ML20117H287

Common Cause Assessment of Refuel Operations at River Bend Station

ML20117H287
Person / Time
Site:	River Bend
Issue date:	06/30/1996
From:	Theesfeld T AFFILIATION NOT ASSIGNED
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ML20117H058	List: ML20117H287
References
96-789, NUDOCS 9609090194
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i Common Cause Aaaument of Refuel Operations at River Bend Station FPI Proprietary Report FPI 96 - 789 June,1996 Prepared by: Approved by:

th Mr.T L. Theesfeld Dr.Ch :hiu Director - FPI International President FPI International The report was prepared for Eneergy Operanoes, Inc., River Band Stanon. No part of this report may be a rM without the express wriesa consent of FPI laternanonni. Reproduenan of stus report by EOI is Pmiuand for ther meernal use only.

' REPORT REI. EASED BY FPT FOR REPRODUCTION AND DISTRIBUTION WITil00T ATTACllMENTS.

9609090194 960829 PDR ADOCK 05000458 P PDR

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4 Cn==n= Cause Ame===* of Refuel Operanons at River Bend Station. FPI Report %789

Table of Contents i

g, I n trod ucti o n . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 i g. Executive Summary . . . . . . . . ................................3 g[1. Assessment Approach and Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 i

IV. A naly si s Re sults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 A. Condition Report Matdx . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

, B. Interview Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 i

V. Conclusions ............................................11

'. VI. improvement Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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vil. References .............................................15 -

I Attachments i i Assessment Metbudology Overvww and Desenpoon of PDC Model 4

!! Dracussion of Specific Topics Related to Human Pe formance 111 Accountabdity Program Guidelmes IV River Bend Condanon Report Datahane Sort

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Figures

!. Performance Pyramid

2. Covey's Theory on Mission Centered Work Priontizanon

. 3. Sample Org=nuarw==I & Pros . Diagnosac Chart (Stream Analysis Chart) and Sample 4 1

Human Enors/Insppropnase Accons Chart l

4. Tune Reliabihty Correlanon for SkuBased, Rule. Based, and Knowledge-Based Human Error -

Rate as a Funcnon of Time to Respond l I 5. Correlation Between Human Error Raas and Quality of Supervimoe

6. l CR Dutnbunoe by Human Error Type

7. CR Dssenbunce by Human Error /Insppropnase Action Category

8. CR Duenbunoe by Human Error /Inappropnase Acnon Fashue Mode l 9. CR Dimenbusson by Org====>w=/"rvy "- Failure Mode

10. CR Duenbunce by Deparanset

, 11. Effects of Ar"lh om Actmty Failure Raae i

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. I f Conanos Caese M-t of Refuel Operstmas at Rmr Bend Stanoa. FP! Report %789 l g Introduction j

f 4 arry 11 Goodman, Reactor Engineering Supervisor at the River Bend Nuclear Power Station, i

pested FPI Intemational(FPl) to perform an mueument of Refuel Operations at River Bend. FPI hasstudied equipment failures, human errors, programmatic deficiencies and orgaruzational l

breakdown for the past decade and has written numerous technical papers and conducted many l p in these areas to improve performance FPI evaluated the documented condition repons l (CRs) and past assessments by EOI and outside organizations in an effort to improve site l l

performance.

i The scope of this assessment included a review of the procedures and policies governing refueling activities, evaluation of recent incidents involving refueling activities, and developing recommended j corrective actions to prevent further problems. This repon documents the results of the assessment and our corrective action recommendations. l ti, Executive Summary FPI evaluated the refueling related condition repons to identify common causes of problems interviews were conducted to validate the Sndings of the review and to validate cause(s) and ,

recommended corrective actions to improve site performance during refueling.

Fin 6ngs and Conclusions The condition repon data review revealed weaknesses in review of technical requirements by the engineenng depanment as well as weaknesses in the knowledge and skills of the fuel handlers. The data indicates the majority of the problems lie withm individual performance de6ciencies, but with an element ofineffective preparation to conduct the actrvities involved. The workers are makmg mistakes, but have little experience and less than adequate guidance to follow when making their decisions. _

The roles and responsibilities of the fuel handling team were not well defined or understood. As a result, inconsistent application of duties occurred durmg this refueling. With little River Bend fuel handhng experience, the management team and the fuel handhng team actually did reasonably well to limit the number of mimakes that were made. His is most likely a direct result of the emphasis on quality rather than schedule dunng the refuehng evolution.

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Common Canse A _t of Refuel Opersuons at River Bend Statwn. FPI Report 96-789 y Cause Determination p equale j Change Management (Poor Transinon Planmng) - This was the first refuel outage 3,pg which Entergy Operations, Inc. personnel ran the actual refuel activities. As such, this was y time evolution for EOI. FPI research has revealed that ten times as many mistakes are made U .

o n first time tasks as on any other. It is a tribute to EOI personnel and management that so few rnistakes were made during this refuel evolution, most likely due to the continued emphasis on quahty, as opposed to schedule. But the following three distinct areas for improvement can be emphasized to compensate for the relative inexperience of the staff:

. better defmition of responsibilities,

- training as a team on important evolutions and

-improved plannmg of refueling activrties.

In addition to the root cause described above, indications of a safety culture issue were identi6ed that are contnbuting to refuel problems and need to be addressed for long term improvement:

SelfRepornng - FPI recommends reporting any unusual instances with fuel regardless of the perceived consequence, for example, bumping into a test weight.

Overriding Interlocks - FPI research indicates that promoting the use of overriding safety interlocks will eventually lead to a signi6 cant accident or event.

Changes to the Fuel Mowment Plan - The Reactor Engineer Designee is not always a qualified RE, but has authority to modify the fuel movement plan.

Recommendationsfor improvement (page 12) i Communicate management expectations, or roles and responsibilities, for the refuel team members. These expectations should be provided in the initial training for refuel team l members and then reinforced through effective field observation and feedback.

2 Establish and mamtam " teams" for fuel handling that balances the experience and abilities of the team members.

3 Establish training for the refuel teams that shares past lessons learned form the refuel l activities, covers survedlance testing requirements during refueling, and covers normal and l abnormal operations on the refueling bridge.

4 Impmve the plannmg and scher+nimg ofrefuel actmties speci6cally regardmg the overall time scheduled for fuel moves and the times that fuel moves are suspended.

5. Perform a Safety Culture A=emt to determme the current level of the culture at the site. l 6 Establish a mechanism that allows update of the refuel procedures easdy and correctly 4

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Common Cause An=eument of Refuel Operanons at Rrver Bend Stanon. FPI Report 96-789 gg, Assessment Approach and Methodology Our assessment of Refuel Activities at River Bend consisted of four major steps discussed briefly hel0W- ,

1. Key procedures and policies related to refuel operations were reviewed.

2. A detailed review of River Bend refuel related condition reports was conducted to support the following:

- characterization of the nature of the human errors and inappropriate actions,

- sequence of events leading to these errors,

- key activities and orgaruzations involved with refueling problems, and

- command, control, communication and co-ordmation of activities. I

3. l Personnel were irnerviewed to validate the information regarding refueling problems.

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Based on the results from the above steps, conclusions and improvement j recommendations were developed. '

A detailed discussion of the assessment methodology and philosophy is provided in Attachment I.

IV. Analysis Results Data was gathered from a variety of sources during the evaluation. The results of the individual investigations conducted by River Bend for recent refueling problems were reviewed (including a detailed review ofCRs and LERs). Formal interviews were conducted with 15 m ' dividuals involved in work activities or overdew relative to refueling. Follow-up discussions were held with five other persons to validate our findmgs The indrviduals interviewed represented the major departments and l work levels associated with refueling. The data collected from the CR review and the interviews correlated strongly, which gives us high confidence in our findmgs and recommendations. Fmally,

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Stream Analysis was utihzed to consolidate the data, determme the common causes of the recent i problems encountered with refueling, and to develop improvement recommendations.

l The results presented in this section are divided into the following areas:

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Condition Report Matrix Interview Results 5

5, Counmas Csome A-=====n of Refuel Operances at River Band Stanon. FPI Rgort %789 Condition Report Matrix 4

giver Bend condition reports documenting recent refueling operations problems were reviewed in g during the assessment. A matrix was produced which provides the following information for each event: Report Number, Date, Orgaruzation Involved, Human Error Type, Human Error / Inappropriate Action block affected, Orgamzation/ Programmatic De6ciency block affected, Much category of operational error was comnutted, key activities and key processes involved.

pome cases there was not suf5cierit detail withm the condition report to reach a decision regarding the key attributes classified. In those cases, the classi6 cation is unknown. The results of the analysis l of the known data provided the following:

1 Reactor Engineering was associated with 36% of the problems reported and Operations personnel were associated with 21%. Mechanical Maintenance personnel and System '

Engineering personnel were each associated with 12% of the reported problems. The remaining 19% of the reports were distributed among seven other departments or orgaruzations (including contractor support). Figure 10 shows the department breakdown contributing to the refueling events.

i 2 Human Errors can be divided into three basic groups; skill-based, rule-based and knowledge- l based. Figure 6 illustrates the breakdown of human error type associated with the condition l reports reviewed. 57% of the reported errors were " Rule Based" and 29% were " Skill

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Based" " Knowledge Based" errors made up 14% of the reported population. In order to discuss the signi6cance of this data it is important to understand each of the three failure modes in more detail. Each of these are discussed brie 6y below.

i Skill-Based Skill-Based errors usually occur during routine acdons ir. a familiar environment; charactenzed by non-cognitive actions. Skill-based behaviononsists of the perfonnance of more or less stored patterns of behavior, e.g. operation of a crane, etc. One pnmary characteristic of skill-based behavior is that no interpretanon of the meanmg of a display is required, the display must be completely unambiguous with regard to the required action to take. Examples of Skill Based errors include " Inattention to Detail" (e.g. unawareness, on-the-job distraction, perceived pressure to complete the task, etc.) and " Committed Actions Not Carried Out" (e.g. on-the-job distraction, shortcuts evoked, etc.).

Rule-Based Rule-Based errors are =====w4 with the application of " stored" rules; characterized by cogneve thought processes leadmg to accons based on past experience In other words, an error is made when conadering the local state ofinformanon and then applymg a " stored" rule to the situation. The term rule-based behavior denotes behavior that requires a more conscious effort (than is the case for skill-based behavior) in foiiowing stored (or written) 6

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Caammas Casse Annemanan of Refuel Operanons at Rivw Band Stanos. FPI Report %789 rules, e.g. calibratmg an instrument. Examples of Rule-Based errors include Misjudgment type enors, e.g. cognitive overload, spatial nus-orientation, mindset, etc.

Knnwindoe-B=ud Knowledge-Based errors occur when a higher level of diagnosis is required to analyze the situation or condition; charactenzed by cognitive thought processes leadmg to actions based on analyns ne stustion is outsde of the individual's " stored" rules. A diagnosis is inferred and correcove actions are formulated. The actions are applied and the results are observed.

This process continues until the problem is solved but the imtial actions may lead to a Knowledge-Based error. He term knowledge-based behavior applies to cases where the stuation is, to some extent, unfamiliar, i.e. where considerably more thmiang is involved in one's deciding what to do. For exar.iple, inadequate trainmg or unfamiliarity with the available information can lead to errors of this type.

In order to develop effective improvement recommendations, it is important to understand the type of human errors committed. Dependmg on the type cf error, an effective strategy for corrective action can be developed. Additional m ' formation is contamed in the chart of

" Human Errors or Inappropriate Actions" included as Figure #3b.

This data from the errors committed during the past several months at River Bend is similar to averages in the industry. FPI has found the industry averages to be approximately 60%

rule-based,25% skill-based and 15% knowledge-beeed.

3 Figure 7 shows the breakdown of the categories ofimman errors committed. As a famdy of human error /inemupriate action difficulties, " Misjudgment" accounted for 36% of the total population. " Inattention to Detail" accounted for 24% of the problems reported and "Cemmitted Actions not Carried Out" accounted for 18% of the problems reported.

" Inadequate Skills or Knowledge" and " Inadequate Mental State" each contributed to 11%

of the error population. A possible driver for these failure modes is:

Misjudgment - inconect or vague procedures. Specifically, research indicates that the predominant causes for " Wrong Assumptions" is that a supposition was made and incorrectly assumed to be true. "Iack of Information Validation or Verification" is a situation where enoneous information is used in a decision making process. "Mmdset" is a situation in which an individual approaches a task with a mental attitude or idea that is not based on cunendy obtained facts.

Inanention to Detad - not paying attention to informahan that is available. An inability to focus on the detads of items of importance. Specifically, our results showed

" Unawareness" as the pnmary driver of this faihne type. " Unawareness" occurs when one is not paying attention to alarms, signals, precautions or informatian ma contained in 7

_ _ _ _ - .. _ _ . _ _ _______-..____m _ __ _

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$' l Common Causs A===== of Refuel Operstmas at Raer Bend Stanon. FPI Report %789 i procedures or guidelines.

Committed Actions not Carried Out - poor planning or over-committing. Research  !

I indicates in many cases a request is made without a firm commitment to take an action (a l hidden non-commitment). "Over commitment" occurs when one does not assess the

] resources (money, time, personnel, etc.) needed to carry out the commitment.

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{ Figure 8 shows the human error common causes (failure modes) for the condition reports .

! reviewed. The graph shows the distribution to be fairly flat across several failure modes.  !

! nis is due to the variety of errors that occurred during this time period and the wide range i of experience of the workers.

' The significance of this data regarding human error types, categones and failure modes ~

j indicates that refueling activity errors are attributable to both the decision making aspects of

thejob and the execution of the job. The predominant failure modes were investigated to  ;

! determme the underlying causes through the interview process. The site must continue to

! stress _ the self-check techniques used during work execution. The site should also

! emphasize the use of data Qualification, Validation and Verification (QV&V) and t l overconfidence avoidance techniques applied to reduce decision-makmg errors.

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! 4. The Orgamzational & Programmatic (O&P) common cause analysis results described j below are shown graphically in Figure 9. The predominant O&P common causes were '

l in the O&P failure modes " Inadequate Job Skills, Work Practice, or Decision Making" j (55 %), " Inadequate Scope" (19%) and " Inadequate Self-Verification Process" (16%).

l " Inadequate Job Skills, Work Practice, or Decision Making" is considered a breakdown

! within a single organization: for example, restricted to the Operations or Maintenance

! Departments. His failure mode is generally present when low morale or excessive human l error rate exists. All types of human errors (skill-based, rule-based, knowledge-based) can j be associated with this failure mode.

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" Inadequate Scope" is a failure mode in the area of programs or processes. It occurs when j the procedures do not cover all the necessary elements to respond to a non-routine situation.

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" Inadequate Self-Venfication Process" is another failure mode in the area of programs or processes. It occurs when a process experiences a high failure rate usually as a result of l a single human error.

j The signi6cance of this data is discussed throughout the report. Most significantly, the j majority of the problems lie in the area of individual perform:nce, but with an element of i

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e l Conanos Cause Aeme== pent of Refuel Operatens at Rnw Bend Stanon. FPI Report 96-789 I

ineffective preparation to conduct the activities involved. Each of these predommant 3 failure modes wre investigated to determine the underlying causes through the mterview .

process.

5 The condition reports were also categorized into four categories of operational errors commnted: command, control, communication and co-ordination. Control errors accounted for 59% of the reported problems at River Bend while command e: Tors accounted for 18%.

Communication errors were associated with 14% and the remammg 9% were coordination errors This indicates weaknesses in formahzmg individual responsibilities within the refuel team FPI research has revealed the industfy averages of 54% control,25% communication,13%

coordmation, and the remamir.g 8% command errors. A command structure needs to be well-defmed in terms of authonty, responsibility and accountabdity for each individual involved in the structure or command errors will occur, allowing outage actrvities to continue after being notified of a nusposrtioned fuel bundle would be an example of a command error. A control-error is an error that resuhs in orgaruzational performance not under control; routine rounds, monitoring status boards, and reviewmg procedures and work control packages are examples of control acuvities. A communication error occurs when there is a failure to communicate  :

i effectively; pre-job briefs and turn-over meetings are examples of communications activities.  !

Coordmation errors occur when the right people are not involved or do not ensure the right

actions are taken; getting a group together to solve a problem or collecting all the data to solve a problem are examples of coordination actrvities.

6 Key processes involved with these condition reports included Engmeenng Support (23%),

Surveillance Testing (18%) and Routine Tasks (15%). Key activities involved with the condition reports included Document Preparation and Review (26%), Routme Field Work (21%), Coordmation of Actrvrties (13%) and actual Fuel Handling (10%). This indicates the problem areas are areas of routine, or repetitive, tasks or actmties. These tasks have been pu furTried before and will be p furir.ed agam If the proper preparation is not included with these tasks, repetmve errors would be expected. These areas are also areas that could effect more than just refueling actmties.

B. Interview Resola Personnel in the following areas were interviewed:

Refuel SROs Refuel Floor Task Manager Refuel Floor Supervisors Reactor Engmeers Fuel Movers 9

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t Common Cause Assammesat of Refuel Operances at Rsver Bend Stanoa FPI Report 96-789 l i Synem Engineer j i Quahry Assurance Auditor

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FME Coordinator j

l 1. Roles and responsibilmes were not clearly understood by the members of the refueling team.

j  ; his was due to indmduals nnumg the refuel team meeting prior to the outage and also due 2  ! to changing condmons during the outage. Some of the individuals were not f=nnliar with the j j document outhnag Refuel Team Duties. Others were f=nnliar with it, but nearly everyone l j  ;

said they knew the bridge actmeies were implenuwad differently among the shifts and among i

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individuals. In some cases, the SRO would give dramans, in others the spotter or RE would l j give directions. In some cases the SRO gave pernusson to ovemde interlocks on each '

j evolution, in others pemnssion was granted at the beganing of each shift.

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l He shea describag the Refuel Team Duties is not very descript when describing the duties i ,

ofindividuals on the bridge. He Refuel SRO, Fuel Handler and Reactor Engineers are all i

l included in the same line with the same duties. Their duties should be separated out based

' upon their possons and clearly described for them. Failure to clearly desenbe responsibilities l and failure to consimently reinforce them correlates with the control error predonnnance l noted in the condition report review.

1 l 2. He experience level of the team =M=rs directly impacted performance. He "best

i I esanstes" of the experience level of the workers and their supervisors provide only 20% of

, the indmduals had River Bad experience moving fuel Nearty 66% had been involved with  !

i fuel movement actmnes ofsome sort at another location. FPI research shows that ten times i as many mistakes occur during firm time evolutions as any other time. His relatively low  :

l experience level was then nadaplied when the team members were rotated through the l

j positions with no compensation for experience. At times, an entire fuel handling team had '

] no previously #M workers. his correlates strongly with the condition report review j

which revealed that ofte individuals were not familiar with the task at hand and they made mistakes due to unawarmess of conditions around them ant described in procedures.

2 it i nis also contributed to surveillance concerns and teming regairement concerns as individuals I

with less expenace conducted the tests. Again, FPI research shows that these issues should l not be w=~*-t As the experience level of the workers decreases, so does the knowledge j

and skins level of those workers relative to their tasks. This leads to a requirement for better

! information and more clearly stated technical or adminierative requirements wahin the

{ procedures to compasste for the lower experience level In any task EOl undertakes with it's own people for the first time, the procedures should be reviewed and updated to i

compasste for the lou in exponence prior to performing the tests or activaies. He Refuel i Bridge system egineer appears to be updatag the procedures, tems and work orders in a j

manner consistant to support this need if provided the time and personnel to support the i, transaion.

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! Conssos Caane A-t of Refuel Operances at River Bend Statma. FPI Repan 96-789 3' Regarding adequacy of resources to perform assigned job duties, nearly everyone said they l need more time or better plannmg to carry out the tasks and roiew the procedures adequately  ;

i for the work performed. Several individuals said if the tasks were planned better and if the i

work was performed according to the plan, the current resources would probably be  ;

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f 4 Distractions led to several interruptions of work and directly impacted the misplacement of I the fuel bundle durmg RF6. FPI research has revealed that " distractions" is the number two 3

cause of problems in the nuclear industry. (Time pressure is number one.) Often the control i room would request fuel movement to stop to vent contamment or re-align cooling loops.

Others dist'racted the refuel acavity by stopping fuel moves to transfer equipment or waste to or from the contamment This kept the fuel handlers from becommg more aware of the 1 I

equipment responsiveness by using it uninterrupted. When the fuel bundle was misplaced, both the Refuel SRO and the RE were distracted by conversation regarding the proper order j to F fvim steps in. Although distractions did not surface as a predominant failure mode in j l the condition report review, these distractions could easily be leading to the failures noted. i 5 Each of the groups interviewed expressed a need for more technical training for their activities. It was recommended that trammg should tie the class, job performance skills, procedure requirements and technical information together i

6. When asked if one conastent message had been sent by management during the refuel outage icping fuel movea, everyone rd hat "quahty t is more important than schedule" was l the message.

V. Conclusions in general, we are impressed with the prvessionalism displayed by the River Bend staff'. The imerviewees were frank and open with their responses. The data obtained from the interviews was very consistent and corrested strongly with the condition report review. As a result, the conclusions a

of this report are based on an extensve foundation of supporting information.

A single common cause contritnsted to the majority of the refueling problems at River Bend:

l Inadequate Change Management (Poor Transition Plannmg).

I Although this refuel outage is entaled RF6, it is reeBy the first refuel outage Entergy Operations, Inc.

! personnel ran the actual refuel actmties As such, this was a first time evolution for EOI. It is a l tribute to EOI personnel and management that so few mistakes were made durms this refuel l evolution. This is most likely due to the continued emphasis on quahty, as opposed to schedule 11 6

Cmunas Caame A====inent of Refuel Operstmas at River Bond Statma. FPI Report 96-789 g foljowing three disunct areas for improvement can be emphasized to compensate for the relative inexperience of the staff

- better defmition of responsibilities,

- training as a team on important evolutions and

- improved planning of refueling activities.

In addition to the root cause described above, indicanons of a safety culture issue were identified that are contributing to refbel problems and need to be addressed for long term improvement.

Self Reporrmg - Although many items were reponed via the condition reporting process, some gesctor Engmeers and SROs stated that they would not report " bumping" into an obstacle with the fuel bundle if they didn't think any damage occurred. FPI recommends reportug any unusual instances with fuel regardless of the perceived consequence.

Overriding Interlocks - Although this was the method chosen by the site for moving blade guides through the " cattle chute", FPI research indicates that promoting the use of overriding safety interlocks will eventually lead to a significant accident or event. For example, refuel bridge operators are already overriding additional interlocks to save time in the IFTS system. -

Chr.ges to the Fue/Mowment Plar - Although two qualified reactor engmeers and their supervisor must authorize the ir.itial FMP, a single reactor engmeer (or designee) may modify it. It is not unusual to fmd a single, qualified individual may modify the plan. In River Bend's case, the RE Designee is not necessanly a quahl reactor engineer This indicates a potential problem area in that I a non-qualified individual may modify the work of three quahfied individuals.

VI. Improvement Recommendations In the developmem of the ' or v ...es i+x s-s=4= dons, we evaluated the actions already taken or planned by River Bend management as a result of these problams in the refuel operations. In general, the resuks of our investigation do not evos. dict any of the conclusions previously reached by River Bend. However, there are differences in the presentation of the data and scope of some of the improvement recommendations. We have identified areas which if strahaaad, will ensure immediate improvement and set the precedent for long-term performance improvement at River Bend.

1. Communicate managemem vadona, or roles and responabdities, for the refuel team members. These vadans should be rW.ded in the istial traming for refuel team members and then remforced through effective Seid observation and fe=dhacir 12

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r==, nan Cause Am===nant of Refwl Operanons at River Bend Stanon, FPI Rsport 96-789 t

l- A recommended example of settmg clear responsibility for the team members could include j the following:

a. Fuel handlers are responsible for safely moving the fuel and other items listed in the refuel movement plan.

j b. Fuel handlers and spotters use two way comrmmication for each step of the fuel

} movement plan. He spotter gives the instruction and the handler repeats it back.

i ne spotter also comrmmimes with the main control room regarding the fuel moves.

Another quahed individual veri 6es each of the moves per the fuel movement plan.

c. He Refuel SRO is responsible for aH fuel moves and has the ultunate authority to authorize fuel movement. He Refuel SRO is responsible for overall control of the refueling activities relative to fuel movement. He Refuel SRO authorizes changes to the fuel movement plan regarding core aherations. He Refuel SRO signs any condition reports generated as a resuh of fuel movement related actmties from the l refuel floor.

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He Reactor Engmeer (a fuDy quahfied RE) is responsible for makmg any changes to l the fuel movement plan. He Reactor Engineer is responsible for ensuring the core i map used on the bridge is kept up to date with the most recent moves.

e. Each member of the refuel bridge team has the responsibihty to sop fuel moves at any l time they perceive a problem.

2. Establish and maatam " teams" for fuel handling that balances the experience and abilities of the tcam members.

I A recommended example of balancing these teams and maintaining their positions could be i as follows:

a. Pick teams with at least two members on each team with past refueling experience. J At least one team =amhar should have site specific refueling experience. ,

b. He teams should rotate (smularly as the operations crews) so that the Refuel SRO,  !

RE, and fuel handlers are normaDy working together with the same individuals. .

3. Establish training for the refuel teams that shares past lessons learned from the refuel actmties, covers surveiBance teming requirements durms refueling, and covers normal and abnormal operations on the refueling bridge.

4. Improve the planning and scheduhng of refuel actmeies by incorporating the foHowing changes;

a. Schedule the overan time aBotted for fuel movemen to a reshstic estunate based upon EOI data for new personnel conducting the job, not based upon the "best ever" prevmus time. His win reduce time pressure on the workers, while providag them a realistic and chaHenging schedule

b. Sdiedule and coordame non-fuel movement activities to coincide with the breaks a I the refueling activities. For example, if the tefuel teams turn-over four times a day, l

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3 I Can=nna Canse Awe of Refuel Operanons at Rmr Bed Statnam. FPI Repon 96-789 schedule the contamment ventmg, equipment moves through containment and garbage pick-up and transfer for those times while the refuel team has stopped inoving fuel.

The Refuel SRO should notify the Refuel Floor Supervisor when fuel moves have stopped and the other activities can be started. The RFS then authorizes those activities (which have all been pre-planned and pre-staged to carry out).

y Perform a Safety Culture Index Assessment to determme the current level of the culture at the site in the following key areas:

Mission and Goals Knowledge and Skills Lateral Integration Work Processes Self-improvement Culture 6 Establish a mechanism that allows update of the refuel procedures easdy and correctly. This process should contain the following elements:

a. Defme the scope, purpose and control requirements of the procedure.

b. Identify the user's needs and profile (experienced, new, other skills, etc.).

c. Prepare a procedure that encompasses a. and b. above.

avoid excess reviews

-locate review points at :,trategic po'mts

-ensure independence of review, veri 6 cation and approval

-ensure fast charge ofincorrect data or statement

-include photographs, colored drawings and lessons learned

-use " sectioning" techniques to present data of diff'erent messages

-mmmuze compound or complex statements

d. Require 6 eld review and approval by Seid workers or Srst line supervisors.

e. Initiate the revision and publicize the change.

f. Have a worker use the procedure real-time.

g. Require worker feedback on the procedure for improvement.

h. Update the procedure as appropriate.

1 l

14

V. ,

Common Cause Ae==== ment of Refuel Opentions at River Bend Stanoa, FPI Report %789 y[L References l

j. C. Chiu, Faihire Diwnnsric Guidebook. Published by Failure Prevention, Inc., San Clemente, CA (1991) 2_ C. Chiu, Roricauw Guidebook. Published by Failure Prevention, Inc., San Clemente, CA (19h').

3 A Couun dsdve Course in Observation & Human Error Reduction Techniones. Published i

by Failure Preven: ion, Inc., San Clemente, CA (1992). '

I 1 A Comorehemive Course in Root Cauw Analysis for Oromahd-mal & Pronrammatic Imorovements 'ublished by Failure Prevention, Inc., San Clemente, CA (1990). -

l 5 Covey, Stephen R., "7 Habits of Highly Effective People", Simon & Schuster, (1989).

)

l 6 "How to Avoid Human Errors Through Work Stress Management by Workers, Supervisors,

, and Managers", FPI Technical Paper 94-588 (1994).

! , 7 "An Integrated Model for Event Rate Reduction - From a Management Perspective", FPI Technical Paper 94-542 (1994).

8

" Nuclear Power Plant Supervisofs Cnocal, But Poody Pafunr44 Jobs", FPI Technical Paper 94-562 (1994).

9 " Lessons Lemmed From Other Regulated Industries About Human Error Rate Reduction - .

From a Mangement Pmyective", FPI Technical Paper 94-581 (1994).

l 10 " A Comprehensrve Model for Monitoring and Trendmg", FPI Techmcal Paper 94-602 (1994). j i 1. "Managmg Nuclear Safety Dunng Transition to a Deregulated Environment", FPI Technical Paper 94-582 (1994).

12. Kohler, et.al., "Amrican Workers Under Pressure", St. Paul Fire & Manne Insurance Company, Techniul Report,1992 13 "The Biggest Nightmare May Come True - Shuttmg Down Nuclear Plants By Our Own Doings", FPI Techmcal Paper 94-644 (1994).

15

P o

Conanon Cause A - --i-st of Refuel Operauons at Rsver Bend Stabon. FPI Report 96-789 4

14 Applicable FPI International Application Notes:

93-36 Optmuzation of Combined Effectiveness of O&P RCA & PMT Programs 93-43 ja itative Root Cause Program Effectiveness 93-45 %!i tization of O&P Root Cause Initiation Criteria -

93 46 Optimization Between O&P RCA & PMT Programs 93-49 Accoumability vs. Punitive Managemem Style 93 56 Performance Degradation After Downsizing 93-60 High Human Error Rate for First Operations Shift 93-64 Automatic Human Error P. eduction

?

93-69 Manager's Role in Human Error Reduction 93-70 Supervisor's Techniques in Human Error Reduction 93-71 Worker's Techniques in Human Error Reduction 93-72 Success Psychology 93-73 Effective Accountability Program 93-74 Comtr,nly Seen Mistakes in Common Cause Analyses 93 81 Human Error Assessment 93-85 Human Error Reduction Program for a Human Error Free Workplace 93 88 Reinforcement Techniques & Misinformation of Mgmt. Expectations 93-89 Commonly Seen Mistakes in Human Error Reduction Programs 93-90 Survey Questions for Human Error Root Cause Analyses 93-92 Persuasion Meetings 94-17 Trending Repeat Events - An Effective Means to Improve Root Cause Program Effectiveness 94-21 Sensitivity Study of Root Cause Program Effectiveness 94-22 Inadequate Scope of the Root Cause Program 94-25 QV&V Versus Star Program 94-45 A Good Accountability System 94-46 Pitfalls of Developing and Accountability Program 94-47 Distribution of Efforts in Prevention, Detection, and Correction of Human Errors.

14 "A Compreerive Approach to Procedure Noncompliance Problems - From a Management Perspective", FPI Technical Paper 94-646 (1994).

15 " Reduction of Ruk-Dased Human Errors From a Management Perspective", FPI Technical Paper 94-652 (1994).

]

16. " Reduction of Procedural Errors - A Comprehensive Study of Procedure Problems in Medical, Power, and Manufactunng Industries", FPI Technical Paper 95-741 (1995).

17 Reactor Engineering Procedure REP-0029 Rev. 2B, Fuel Movement i

l 16

p-o o

C - CanseA . =t of Refuel Opera 6ons at River Bend Staten. FPI Report %789

18. Fuel Handling Procedure FHP-0001, Rev.16, Control of Fuel Handling and Refueling Operations.

19 Surveillance Test Procedure STP-055-0705, Rev. 9A, Fuel Handling Platform Operability Test.

20. Fuel Handling Procedure FHP-0003, Rev. 7, Refuel Platform Operation.  ;

21 Fuel Handling Procedure FHP-0002, Rev.10, Fuel Handling Platform Operation.

4

21. NRC Inspection Report 50-458/96-01 and Notice of Violation, April 18,1996.

s j

17 s

,e' k .

O ENCLOSURE 2 ,

Entergy Operations, Inc. !

August 19,1996 Meeting  :

Attendance List  ;

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i MEETING: FIRS MANAGEMENT MEETING  ;

DATE: AUGUST 19,1996 ATTENDANCE UST l (PLEASE PRINT CLEARLY) i I

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