety concem, the employees did state that they woald raise the concern with someone to ensum its resolution.

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5. Lack of " straight and timely" answers to employee questions at the supervisory level in l Unit 1 and Unit 2 is a concern expressed by some of those interviewed. The .

1 unanswered questions generally do not relate to nuclear safety, but to topics of employee interest and routine work. This is also seen as a general concern within

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l 6. The task group feels that lawyers are unduly influencing policy e allegations issues

! rather than providing legal advice on issue asolutio,n.

7. Mixed signals from management are demoralizing. Most notably these are alated to I economic performance. These signals come from many management levels and are ,

exemplified by the very frequent and rapidly changing updates of the company's financial condition. Many believe the PSNH acquisition is responsible for this and I further believe it is occupying an excessive amount of senior management's anention.

This uncertainty erodes trust in management and may cause some to avoid the use of the COC in resolving concems.

8. Senior management within NE&O is viewed as not providing strategic leadership, but rather, as being practitioners of micro-management by commitment follow programs, and subscribers to decision by committee or task force.

9. Some issues are not readily brought forward because of the expected d:nial of resources to correct the problem. These issues have the potential of becoming concerns. Also, for the same reason, there is reluctance to pursue items that have been cut from the budget, even when there is a strong feeling that the issue must be resolved.

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10. An effective management development program does not exist for NE&O personnel. A formal needs assessinent is not conducted and needed training is not developed and I

delivered in a timely manner.

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11. The current method of having internal department personnel msponsible for the investigation and final disposition of allegations has resulted in a significant nsource burden on the affected departments and, over the long run, could lead to a conflict of interest and loss of objectivity. ._

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12. It is not clear that there is a master-plan for closure of the allegation issues and who is ,

in charge. Opportunities for clostne may be missed as a nsult. A perception exists that the Vice President of Nuclear Operations should have been more involved.

RECOMMENDATIONS .

Coc-1. Assign a company officer to the Millstone site, to oversee the msolution of allegation issues. A dedicatal technical staff must be provided immediately from outside the line organization to myiew and respond to ongoing NRC allegations.

i coc-2. Provide counseling and training on an individual basis to all of the station and unit directors. Concentrate specifically in areas oflessons learned as a nsult of allegations, listening skills, establishment of trust among subordinates, communications, openness, l the value of " management by walking around", and the elimination of elitist attitudes.

Consideration should be given to using a consultant such as RHR to deliver this on an individualI asis.

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( coc-3. Provide additional first line supervisor positions in the Maintenance and I&C Departments. This will allow periodic assignment of first line supervisors to other roles within their departments, so as to provide job enrichment and a break in the day-to- day action.

coc-4. Pay close attention to, and provide management support and counseling for the new maintenance and engineering managers at Millstone Units 2 and 1 nspectively. The Unit 1 Engineering Depanment is hopefully just now ending a long period of frequent management changes. Personnel specific sensitive infonnation and mcommendaticns slating to Unit 2 Maintenance have been communicated to senior management.

Coc-5. Evaluate supervisory candidates for their ability to deal with employee issues. Expand the Assessment Center concept to higher. levels of management. Provide support and counseling to personnel entering new management positions. Ensure promotions are l

performance based.

Coc-6. Ensure that the station first line supervisor training program places strong emphasis on f " management by walking around", providing " straight and timely answers" and I

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Coc-7. Provide adequate resources to ensure that important improvements a made in a timely, proactive manner. (e.g. computerized tagging, procedure upgrades, procurement program enhancement, reliability centered maintenance, etc).

'coc-8. Establish permanent omce space for the Unit Directors in the vicinity of their respective units. Emphasis should be placed on interacting face-to-face with allievels of the unit ,

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i l 2.2.2 THE NUCLEAR SAFETY CONCERNS PROGRAM (NSCP) i The NSCP is another vehicle in the employee nuclear safety concems resolution l process, intended to be utilized when success in working with the COC has not been achieved. .

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I. In its evaluation, the task group gave the greatest significance to the opinions of those j interviewees who are expected to have the greatpst need for this intemal option. The

! task group believes that a major weakness of the NSCP is that it is lent likely to be a l respected option for those who most need such an option, since their distrust and lack l

of respect is directed toward management in general and therefore applies to NSCP.

i i CONCLUSIONS i 1. He NSCP personnel and process are not well known to many, probably due to the excessive emphasis placed on the maintenance of confidentiality, and their absence a from the work place. Their location, being remote and accessible via a "back entrance"

! is one example of the secretive and mysterious nature of the group.

l 2. The NSCP is perceived by some as an ann of NE&O management.

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3. The NSCP needs major improvement. From the start, the NSCP was disadvantaged from having been created in the midst of serious ongoing allegations. His program is perceived as having been created for the NRC, somewhat as window-dressing.

l Personnel specific sensitive information and recommendations on this situation have been communicated to senior management.

4. The NSCP is designed to be neutral but is perceived to be pro management.

5. We feel station employees may be more likely to take concerns to the NRC resident j inspectors rather than to the NSCP because of familiarity, credibility, and accessibility.

! RECOMMENDATIONS '

I NSCP-1. De program should be broadened to be an employee concems program and not limited 5

to nuclear safety concems. All concems present potential problems.

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NSCP.2. De program should be employee advocate based, by design.

NSCP-3. Increase the resource level available to the NSCP to support a greater field visibility and easier access. Imate personnel at Millstone, Connecticut Yankee and Berlin.

NSCP-4. Market the program to ensure employee awareness and demonstrate support from all levels of management. Promote the use of the NSCP to generate increased usage.

Accept the fact that some who would have used their COC will now go to the NSCP since this will also reduce the number going to the NRC.

NSCP 5. Staff the program with people who can relate to employees in their assigned locations and who will be accepted as employee advocates. Consider use of working level personnel.

NSCP.6. The NSCP should report to the Chairman of the Boarti of Trustees, providing periodic updates on overall status and unresolved issues to the entire Board. Officer incentives should be based, to a degree, on the success of NSCP.

NSCP-7. He Task Group feels that personnel running the NSCP should:

. be strong employee advocates

- have stronginterpersonal skills

- be capable of being frank with management

- be known and accepted by employees at alllevels NSCP-8. Consider expanding the role of the HPES coordinator to be a field resource and advocate for the NSCP.

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l 2.2.3 THE NUCLEAR REVIEW TEAM (NRT) l

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The NRT is a management consulting organization employed by Northeast Udlities to i act in two separate roles. Their predominant role is to provide consultation into areas of l interest as identified by top management. Their second role is to serve as an outside independent organization staffed with industry experts having direct communications lines with senior NU management, available to resolve employee concems.

, l CONCLUSIONS

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1. Experiences some employees have had with the NRT in their management consulting j i

role have generated bad feelings that will reduce the likelihood of these employees l t

using the NRT to resolve an employee concern.

2. Employees are generally aware of the existence of the NRT and would be able to contact them if the need arises, however, the process of having to make a collect call to contact the NRT in and ofitself, destroys the ability to maintain confidentiality.

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3. In their management consulting role the NRT is perceived by some employees as arriving for discussion with preconceived conclusions for which supporting information is being sought.

4. There is a strong impression that some messages and suggestions brought to senior management by the NRT are not acted upon.

5. We believe that station employees are more likely to take concems to the local NRC resident inspectors than to the NRT. NRT personnel cre not well known at the lower levels of the organization and this reduces the likelihood of the program being used.

RECOMMENDATIONS NRT-1. Effectively market this program to improve the level of employee recognition of NRT personnel.

NRT 2. Evaluate eliminating the NRT from their mle in the nuclear concerns process once the recommendations conceming the NSCP have been successfully i:nplemented.

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3.0 ANALYSIS OF ALLEGATION LETTERS FROM THE NRC '

3.1 TASK GROUP CHARGE AND SCOPE OF REVIEW De task group was charged to review issues idendfied in NRC letter allegations which have been turned over to the Northeast Nuclear Energy Company (NNECO), with a request for response. De review was limited to the first 23 letters for which NNECO had already provided the requested information to the NRC. It was also the task group's charge to evaluate the accuracy and seriousness of the allegations made, with l the goal of finding any " common threads" which could support the identification of root causes, for the allegations. Recommendations for corrective actions to reduce or prevent recurrence were also requested.

3.2 METHODOLOGY l

After performing a aview of the NRC allegation letters and NU responses, the task group determined that the reqaired information could best be compiled and analyzed using a "Ceman Dread Assessment" matrix.

Having designed the Common Thread Assessment Matrix, the team then completed a thorough review of the 23 NRC letter allegations and their responses. This information l

was evaluated by the task group to idendfy any commonalities or groupings.

The review indicated an opportunity to improve the format and content of responses to  ;

i NRC letter allegations. Appendix B provides a copy of the task group's recommendation memo and the response received from the line organization.

3.3 COMMON THREAD ASSESSMENT 3.3.1 ALLEGATION ACCURACY l De task group completed a detailed review of twenty-three (23) NRC letter allegations

! containing seventy (70) separate allegations issues. Twenty-four (24) of these issues were substantiated,i.e., found to be descriptive of actual de5cient conditions.

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3.3.2 SAFETY SIGNIFICANCE OF SUBSTANTIATED ALLEGATIONS

• Of the twenty four (24) substantiated allegations issues, twenty (20) were determined i

to have no safety significance. Four (4) were determined to have some relationship to safety. .

l 3.3.3 COMMON THREAD IDENTIFICATION i The majority of substantiated allegations (21 of 24) are identified as having causal factors related to procedural accuracy and compliance; and documentation accuracy, l

primarily drawings, i

! 3.3.4 PROPOSED CORRECTIVE ACTION i The task group considers the majority of allegations reviewed to fallinto the category of day to-day issues expected to be raised by employees and resolved within their j depamnent. The inability to resolve these issues at the local level has close ties to the second root cause listed in the Executive Summary:

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" Insufficient management sensitivity to routine employee issues which results in a failure to provide timely and objective resolutions" The task group recognizes and endorses the ongoing cornetive actions which place a high level of emphasis on procedural compliance and quality, attention to detail and documentation accuracy issues. Further, programs ongoing to improve procedures and documentation accuracy should be completed without interference from other initiatives.

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'4 Appendix A May 1991 AL12GATIONS ROOT CAU5g TASK GROUP

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Racktround 2n the Safety Assessment /0uality Verification functional area in the most recent Millstone SALP Report, the NRC published the following Board Reconsendations:

1. Aggressively identify and address the root cause for...the continuing employee safety concerns.

2. Adopt a more aggressive approach toward dealing with continuing

- employee safety concerns in a way that fosters employee confidence and assures that all concerns can be dealt with consistent with their safety priority. .

Charter The charter of the Allegations Root Cause Task Group is to evaluate existing information and documentation with the objective of responding to Excluded from the scope the first SALP Board Recommendation noted above.

of this effort is direct contact or interviews with NU employees known to have filed allegations.

Two specific activities are required. The first is based upon the recognition that there are three vehicles available for NU employees to express concerns without accessing external agencies. These are chain of command, the Nuclear Safety Concerns Program (NSCP), and the Nuclear Review Team (NRT). Employees express concerns to external agencies (principally the NRC) because there is some deficiency (s) in the three internal options, or because of personal preference. With this background, the first activity involves an assessment of the workability of the three internal options (why would an individual elect to bypass all three?), and to propose to management measures for improvement. Criteria to consider include timeliness, thoroughness and sensitivity with which past safety concerns have been handled, and how those expressing concerns are treated throughout the process.

The second activity involves a more analytical effort dealing with the substance of the safety concerns expressed via allegation letters from the NRC, or other sources that are not confidential. Focusing on the big picture, safety concerns should be logically grouped, e.g., tagging, procedural compliance, attention to detail, timeliness. Such a grouping should reveal any root cause regarding technical aspects of the concerns.

From this, corrective measures are to be proposed to management.

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l l Proposed corrective actions are to be directed toward the root causer for esaaple, if the root causes are local, generic or sweeping solutions are to be avoided.

gairman ,

he Chairman of this task group is Richard J. Schmidt.

Members 1 .

The other six seabers of this group are:

C. B. Bouchard V. J. Dietz R. T. Laudenat .

G. R. Pitman

• P. J. Przekop W. L. Varney Deliverable A report summarizing the major findings and recommendations for improvement is to be provided to the SVP NEO by August 9, 1991.

Access to Other Resources The Chairman is authorised to obtain additional resources from within NEO or external to NE0 as necessary to fulfill the objectives of this task group.

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App 2ndix B NottTHIIAlif UTilJTMts M s  : M ~% ~~

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June 4, 1991 TO: E. J. Mroczka i b l FROM: R. J. Schmidt /) l Chairman, ARCT ,

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SUBJECT:

Allegations Root Cause Task Group (ARCTG)

Suggestions for Responses to NRC Letter Allegations i i

our initial review of NU responses to NRC Letter Allegations indicates that they should provide clearer feedback to the l concernee. We suggest that the NU response ,

l o be of a style directed to the concernee, not the NRC j 4 o whenever possible, acknowledge the portions of the allegations with merit in the. opening paragraph ,

o directly answer all questions.

o avoid verbose defensive responses l c identify any prior notification of the concern to NU The practice of assigning the area supervisor the task of responding to the allegation any not allow the open acknowledgment of shortcomings. We suggest that the response be developed by an independent individual, with input from the area supervisor.

The ARCTG can assist in the development of an expanded checklist to ensure that key aspects are included in NU j responses to NRC letter allegation.

Please call me if you have questions.

R35:15s 7769 c: R.'M. Racich ARCTG Members ,

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l NORTHEAST UTILITIES i i L'. ", Z 1 " = C ""

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@ . .l Tot E. J. Mroczka July 18,1991  !

l NO 90 MP-763 FROM: W. D. Romberg

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SLAUECT: NEO.866 - Affecations Root Cause Tank Groun rARCTG)

As you requested, my staff and I have worked with the Nuclear Ucensing Group to assess the l appropriateness of the seven (7) suggestions made by the allegations Root Cause Task Group.

The following are our observations on the suggestions.

! 1. "be of a style directed to the concemee, not the NRC" q

l This suggestion is being implemented to the extent appropriate, recognizing that these responses

! are sent to the NRC Public Document Room. The responses that are being prepared focus on the specifics of the issue. To the extent that the specifics of the issue will allow, we reflect as much l

cf a personal style as possible. The current practice that the NRC is using of discussing the j issue with us in advance of a letter is helping substantially in this regard. The process allows additional dialogue with the NRC which helps place the issue in context to a greater degree than i the simple letter transmittal does.

j 2. *whenever possible, acknowledge the portions of the allegations with merit in the opening j paragraph" This suggestion is being implemented. Issues with merit are acknowledged.

3. *directly answer all questions" This suggestion is being implemented. The current tum.over process with the NRC is helpful in implementing this suggestion. Having some additional perspective on the issue helps identify the basis for the NU response.

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• avoid verbose defensive responses" This suggestion is being implemented. Severalissues in the past were of a subjective nature and additional discussion was provided in the NU response to place the issue in perspective. This can be viewed as defensive by some, but we remain mindful that the concernee is not the only individual who will read and interptst our response. This was not our intent in preparing any of these letters and the observation by the ARCTG was helpful in identifying this concern to us.

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• identify any prior notification of the concern to NU" A" .

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This recommendation is being implemented. In many of the past NRC letters, NU was not aware  !

I of theissue.

8. *klevelop each response by an independent individual, with input from the area supervisor" This recommendation is being considered, as a balance must be struck between independence in i the review process and ensuring that adequate knowledge of the details is available. We are in  ;

the process of assigning additional personnel to be directly, responsible for issue response i

preparation. We are evaluating various organizational opfions for conducting the investigations including the use of qualified personnel from the non stfected units. The level of detail that these issues represent requires that substantial input be provided from the local area. This i requires more than Just input from the area supervisor. We intend to apply additional  !

resources to this problem to relieve the line managers of the burden of responding to !ssues while at the same time improving the timeliness and the quality of the responses. We intend to partially implement their recommendation, with the details to be arrived at in the near future.

7. %e ARCTG can assist in the development of an expanded checklist to ensure that key aspects are included in NU responses" l We encourage continued input from the ARCTG. Further input from the group at the conclusion of their effort is suggested as an appropriate action to take. A number of issues are being evaluated by the ARCTG which will provide additional perspective on the process in use at NU. A  !

large number of responses to NRC issues are being prepared. The ARCTG will have access to l these letters in the near future and will be able to further assess our responsiveness to their recommendations.

WDR/amk cc: M.V.Bonaca E. A. DeBarba R. T. Harris l f

R. M. Kacich 1

P.

R. J.F.Schmidt Santoro /

C. F. Sears CR 8191 NO610461 ,

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