ML20132A624
| ML20132A624 | |
| Person / Time | |
|---|---|
| Site: | Vermont Yankee File:NorthStar Vermont Yankee icon.png |
| Issue date: | 12/10/1996 |
| From: | David Desaulniers NRC (Affiliation Not Assigned) |
| To: | Ramsdell R VERMONT YANKEE NUCLEAR POWER CORP. |
| References | |
| NUDOCS 9612160203 | |
| Download: ML20132A624 (20) | |
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December 10,1996 i
1 Mr. Roy Ramsdell i
Vermont Yankee Nuclear Power Corporation P.O. Box 157 j
Govenor Hunt Road 1
Vernon, VT 05354-0157
Dear Mr. Ramsdell:
In response to your telephone inquiry concerning the Human F9ctors information System i
(HFIS) I have enclosed excerpts from the HFIS User's Marsua!. These excerpts are the guidelines that the staff uses for coding Licensee Event Reports and inspection reports.
As discussed in our telephone conversation, public access to data in HFIS will be made available through the World Wide Web during the next 6 to 12 months. The U.S. Nuclear l
Regulatory Commission's address on the World Wide Web is WWW.NRC. GOV.
i If you have any questions concerning the information I have provided you can contact me i
at 301-415-1043.
l Sincerely, 1
Cri[@.C! t ', '
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Cavid R. Desaulniers Human Factors Engineer Human Factors Assessment Branch y
Division of Reactor Controls and Human Factors Office of Nuclear Reactor Regulation
Enclosure:
As stated cc:
CThomas w/o enclosure i
i Distribution:
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02/18/94 gEVISION 1 HUMAN FACTORS INFORMATION SYSTEM LER CODING INSTRUCTIONS General guidance:
First, determine if LER is human performance related (HPR).
This can usually be done by reading the root cause section of the LER.
An event is HPR if the root cause involves:
personnel error procedure problems planning and scheduling problems training problems communication problems i
work environment problems Code all human performance related LER's, even those identified as voluntary.
If cause is unknown and report indicates in block 14 that supplemental information will be submitted, discard LER and code when supplemental report is filed.
Plant name:
select name from pick list on HFIS.
Docket number: enter 3-digit number Event date:
enter date as it appears in block 5 of LER.
Always use 2-digit entries for day and conth.
LER Number enter year and sequential number of LER shown in block 6 of LER.
Sequential, number should always be 3 digits.
Use zeros to any empty spaces.
Example: 93-003 or 93-022 l
Event ime:
enter information ~. sed on a 24-hour clock.
Each l
time entry should contain 4 digits.
The time should reflect the time the action / event occurred I
(ESF actuation, time of inappropriate action) or should have occurred (time of day of missed fire watch) and not the time the error was discovered.
I HFIS User Manual E-1 Appendix E
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l 02/18/94 REVISION 1 1
I Enter "NA" for event time if the time is not stated, or if the time when the error is discovered is not related to ".he original error.
For example, the discovery time for an incorrectly assembled valve or the discovery of an incorrect calculation are not related to the original error and should be coded "NA".
The one exception to this is if the LER states the time of the original error. Using the above example, if the LER states the time that the valve was incorrectly assembled, then code the time.
NA. isa.not acdeptedias a 5511d?eVfd5 Chi 5ie!
A L "0".i~s f used - if ths" event 31me$is i unkrfownsor)not applicabl.9.
If the powerD1eveldisiNAEindithe event-time is'O, this is equiv51ent 661dventrtime being.NA.
A known-.or. unknown power level and'a'0 event time is equivalentJto an unknownievent. time.
Issue date:
No data entry required.
Power level:
Enter the actual power level when an event occurred during and is related to the power level.
l Enter "0" only when the event occurred during and is related to the shutdown condition.
Enter NA when the reported event is unrelated to the power level. (Example: engineering re-analysis)
Micro fiche:
No data entry required S Jtems Involved:
No data entry required 3
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Appendix E E-2 HFIS User Manual
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REVISION 1 i
j Personnel l
Category:
General guidance:
]
- Choose all that apply.
- Each category contains both workers, supervisors, planners and procedure writers in j
that work group.
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- Choose only those individuals involved with j
committing or exacerbating an error not those that 1
discover the error.
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- If the personnel category of the worker i
committing the error is unknown, leave the
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category blank.
- Text may not specifically name a personnel category.
However, if the text contains sufficient inforniation to identify the category, i
code as appropriate using work group definitions.
- If the LER does not specifically state that i
operations workers are licensed, select "non-l licensed operator".
- If personnel are contract workers, code by work l
area and enter " contractor" under "other".
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Work group definitions:
Licensed Operator: all licensed operators
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including RO and SRO, regardless of position.
This category included SS and STA(if the text specific'11y states that the STA is licensed.)
i Non-licensed operator: operations personnel when the LER does not specifically state that workers are licensed and includes rad-waste opera *. ors, j
auxiliary operators, and plant equipment j
operators.
Instrument and control: includes technicians I
referred to by this name; may also include those titled maintenance technicians.
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Electrical: includes electricians and electrical
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maintenance personnel.
Mechanical:
includes mechanics and mechanical maintenance personnel.
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4 HRS User Manual E-3 Appendix E 1
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i 02/18/94 REVISION 1 t
f Personnel Engineer: includes all types of engineers.
4 Category I
Cont'd Radiological protection: includes health physics, RP or HP technicians.
Chemistry:
includes chemistry and radiochemistry technicians.
Security: includes all security workers Other:
include the following personnel in this category by writing in the name of the group.
QA/QC, Fire, and Contractor (together with the category the contractor is working).
Appendix E E.4 HFIS User Manual
o N 02/18/94 REVISION 1 Work Type:
General guidance:
- Check all that apply
- Focus on the type of work being done when the I
error was committed, not the work in progress when the error is discovered.
If unable to determine the work type when error was committed, then leave blank.
Work type definitions:
Operating: all normal, abnormal and emergency operating activities including planning and scheduling, fire watch, walkdowns, operator rounds 1
and general outage activities Testing: testing of equipment including all post maintenance and surveillance testing.
Calibration: all calibration and adjustment activities.
Troubleshooting: activities involving a set process used to identify source of a known problem.
Maintenance: general maintenance and repair Engineering: all engineering activities including calculations Procedure development:
all work involved with the development and revision to procedures Refueling: limited to refn -, "loor activities Modification: any activities involving physical installation of a design change to the plant.
Other: includes housekeeping (events involving cleaning activiti's) radiologi. cal (decontamination 6:tivities), and QA/QC.
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HFIS User Manual E-5 Appendix E
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02/18/94 l
REVISION 1 l
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Type of Task Behavior:
Skill-based - highly automated sensory-motor and cognitive performance taking place j
without conscious control i
Rule-based - rules or patterns of behavior that are to some extent able to be memorized l
Knowledge-based - decision making and problem i
solving occur i
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Action Error:
Focus on the error when it was committed not when it is discovered.
This may require some level of l
interpretation.
l If available information is insufficient to make a l
determination, select " Unavailable" l
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t Action error definitions:
l Untimely action: correct action at the wrong time i
l (ex. beginning work before authorized)
Omission:
failure to perform all steps in a task i
(both procedure governed and non procedure governed (ex. failure to notify control room of I
beginning of test)
Out of sequence: perform task steps in the wrong 4
order l
Wrong action: correctly performs an action which i
should not have been performed (ex. wrong unit / wrong train)
Extraneous: unintentional action (ex. bumping into aquipment, dropping tools) i 4
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Apperdx E E-6 HFIS User Manual I
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02/18/94 l
REVISION 1 1
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Contributing Factors:
Focus on the error when it was committed not l
when it is discovered.
This may require some j
level of intarpretation.
If available information is insufficient to make a i
i determination, select "Information unavailable" Contributing factors definitions:
Inadequate training: training not sufficiently detailed or not specific.
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Improper training: wrong information presented in i
training (ex. training taught task differently than how task is performed at the plant) i No training: no training presented 1
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Procedure not followed: worker failed to follow i
(failed to take procedure to the work site, i
brought wrong pracedure to the work site, abandoned use of the procedure) faileditoJuss adequatQselfjdiecking
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j Procedure inadequate:
procedure less.than adequate due to problems with format, content, i
equipment identification, and/or quality of graphics Lack of procedure: no procedural guidance available i
Procedure wrong: procedure contains wrong information, wrong sequence of steps, wrong equipment identifications, does not reflect current plant configuration.
Human system interface: less than adequate:
labels, arrangement or placement on panels or controls, information on a display, panel design Work environment: less than adequate lighting, excessive noise, temperature extremes, cramped work space, raditlogical cond2. ions j
l Verbal communication: missing or less than adequate verbal communication j
Written communication: work order packages, technical specifications ~
HFIS User Manual E-7 A A xE
02/18/94 REVISION 1 Work Schedule: shift length, excessive overtime Work load: too many things to do, pressure to maintain schedule Management and P'arning:
Original design /installatian errors.that,.should~have.been detected through surveillance,.;inspectionsic:~etc, Shift turnover: less than adequate or no turnover l
1 Appendix E E-8 HFIS User Manual
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02/18/94 l
REVISION 1 Plant Identified l
Root Cause:
Enter text from report if specified i
Corrective Actions:
Enter text from report if specified Type of Event: No data entry required Cognitive Errors:
Focus on the error when it was committed not when it is discovered.
This may require some level of ir.terpretation.
If available information is insufficient to make a determination, select "Information unavailable" Personnel Effect Code:
No data entry required Reportability 1
Code:
Select all that are marked on LER Personnel Activity Code: No data entry required l
l HFIS User Manual E-9 Appendix E
i LER DATA ENTRY SHEET Plant name: (as marked on LER and selected from HFIS pick list)
Contributing factors:
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information unavailable inadequate trauung unproper training j
Event date:(as marked on LER) no trauung.
l procedure not followed LER ruirnhar:(as marked on LER) procedure inadequate lack of procedure Event time:
procedure wrong human system interface
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work environment j
verbal co,vrainicaten i
Power level:
written caa=r=iaication work scheduk work load management and planning shiA turnover Personnel category:
licensed operator Plant identified root cause:
non-licensed operator (as marked on LER by coder) instrument and control i
electncal Alternative root cause: (coder must specify here.)
mecharucal engmeer radiological protection chsaustry secunty other Corrective Actions:
Work type:
(as marked by coder) operating tentag calibration troubleshooting mantenance Cognitive error:
l engineering attesion deficit procedure development misinterpreting information refueling forgetting l
modification false assumption
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other poor judgernent l
boredom
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Task behavior:
other skill rule Reportability codes:
knowledge (as marked on LER)
Actmo error:
unavailable urvi-ly action oinassma out of sequence wrong acten extranamis action i
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Appendix E E 10 HFIS User Manual a
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Appendix F - HFIS Inspection Report Coding Instructions Selecting Department Department definitions:
Operations:
all licensed operators including RO and SRO, regardless of
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position. This category includes SS, STA, Non-licensed operators, rad-waste operators, auxiliary operators, plant equipment operators, fire department, work planning, outage planning, and project management group.
Instrument and control:
includes technicians referred to by this name; may also include those titled maintenance technicians or instrument technician. Tasks are usually associated with conducting surveillance or calibrating and functionally testing equipment Electrical:
includes electricians and electrical maintenance personnel.
Mechanical:
includes mechanics and mechanical maintenance personnel.
Chemistry:
includes chemistry and radiochemistry technicians.
Radiation protection:
includes health physics, RP or HP technicians.
Engineer:
includes all types of engineers. (ie: design, plant support.
system engineers)
Contractor:
includes all contractors regardless of area Training:
includes all training personnel QA/QC:
includes all QA/QC may include in-service testing and inspection. and non destructive testing personnel Plant Management:
includes all management and supervisory personnel regardless of denartment Planning & Scheduling includes all staffin outage planning and work control HFIS User Manual F-1 Appendix F
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' Selecting Area and Details for:
A. Training Areas A. Initial j
if training is basic training leading up to ini ial qualifications t
l B. Continuing or reque'ificativa if training present advanced topics or presents refresher training on basic topics C.OJT if training is job performance oriented and is leading to task qualification D. Simulator if training is conducted using a control room simulator Details 01 No training if the problem is due to no providing any training on a specific topic 02 Inadequate training if the problem is due to incomplete or incorrect training 03 Training Process Problem if the problem is due to a break down in the SAT (examples:
inadequate job or task analysis, inadequate program evaluation or feedback, failure to keep lesson materials current) 04 Task qualification if the worker is not qualified to do the job assignment 05 Individual knowledge LTA if the individual worker completed training but was unable to put training into practice Appendix F F2 HFIS User Manual
l Selecting Aru and Details for:
B. Procedures & Reference Documents Areas:
E. Normal procedures related to all phases of normal plant operation including:
- corrective and pr :v:vative maintenance
- operation and response to transients
- radiological and decontamination F. Off-normal procedures related to refuehng, G. Emergency all EOPs H. Surveillance and test procedures governing activities related to:
- testing of equipment.
- calibration
- troubleshooting
- 1. Administrative procedures related to general activities such as:
- tagging
- housekeeping
- configuration control J. Special procedures related to unique situations such as once in a plant life test, installation of modifications, QA/QC.
Details:
06 No procedure / reference document if a document does not exist 07 Inadequate procedure / reference document if a document exists by does not provide sufficient guidance for the worker to avoid error or if the document contain incorrect information 08 Failure to follow procedure / reference document if the document content is correct but the worker fails to follow the guidance or 09 Procedure / reference docu aent development or maintenance program i TA if the document was developed using inadequate analysis or if has not been updated in either the original or in a specific copy.
10 Made an error using procedure / reference document if the correct document was used but a step was skipped. misread or l
misinterpreted by the user HFIS User Manual F-3 Appendix F
Selecting Area and Details for:
4 C. Organizational Issues f
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Area:
K. Staffing if the issue is due to the number of workers or how they were used Details:
11 Inadequate staffing if the problem is du, to inadequate number of workers 12 Poor task allocation if the total number of workers was adequate but the way in which work was distributed was uneven or ifindividual work overload, too many actions required at one time, too much information had to be processed concurrently Area:
L. Overtime if the issue is due to use of approved or unapproved overtirne Details:
13 Inadequate controls if there is no guidance for approval and use of overtime or if the guidance is weak 14 Excessive number of hours worked if the problem was caused by worker fatigue due to the number of hours worked or change in shift cycle -
15 Frequent use of overtime if there is no guidance to limit the amwnt of overtime or the conditions under which overtime may be used e
Appendix F F.4 HFIS User Manual
Selecting Area and Details for:
D. Management and Supervision Area:
M. Attention and oversight if the problem is due to management of a work activity Details:
16 No supervision if the problem is 'ue to a lack of supervision 17 Inadequate supervision if the problem is due to less than adequate supervision if supervisor did not detect fatigue or fitness-for-duty problems l
18 Management expectations LTA if standards or expectations are not adequately defined or inconsistently enforced Area:
N. Work Control if the problem is due to how work is assigned and managed l
Details:
19 Scheduling and planning if the problem is due to missing or inadequate scheduling or planning l
(examples - bringing the wrong tools to thejob) 20 Worker selection if the problem is due to the fact that the worker is not qualified to perform the task l
Area:
O. Corrective Actions if the current problem is because previous problems were not adequately l
l addressed l
Details:
21 Individual action less than adequate if a specific fix was not completed or if completed, failed to prevent recurrence 22 Action not yet started if a specific corre:tive action was previously identL.ed but not yet begun 23 No action planned l
if a previous occurrence did not identify any corrective action 24 Corrective action program LTA l-if the overall program for identifying and correcting problems is inadequate Area:
P. Self-evaluation if the problem is due to inauequate or missing licensee evaluation Details:
25 Root cause less than adequateif the root cause determination process does not identify true root causes i
HFIS User Manual F-5 Appendix F
Selecting Area and Details for:
E. Communications Areas:
Q Verbal if the problem is related to instructions or information transmitted orally R Written if the problem is related to instructions or information other than that in procedures which is transmitted in writing (examples: night orders, memos, operator aids for operation of equipment)
Details-
'6 Misunderstood information if the information is correctly stated or written but is not understood 27 Communication ne' ri,qely if the correct information is received late (example: starting a test before informing the control room) or if groups fail to cross check l
28 Communication LTA l
ifinformation it missing key elements (examples: not specifying a particular train) or if the information is incorrect (misstating information -
providing the wrong identification number for a piece of equipment) or if communication is confusing j
29 No communication ifinformation is not shared at all or l
If group fails to cross check when appropriate i
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l Appendix F F-6 HFIS User Manual
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Selecting Area and Details for:
l F.
Human System Interface Area:
S. Equipment T. Instrumentation and controls l
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U. Displays V. Panel / work station layout il W. Equipment X. Tools and materials J
Details:
30 Labels less than adequate if the wrong equipment is selected because of missing, wrong or diff.m..
to read labels or l
iflanguage on label is inconsistent with language in the procedure l
31 Information organization LTA i
if the understandability ofinformation (test / content) and identifiability i
i with associated alarms, controls, displays is inadequate a
32 Size, shape or coding l\\LTA if the size, shape, coding, or scale marking scheme is madequate i
33 Placement oflocation LTA if the placement, location, spacing, or arrangement of alarm, control, display, panel or workstation, tools, materials or equipment are inadequate i
34 Information format LTA i
if the presentation of information on menus for CRT screens or large overview display panel are inadequate i
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1 Appendix F F-7 HFIS User Manual 4
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Selecting Area and Details for:
G. Work Factors Area:
Work Practices Details:
35 Work practices or skill of the craft LTA if the skill of the craft activities are not performed consistent with managemen' upectations, safety significance of activity or industry standards 36 Non-conservative decision making / questioning attitude LTA l
if personnel fail to stop work or establish appropriate controls when j
presented with unfavorable or uncertain conditions l
l 37 Tag outs if the problem is due to missing or incorrect tagging 38 Pre-job preparation if the pre-job briefing or walk thm was missing or inadequate l
39 Work package quality if the work [ ackage is missing information or if the information contained in the package is incorrect Area:
Z Work Environment 1
Details:
40 Temperature if the problem inue ta temperature or weather conditions 41 Light if the problem is due to level oflighting, glare or wrong color lighting 41 Noise if the problem is due to distracting noise leve' 42 Radiation if the proble i is due to work practices required because of the radiation level or if performance of the task was made difficult by requirements of worker to wear protective clothing 43 Work Area / Layout if the problem is due to limited access to equipment or controls or l
if the work art e is ; mall or if there is insufficient space to preform the task Appendix F F-8 HFIS User Manual l
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Area:
AA Attention t.
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Details:
45 Independent verification / plant tours LTA if personnel fail to identify errors through independent verification or' j
perform verifications inconsistent with management expectations or industry standards i
46 Attention /self-checking LTA j
if personnel become dis" acted, fail to verify appropriate actions prior to i
taking action i~
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1 HFIS User Manual F-9 Appendix F