ML20134K582
| ML20134K582 | |
| Person / Time | |
|---|---|
| Site: | Salem  |
| Issue date: | 04/22/1993 |
| From: | Martin T NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| To: | Jason White NRC OFFICE OF INSPECTION & ENFORCEMENT (IE REGION I) |
| Shared Package | |
| ML20134J860 | List: |
| References | |
| FOIA-96-351 NUDOCS 9702140099 | |
| Download: ML20134K582 (118) | |
Text
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Dates Thursday, April 2I 1993 1:34 pm j MTG: PSE&G INVESTIGATION-SRG ISSUE
Subject:
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- BASED ON A MEETING THAT I HAD WITH JIM WIGGINS TODAY, DRP (WHITE, i WIGGINS, WENZINGER) BELIEVE THAT IT IS NECESSARY TO MEET WITH YOU (OR W. KANE), B. LETTS, AND D. HOLODY, TO DISCUSS INFORMATION :
l THAT I LEARNED ON APRIL 20, 1993 FROM MEETING WITH S.
MILTENBERGER AND REVIEWING PSE&G'S SPECIAL INVESTIGATION OF THE
, CONFLICT.BETWEEN THE SALEN SA1>ETY REVIEW GROUP AND SALEN
! OPERATIONS. GIVEN THE POSITIONS OF THE PERSONNEL INVOLVED l i (C. VONDRA-GENERAL MANAGER, SALEN OPERATIONS; :
V.POLIZZI-OPERATIONS MANAGER-SALEN; S. MILTENBERGER-SENIOR VICE !
l PRESIDENT AND CHIEF NUCLEAR OFFICER-PSE&G; S. IABRUNA- PREVIOUSLY ,
VICE PRESIDENT-NUCLEAR OPERATIONS; AND L. REITER-PREVIOUSLY GENERAL MANAGER, QUALITY ASSURANCE AND NUCLEAR SAFETY REVIEW) ;
i RELATIVE TO THE LICENSEE-IDENTIFIED INTIMIDATION AND HARASSMENT l i THAT TOOK PLACE AGAINST TNO SAFETY REVIEW GROUP MEMBERS, IT IS ADVISABLE TO CONSIDER POSSIBLE OI INVOLVEMENT, THE CHILLING l
- EFFECT OF THE ISSUE, THE ENFORCEMENT ISSUES (INCLUDING APPARENT i VIOLATION OF 10CFR50.7), AND PERTINENCE OF THE MATTER TO DOL. l' j THIS MATTER-MAY ALSO HAVE CONSIDERATION RELATIVE TO THE JUNE j SENIOR MANAGEMENT MEETING AND THE CURRENT SALP PERIOD ASSESSMENT. f j ACCORDINGLY, I HAVE SCHEDULED A MEETING INVOLVING J. WIGGINS, E. ;
- WENZINGER, B. LETTS, D. HOLODY, T. JOHNSON, AND MYSELF WITH YOU J q ON 10
- 00, MONDAY, APRIL 26, 1993. ;
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l l APRIL 22, 1993 (1530) TutuPEONE DISCUSSION WITE STEVE MILTpKBERGE SENIOE VICE PEREIDENT u n CEIEF NUr'L*** OFFICER, PUBLIC BERVICE lj wtnCTRIC un rama returw13Y, AMD:
- Jrunr R. WRITE, cETEF, M**r' TOE PROJECTS SECTION 21 Euginn C. WEMEIMGER, CRTEF, awar' TOR PRMECTS **WCK 2 ON APRIL 22, 1993 I BRIEFED JIM WIGGINS AND ED WENZINGER RELATIVE I THE INFORMATION THAT TOM JOHNSON, STEVE BARR AND I LEARNED FROM A l
MEETING WITH STEVE MILTENBERGER, JOE HAGAN-VP, NUCLEAR OPERATIONS i AND BOB BURRICELLI, GENERAL MANAGER-INFORMATION SERVICES AND '
EXTERNAL AFFAIRS, ON APRIL 20, 1993. THE MEETING WAS IN REGARD T PSE&G'S SPECIAL INVESTIGATION OF THE CIRCUMSTANCES AND EVENTS j INVOLVING THE APPARENT HARASSMENT AND INTIMIDATION OF TNO SAFETY l REVIEW GROUP ENGINEERS (PAUL CRAIG AND BERT WILLIAMS) BY CAL VONDRA-GENERAL MANAGER-SALEM OPERATIONS, AND VINCE POLIZZI-l i OPERATIONS MANAGER-SALEN. FOLLOWING THAT MEETING I ALSO BRIEFED j BARRY LETTS, DIRECTOR, OI FIELD OFFICE. AN OPEN QUESTION IN BOTH j BRIEFINGS WAS THE DISCIPLIhE AND CORRECTIVE ACTION THAT PSEEG NAS 1 EXPECTING TO TAKE RELATIVE TO VONDRA AND POLIZZI.
} ACCORDINGLY, ED WENZINGER AND I CALLED STEVE MILTENBERGER TO j DETERMINE WHAT ACTION HE HAD ELECTED TO TAKE NITH THESE 4
INDIVIDUALS. THE FOLIDWING PERTAINS:
4' MILTENBERGER STATED THAT HE MET WITH VONDRA ON APRIL 20, 1993. H l
- DISCUSSED THE FINDINGS OF THE INVESTIGATION REPORT. HE INDICATED j THAT THERE WAS A " TREMENDOUS REVELATION" IN THAT DISCUSSION.
j VONDRA INDICATED THAT WHEN HE NET NITH CRAIG AND WILLIAMS ON j DECEMBER 3 (OR 4),1992, HE (VONDRA) WAS UNDER THE IMPRESSION THA 1 l
j INCIDENT REPORT THAT WAS BEING DISCUSSED HAD ALREADY BEEN FILED A
) IN THE PROCESS IN ACCORDANCE WITH APPLICABLE ADMINISTRATIVE PROCEDURE " NAP-6"; AND THAT THE DEBATE IN HIS OFFICE INVOLVING PO l
j AND HIMSELF VERSUS CRAIG AND WILLIAMS REGARDED THE OPERABILITY AN 1 REPORTABILITY OF THE SRG'S FINDINGS INVOLVING THE CONTAINMENT FAN j COOLERS (UNIT 1/2). MILTENBERGER STATED THAT VONDRA INDICATED HE
- (VONDRA) WAS NOT AWARE (UNTIL THIS 4/20/93 MEETING) THAT THE INCI REPORT HAD NOT BEEN ACTUALLY SUBMITTED. MILTENBERGER STATED THAT 1
900 TO 1000 OF THE INCIDENT REPORTS (irs) OR DEFICIENT ENGINEERIN -
lI FINDINGS (DEFs) ARE PROCESSED ANNUALLY THROUGH THE SENIOR NUCLEAR SHIFT SUPERVISOR IN ACCORDANCE WITH " NAP-6", AND THAT THIS WAS TH
- FIRST INSTANCE THAT ONE HAD EVER BEEN DIRECTLY BROUGHT TO VONDRA'
' ATTENTION OUTSIDE OF THE NORMAL HANDLING PROTOCOL...SO IT WAS 3 POSSIBLE THAT VONDRA WAS CONFUSED AT THE CRAIG/ WILLIAMS MEETING.
l' MILTENBERGER FURTHER INDICATED THAT VONDRA UNDERSTOOD AND ACKNOWLEDGED HIS POOR JUDGEMENT AND INAPPROPRIATE BEHAVIOR, AND THAT HE (VONDRA) RECOGNIZED THAT Hf HAD MADE A " MAJOR MISTAKE" IN I HIS HANDLING OF THE MATTER. MILTENBERGER INDICATED THAT HE j BELIEVED THAT VONDRA WAS FOCUSSED ONLY ON THE SAFETY ISSUES i RELATIVE TO THE TECHNICAL CONCERN AND FAILED.TO RECOGNIZE THE l PERSONNEL ISSUES INVOLVED AND THE IMPACT THAT HIS ATTITUDE AND j BEHAVIOR HAD RELATIVE TO CRAIG AND WILLIAMS.
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(F (NOTE: IN DISCUSSION WITH MILTENBERGER ON 4/20/93, IT WAS REVEAL THAT POLIZZI HAD PREVIOUSLY APPLIED FOR THIS POSITION, AND THAT H WAS ACTIVELY BEING SOUGHT BY WESTINGHOUSE FOR THE ARC. HE HAD ALREADY SOLD HIS HOUSE AND WAS PREPARED TO MOVE BEFORE MEETING WITH MILTENBERGER ON 4/22/93. ACCORDINGLY, THIS ACTION MAY NOT B t STRICTLY PUNITIVE.)
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] MILTENBERGER INDICATED THAT PAUL CRAIG AND BERT WILLIAMS HAVE BEE COMMENDED FOR THEIR PERFORMANCE IN THIS MATTER, AND HAVE RECEIVED FORMAL APOIDGIES FROM VONDRA AND POLIZZI. MILTENBERGER INDICATED 4
THAT BASED ON HIS DISCUSSIONS WITH CRAIG AND WILLIAMS, THE l
{
INDIVIDUALS WERE ALWAYS AWARE OF THEIR RIGHT TO ESCALATE THIS
' MATTER TO THE NRC'S ATTENTION...HE WAS UNSURE IF THEY WERE AWARE THEIR RIGHTS RELATIVE TO DOL SINCE THAT SUBJECT DID NOT COME UP WITHIN THE CONTEXT OF THE DISCUSSION. HOWEVER, HE BELIEVES THAT THEY ARE AWARE OF THEIR RIGHTS. f
! MILTENBERGER ALSO INDICATED THAT A SPECIAL " MANAGER'S DIALOGUE j MEETING" WAS SCHEDULED FOR 4/23/93. THE MEETING INVOLVES THE TOP
) MANAGERS ON-SITE, AND WAS BEING HELD TO SPECIFICALLY DISCUSS THIS
- OCCURRENCE AND THE CIRCUMSTANCES THAT PERTAINED. BOTH POLIZZI AN j VONDRA WERE EXPECTED TO DISCUSS THEIR PARTICULAR INVOLVEMENT IN THE SITUATION AND LESSONS-LEARNED.,
I WHEN MR. MILTENBERGER WAS ASKED'SPECIFICALLY BY WHITE AND [
i l WENZINGER WHETHER HE BELIEVED THAT VONDRA AND POLIZZI ACTUALLY HARASSED AND INTIMIDATED CRAIG AND WILLIAMS BY THEIR ACTIONS, HE l
ANSWERED "YES". WHEN MILTENBERGER WAS ASKED WHETHER HE HAD i REASON TO BELIEVE THAT AN ACTUAL VIOLATION OF 10 CFR 50.7 HAD OCCURRED, HE RESPONDED BY INDICATING THAT THE CORPORATION WOULD j
NOT HAVE EXPENDED THE RESOURCES, TIME, AND EFFORT TO INVESTIGATE d
THIS NATTER IF PSEEG DID NOT BT1IEVE THAT THE SITUATION WAS VERY
- SERIOUS.
L 4
JOHN R. WHITE, CHIEF REACTOR PROJECTS SECTION 2A
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! l i l SALEM GENERATING STATION L F
! SENIOR MANAGEMENT MEETING !
1 FEBRUARY 24,1994 l
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'f SALEM GENERATING STATION
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SALEM GENERATING STATION SENIOR MANAGEMENT MEETING .
AGENDA OBJECTIVE l
MISTORICAL PERSPECTIVE COMPREHENSIVE PERFORMANCE ASSESSMENT l
l COMPREHENSIVE PERFORMANCE ASSESSMENT ACTION PLANS NEAR TERM ACTIONS PERFORMANCE MEASURES
SUMMARY
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! SALEM GENERATING STATION l SENIOR MANAGEMENT MEETING .
i OBJECTIVES r j
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j e PROVIDE AN HISTORICAL PERSPECTIVE OF f IMPROVEMENTS (EQUIPMENT, PROCEDURES, PEOPLE)
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1 l e DISCUSS THE COMPREHENSIVE PERFORMANCE l ASSESSMENT METHODOLOGY AND FINDINGS I
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- i e IDENTIFY ON-GOING AND FUTURE CORRECTIVE I ACTIONS
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e IDENTIFY MEASURES OF SUCCESS 1
i, 9 DISCUSS ORGANIZATIONAL ISSUES AND CHANGES i
l 1 # PROVIDE CONFIDENCE AND ASSURANCE THAT PSE&G I IS TAKING THE ACTIONS NEEDED TO IMPROVE SALEM f, PLANT PERFORMANCE
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SALEM GENERATING STATION !
l i SENIOR MANAGEMENT MEETING '
HISTORICAL PERSPECTIVE l j
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1990 SALEM IMPROVEMENT FOCUS )
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e EQUIPMENT:
- WORK ORDER BACKLOGS AND PREVENTIVE j l '
4 MAINTENANCE RATIO
- MATERIEL CONDITION UPGRADES j 8 .
- REPETITIVE EQUlPMENT PROBLEMS 1
e PROCEDURES:
! - PROCEDURES UPGRADED
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- PEOPLE:
- WORK PRACTICES AND STANDARDS 4
4 INITIATED SALEM REVITALIZATION 3
64MM228
SALEM GENERATING STATION SENIOR MANAGEMENT MEETING '
HISTORICAL PRESPECTIVE SALEM REVITALIZATION A MAJOR IMPROVEMENT WITH 5 KEY FUNCTIONS e MATERIEL CONDITION UPGRADES .
i e PROCEDURE UPGRADES
- PERSONNEL PERFORMANCE IMPROVEMENTS
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! SENIOR MANAGEMENT MEETING '
- HISTORICAL PERSPECTIVE e ,
4 SALEM REVITAllZATION OBJECTIVES 3
j e ACHIEVE MATERIEL CONDITION ABOVE INDUSTRY j AVERAGE e IMPROVE COMPONENT / EQUIPMENT RELIABILITY q!
- ACCOMPLISH UPGRADES CONCURRENT WITH NORMAL '
OUTAGE AND NON-OUTAGE CYCLES i
! e IMPROVE PLANT PERFORMANCE
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i e PROVIDE PLANT PERSONNEL WITH TECHNICALLY
! ADEQUATE AND HUMAN FACTORED PROCEDURES AND
! PROCESSES e SUSTAIN INCREMENTAL MATERIEL IMPROVEMENTS i
I e COMMITMENT TO EXPECTATIONS AND STANDARDS l1 s ,
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I I MAINTENANCE PERSONNEL MATERIEL MATERIEL CM & PM PROCEDURE PERFORMANCE CONDITION CONDITION BACKLOG UPGRADES IMPROVEMENT!
UPGRADES MAINTENANCE REDUCTIONS t
e DECREASE HUMAN FACTOR ;
e MAINTENANCEWORK G REVIEW / DEVELOP / UPGRADE M M AE 6 8 FAINUNG S DESIGN CHANGE ORDERS Om M FROCEDURES FACKAGES S INSULATION
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. FRonCT ENGam- . MmOR REFAIRS S NANCERECURRmG MtOCEDURE CONTROL N # REDUCE PERSONEL ERROR IIRS l{
E" TASKS i. i e IABEUNG 9 IMPROVED MONITORNG f[
e MSTALLANN e REDUCEPERSONNEU 9 REUABluTY CENTERED yROCEDURE REIJ1TD IIRS OFSTATION ACTIVITIES i[
- MOUSEKEEFtNG MAINTENANCE APPROACM
- COMMITMENTS ANNOTATED SIMPROVE COMMUNICATIONS IN PROCEDURES 8
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SENIOR MANAGEMENT MEETING '
lI HISTORICAL PERSPECTIVE '
MATERIEL CONDITION UPGRADE l9 -
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! e OBJECTIVE f - IMPROVE COMPONENT / EQUIPMENT RELIABluTY AND SUSTAIN INCREMENTAL MATERIEL IMPROVEMENTS TO l
! IMPROVE PLANT PERFORMANCE AND ACHIEVE
! MATERIEL CONDITIONS THAT ARE ABOVE THE .
INDUSTRY AVERAGE 1
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- KEY RESULTS
- SIGNIFICANT RESOURCES INVESTED l3
- MAJOR HARDWARE UPGRADES COMPLETED
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- IMPROVED PLANT RELIABluTY AND PERFORMANCE i
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! SENIOR MANAGEMENT MEETING
- HISTORICAL PERSPECTIVE 1
il CORAPLETED FOR UNIT 1 A90/OR UNITE j
I e CONTROL ROOM MODIFICATIONS AND HUMAN FACTOR UPGRADES a
e UPORADE OF 10,000 UIEAR PEET OF SEIMCE WATER MPING e CLEANCHERNSTRYLABORATORY e MAJOR SWITCHYARD EXPANSION AIG UPGRADE e SUS 3..UM.T ==T= =PuCEMa 3
e NO.1 RENTRANSPORMER UPGRADES e STEAM GE9ERATOR SAFETY VALVE REPLACEARENT o CIRCULA11NG WATER FISH TROUGH REPLACEMEN11 e CONTAINAAENT STEAM GENERATOR BLOW DOWNVALVE UPORADE
- PRESSURIZER INSULATION REPS esusagt e SAPEGUARDS EQUIPtAENT CONm0LLM INSTALLATION e LUBEOIL8TORAGEFACluTY
' < ATALLATION OF SYSTEM TO ADO CHERAICALS TO Aul0UARY FEED SYSTEM e UPGRADERADWASTEPANEL(l&C) e .WP Ar.snasegy or massess e ausnaam CONC & LATE STRAllERS
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e ROD CONTROL 24 VDC POWER SUPPLY REPS esnasegy l
- MlO LOOP INSTRUMENTATION BAODIFICAfl0le e GENMATOR HYDROGEN DRYhR DEW POINT BADNITOR PURGENENT e OlBELGOERATOR HVAC RIPROVEMENTS !
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f SALEM GENERATING STATION SENIOR MANAGEMENT MEETING HISTORICAL PERSPECTIVE e CIRCULATINGWATER MECHANICALUPGRADES e SORIC ACID CONCENTRATION REDUCTION e CIRCULATING WATER AIR REMOVAL SYSTEM e UPORADED INTERNALS FOR PRESSURIZER CODE SAFETY VALVES AND EUMINATED LOOP SEALS 1
- UPGRADED PORY AND SPRAYVALVE ACTUATORS ,
e UPGRADED INTERNALS OF ALL AUX FEED WATER CONTROLVALVES e UPQRADEDWASTEGASSYSTEM ANALYZER e UPQRADED CONTROL AIR AND NITROGEN VALVES TO CONTAINMENT e UPQRADED BORIC ACID AND PRIMARYWATER FLOWINSTRUMENTATION
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e SMALL BORE PIPING REPLACEMENT > 5,000 PEET e ELECTRO HYDRAUUC CONTROL PUMP UPORADES e STEAM QENERATOR FEED PUMP CONTROLOIL SYSTEM UPQRADE e INSTALLED PERMANENT SACK UP POWER SUPPUES TO EUMINATE
) TEMPORARY POWER FEEDS e DURING OUTAGES \
e UPORADED THE SEC AUTO TEST CIRCUlf e UPORADED THE CONTROL ROOM ANNUNCIATOR SYSTEM
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1 e REPLACED ROD CONTROLSTEP COUNTERS e UPQRADED MAIN STEAM FLOW MEASUREMENT 94 MMS-116
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MATERIAL CONDITION IMPROVEMENT PROJECT SALEM STATION l i
100 77 80 -
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1991 1992 1993 6 119
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i SALEM GENERATING STATION I SENIOR MANAGEMENT MEETING '
- HISTORICAL PERSPECTIVE 4
! MATERIEL CONDITION MAINTENANCE l
e OBJECTIVES i
i - IMPLEMENT A PROGRAM WHICH WILL RAISE THE MATERIEL CONDITION AT SALEM TO A LEVEL ABOVE i
THE INDUSTRY AVERAGE i
e AREAS IDENTIFIED FOR IMPROVEMENT APPROACHED AS FOLLOWS
- ! - HOUSEKEEPING
- EQUIPMENT CONDITION
- PAINTING
- INSULATION
] - LIGHTING e KEY RESULTS
- SIGNIFICANT IMPROVEMENT IN PLANT CONDITION 4
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Salem Station 2.65 ,
Better Target Monthly score 2.6 o
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SALEM GEN'IRATING STATION l SENIOR MANAGEMENT MEETING '
1 HISTORICAL PERSPECTIVE I i
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l MAINTENANCE BACKLOG REDUCTION e OBJECTIVE
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- IMPROVE COMPONENT /EQUlPMENT REUABluTY I
- IMPROVE PLANT PERFORMANCE i
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e KEY RESULTS
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- REDUCED CM BACKLOG FROM = 2500 TO - 1000 I
1 WORK ORDERS SINCE 1990 l
- PM OVERDUE REDUCED FROM 600 IN 1991 TO LESS
'! THAN 40 l1
- - PM/CM RATIO INCREASED FROM 29.3% IN 1990, 37.4% IN 1991, TO 56.2% IN 1992 TO 64% IP, 993
- TOTAL PLANT LEAKS DECREASEu FROM 760 IN 1990 TO APPROXlMATELY 81 IN 1993 i
- COMPLETED REUABluTY CENTERED MAINTENANCE Il 1 REVIEW OF KEY SYSTEMS l
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i Corrective Maintenance Backlog Salem Station 3,000 2,500 2,200 2,000 3 1,500 1,000 1991 1992 1993 1990 All Priorities 2/22/94 18AO-3S ,
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i PROCEDURE UPGRADE PROJECT (PUP) ;
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- TO PROVIDE IMPROVED PROCEDURES OF CONSISTENTLY
! HIGH QUALITY IN TERMS OF FORMAT, CONTENT, LEVEL OF DETAIL, TECHNICAL ACCJRACY & HUMAN FACTORS
! e KEY RESULTS i
- REVIEWED, DEVELOPED & UPGRADED OVER 3500
] PROCEDURES (CHEMISTRY, OPERATIONS, MAINTENANCE)
- INSTALLED AND UPGRADED A COMPUTERIZED PROCEDURE
]
i CONTROL SYSTEM '
i l - REDUCTION IN PROCEDURE AND PERSONNEL RELATED l LER'S
! - RECEIVED POSITIVE FEEDBACK FROM USERS
!I - COMMITMENTS ANNOTATED IN PROCEDURES
- PROJECT IS CLOSED OUT.
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SALEM GE!;ERATING STATION l
SENIOR MANAGEMENT MEETING l -
- HISTORICAL PERSPECTIVE i
mammmmmmmmmmmmmmmmme
! PERSONNEL PERFORMANCE IMPROVEMENT PROGRAM i
! - e OBJECTIVE .
- INSTILL PRIDE AND A BELIEF IN OURSELVES THROUGH AN' UNDERSTANDING OF AND SUPPORT OF OUR f VALUES AND OUR VISION OF BEING "AMONG THE i
BEST"
' ?.
- STRATEGY '
3 f
- STATION PERSONNEL PERFORMANCE IMPROVEMENT l
IS CONSIDERED TO BE AN ONGOING PROCESS
[
A CLEAR EXPECTATIONS t
A CONSTANT REINFORCEMENT
]
' A ACCOUNTABILITY ^
v A FEEDBACK t
A IMPROVED WORK ENVIRONMENT
- THE ROAD TO LASTING IMPROVEMENT LIES IN AN
'l INTEGRATED APPROACH TO THESE El.EMENTS i
l I
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! l SALEM GENEhmilNG STATION I
SENIOR MANAGEMENT MEETING -
e
- HISTORICAL PERSPECTIVE i
KEY INITIATIVES TAKEN l r i
e PERSONNEL PERFORMANCE ENHANCEMENT PANEL l
e
!
- SELF VERIFICATION CARDS l
e WORK PRACTICES AND STANDARD 1 e OFF HOUR HOUSEKEEPING TOURS -
i i
e WORK CONTROL PROCESS IMPROVEMENTS i
e REWORK ACCOUNTABILITY l .
i' e MONTHLY TEAMWORK AWARDS '
i L
l
- ATTENTION TO DETAIL VIDEO '
re ROOT CAUSETRAINING
!1 e INCIDENT REPORT ROOT CAUSE TRENDING '
1 i
l I
e VISION ROLLDOWN MEETINGS / TRAINING l
! e DAILY ACCOUNTABILITY MEETINGS e CONSTANT REINFORCEMENT i
l 3
esam:248 I
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t .
I _
l 4
SALEM dL.JERATING STATION
- SENIOR MANAGEMENT MEETING '
HISTORICAL PERSPECTIVE .
KEY RESULTS \
e DECREASING PERSONNEL ERROR LER'S )
i e DECREASING TREND IN HUMAN PERFORMANCE ERRORS j
e EMPLOYEES ARE BEGINNING TO TAKE MORE OWNERSHIP ;
~ - ----~~
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,_, ._ _o t
Licensee event Reports i Salem Station ,
i 120 4
100 84
' 80 i
e .59 _
$o 60 Z 42 I
~ ,
34 O 1991 1990 l
2/7/94 28TO-3S I
~
_ __ _ _ I_._____._____.___.___._..___._________________ -_ -
Personnel LER's l Salem Station 50 40
, 30
.E 5
20 0 1992 1993 1990 1991
\\
1/1/94 280-3S fl l
.i
. i HUMAN PERFORMANCE INCIDENT REPORTS 70 ,
6 60 -
50 -
. - -_ _ _ _ - y i ,
i i O i i j
1st Qtr 93 2nd Otr 3rd Qtr 4th Qtr 3rd Qtr 92 4m Otr SALEM AVERAGE SALEM ACTUAL v//////>
- - -e = = =
34Mht2112 e- g_ e n m -, -
SALEM GENERATING STATION SENIOR MANAGEMENT MEETING ,
HISTORICAL PERSPECTIVE i
1 I
l1 OVERALL o l l
PLANT l t .
/
u PERSPECTIVE I
t 94MI42-108 1
}-
- 'A --~== .c . . .
Unplanned Automatic Scrams- -
1 Salem Station ,
10 :
9 Industry Median Salem 1 Salem 2 :
,9 - - - - - - - - - - ix x x.3 yeee1 7
-N/ N/
~
8 N/
k\! h
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m 6 N/-
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/ N/ \/ 111 1
- \f t/ s3 i
4'3' 4' 3'
\7 m
^ 3' 43'
\
o 0 1989 1990 1991 1992 1993 1986 1987 1988 1/17/94 056-3S i
Radiation Exposure j Salem Station l
600 i 546 Industry Median
'x' 500 ,
g 416 414 N ,,379 4 ----- -
E e
&i C 300 r O
E e
1 200 100 0 1991 1992 1993 1990 l:
1/17/94 100-3S i;
OSHA & First Aid ;
Salem Station 18 ;
16 14.8 14 12 10 .
1989 1990 1991 1992 1993 1987 1988 1/17/94 OSHA 7-3S
I l
i l
Salem Composite Safety Index l
Status as of 12/31/93 (Year-End Goal /YTD Actual) I' 1
l 3
Red ' ~ ' ,
l
- - a l .. .
Unplanned '
Auto '
Scrams .
)
, J ,
h (2/4) .
Red Red Skin & Clothing I Lost Time &
' Restricted Duty
- l
' ? Contaminations -
e .
Accident Rate (200/243) (0.95/1.24) t Legend: Yellow - needs improvement
- Green - significantly exceeds goal Red - significant weakness Green
- achieves goal .
escit 24
( 1-B 1
l I
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4 .
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i '
4 Salem Key Focus items ,
Comparison to YTD Goals Thru December j Worse Better sss=de ! !
! :(13) j ;
Capacity Fac Unit 1 - i .
- i : : :
i i 5=""+M i i (1a) l Capacity Fac Unit 2 - ; .
i i : ;
(2) i Materiallmprovement - ! : : !
i -
! ! i- i. i Corr Maint Backlog - l o i. !.
- : i i i Prevent Maint Ratio - l:
l:
e$
m1 i i Repetitive Equ!p Prob - i m 3, > :
]
- i i 6
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- l LER-Personnel Error - .
(4) x
" j i i i ! i Maint Sched Adher - : : : : i :
i i ! (1) ! ! !
1 j ; j i Spvr Face-Face Time - j j : : .;
=
Work Pract-Standards - , l gj -
1 Reliability Cent Maint - : ,
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0 10 20 30 40 (40) (30) (20) (10)
Percentage FOCtBIND (1-10) 02 01-04
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' v0m,reaensive 3er::Ormance Assessmen "eam W
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July 26 - December M 1993 February 18 - February 24,1994 I
l f
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i Charter Highlights l
! o Full-time, multidisciplinary, dedicated team o Report directly to the Vice President and Chief Nuclear Officer o Assess a defined set of 27 occurrences t
o Look for previoicaly undiscovered, ,
underestimated, or overlooked root l
causes, failed barriers, and contributing / causal factors o Look for " threads" common to
]# multiple occurrences identify responsibility for correcting o
the root causes, restoring the failed barriers, or eliminating the causal l l factors 1
o Act as change agents 1
l
^)
l !
4 4
Team Members ,
I o Dana Cooley, Manager - Quality Performance i
o Tom DiGuiseppi, Emergency Preparedness Mgr.
o E. J. Galbraith, Chemistry Engineer - Salem 9
o John Wilson, Nuclear Engineering Consultant -
)
j E&PB
) o Charlie Manero, System Engineer - Salem Technical i
! o Greg Mecchi, Principal Nuclear Trainer - Operations .
j o Roberta Kankus, Senior Strategic Planning j '
Specialist (Peco Energy Corporation)
!' o Craig Assimos, Nuclear Technician - Controls -
! Special - Salem '
! o' Ron Sutton, Career Pathing Administrator -
Human Resources l'
o Steven Spiese, Certified NRRPT Rad Pro Technologist - Nuclear Operations - Hope Creek ,L 2
o Bruce Little, Former NRC Senior Resident inspector / DOE Certified Accident investigator l l o Judy Almond, Senior Secretary - Site Services 4
?
, _ .. _ - ~_ - .
i
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Senior Project Oversight Group Team reported monthly to this group, whose .
purpose was:
o Satisfy ourselves that the review is ;
thorough and appropriate o Ensure both short and long-term buy-in .
from our senior managers o Provide the impetus for timely action o Share experience with nuclear plant change management ;
Counsel the senior managers and the o
assessment team I o Foster external credibility I
!I I'
l l
l
$~ ,
l Senior Project Oversight Group '
Membership i
o S. E. Miltenberger - Vice President and CNO o J. J. Hagan - Vice President - Nuc Operations l
o S. LaBruna - Vice President - Nuc Engineering o M. V. Butz - General Manager - Nuclear Human Resources & Administration l
o R. N. Swanson - General Manager - QAl .
I Nuclear Safety Review o S. P. Cohen - Director - Nuclear Finance o R. A. Burricelli - General Manager - Info Systems and External Affairs o G. Rainey - Vice President - Peco Energy Co.
1 o J. Cross - Senior Vice President - Portlap General Electric Company o J. S. Carroll - Professor - Sloan School of Management - MIT
, o M. Pelfer - Institute of Nuclear Power Operations i
a
/ r l
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1 I Project Phases ,
I' '
l j 1. Occurrence Data Analysis (7/26 - )
I l
- Focus on the "past" :
i
- Digest information from reports ,
.- - H-B-T and MORT analyses l
- recurring " themes" l
I i
- 2. Pr tatement Development (8/26 - 10/18) j l
il
- Focus on the "pdesent" g Plan and conduct interviews l l
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- Interview data reduction '
j - Change analysis
- Problem statement prioritization/ grouping l} - Deliver preliminary problem atements l
l i .
Action Agreement and Planning (10/18 - 12/15)
,)['
l 3.
b /
Focus on the " future" l - Final sponsorship determination
- Identification of existing and plannod [
! initiatives and actions l - Data transfer to sponsors
- Line management action
- Communication l
4 i
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3
! [
j -
Occurrence Summary Mid 1991 - June 1993 Nature Salem HC Common Trips / scrams with minor 10 3 N/A secondary consequences Transients with minor 2 0 0 secondary consequences Programmatic / analytical 2 1 1 concems Group / individual 1 0 1
}
interactions Plant readiness / operability 4 1 0
~
problems Trip / transients with 1 0 0 I substantial damage Tots /s 20 5 2 c ,
f
~ :- .
1
l Management Oversight and Risk Tree (MORT) .
Safe, Efficient Problem-Free Operation Specific Control Management Factors _
System Factors S
E OWhy?)
(What? How?)
T R E V H-B-T C H, C i / Policy l
Readiness for N E implementation Service / I C -
S Accountability ,l l
Maintenance A i! '
L Appraisal inspection / Testing i Hazard Analysis Supervision N
' F Concepts &
Task Performance O Requirements Emergency Design / Plan l
Response
Human Factors !
i Procedures Oversight and -l Review
)
9 s
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Recurring Themes in 27 Occurrence i
e
- 1. Risk Assessment Policy i*
i l
- 2. Quality Assessment 's/
f i
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- 3. Information Flow / Knowledge j
- 4. Risk Assessment implementation i
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- 5. Ownership / interfaces i
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- 6. Task Execution 1 ..
- 7. Hazard Correction l l
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sn,+m.s .a am 1
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i Project Phase 2 - Problem Statement Development '
l i '
1 i
Transform " themes" into problem statements i
that reflect the actualpresent situation j
interview design and " bottom-up" ,e o
scheduling ,
o Data collection j
- 44 group irterviews 1
- 21 individual interviews 257 persons interviewep/ ,
l s.,
i
o interview data processing j
o Database creation, checking and use
} ~
o Data analysis by source l
o Data analysis by "subtheme" 1 !
l, \ \
o Organization of significant co ns !
into problem statements o Problem statement prioritization
)
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l Problem Statement Organization and Prioritization I
o Analyzed interview data by source, l subtheme, and intensity of positive and j
i negative content I I o Grouped recurring, related interview responses into distinct root cause areas l
l relevant to the 27 occurrences and still evident in the present.
i o Refined the groups into 15 specific problem statements closely aligned with l
- certain detailed MORT categories, and all
! supported by examples.
4
! o Nominal group technique ranking using i '
this criterion: "So/ving this prob /em i
j would add the most value to sustaining j
improvement and preventing significant
! unplanned occurrences."
o Validated resulting priorities using data l
l from the 27 occurrences. .
i o Clustered problem statements into three 3
natural groupings suggested by MORT t
l areas i
l l
l -
J
t[ rf\ t6 Y .
y* '! Y Yh QPREHENSIVE PERFORMANCE ASSESSMENT TEAM PROBLEM STATEMENTS T 1(( v
\/ Q MANAGEMENT - EOPLE PERFORMING PROBLEM SOLVING AN e1 l PHILOSOPHY, SKILLS -THE WORK FOLLOW-UP /
AND PRACTICES Supervisory practices that - -1 to :nnely and S-1 Root cause determmat proPedy support W techmeal ardixmshon
$ N f who make decessons and reliance on imerpersonal -2 Convective action follow through.
h #$ perform wodt. contacts.
S-3 Performance trending for systems ,
{
O M2 Management risk as W-2 EHisctive use ofwork and -4', . important to reliabilitf
' planung and and operational control. Action upo and pnontaastoon. '
reisuks.
M-3 Managesnent acasons and W-3 Process work-arounds S-4 Operatog Expenence Feedback
{ versus ownershsp and estabbshment of continuing o.
(OEF) dehvery and tracking that q ,
meets thejob needs ofrecipien I
M-4 Content and dehvery of managensent trasning to W-4 T'anely and accurate part for information.
i '
essetively support
- infonnamon and availability and groups. appropriate levels ofend-user I intervention.
Management self-processes. W-5 Content and dehvery of
/ trasnes to eGisctively suppory / lj h(
edivuluals and groups /
l l
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/
W-6 Standards and rnethods l
contractor perfonnance .
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! I From Problem-Finding to Problem-Solving Senior management regards Management fI o Philosophy, Skills, and Practices as an l
l Integrated group that they must spearhead.
o People Performing the Work and Problem SoMng and Follow-Up are important. RIC j g managers and senior individuals have been .
named to determine the appropriate actions
! for these.
t
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- w ~ wa ,,,, ._
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i COMPREHENSIVE PERFORMANCE ASSESSMENT TEAM i
~
PROBLEM STATEMENTS
- i PEOPLE PERFORMING PROBLEM SOLVING AND MANAGEMENT FOLLOW-UP !
PHILOSOPHY, SKILLS THE WORK AND PRACTICES '
W-1 Access to timely and accurate S-l Root cause deternunation.
MI Supervisory practices that '-
technscalinformahan versus Corrective action fonow through properly support , -i_' rehence oninterpersonal S-2 who make deanions and i contacts. Performance trending for systems perform work. S-3 t
and equipment unportant to reliabihty W-2 Effective use ofwork and operational control Action upon !
M-2 Management risk assessment p$naning and schedules. .
and prioritization. reisuks. !
W-3 Process work-arounds j M-3 M_._,,__ - actions and S-4 Operating Expenence Feedback
"^y. vermes ownershsp and ^ (OEF) dehvery and tracking that
[
estabbshment of--- contmums ,_ ~ i meets thejob needs ofrecipients W-4 Tanely and accurate part for information. ,
managensent tranung to infonnehon and availability with 1- .f; supportindmduals apprepnase levels ofend-user and groups. intervennon. l M-5 Management self-assessment W-5 Content and dehvery of teciwucal prae trenungto .d isupport indmduals and groups .i W-6 Standards and methods of contractor paiu,_ _ e ~
.l
.. __.__?______-____-_--__- _ _ - _ _ _ _ - _-__ _ - - _ . _ _ _ - _ _ _ _ _ _ _ _.___ - _ _ _ _ -___ -
1 l
I -
4 Il T
~
4 CPAT Recent Occurrence Review
- - r Evaluated outage occurrences 4
l' o '
i
- o Evaluated recent occurrences i
i
- o All events demonstrate examples of CPAT i problem statements
- s. (
l o ~ No event arose from completely new problem area (s) or root cause(s), although some equipment failures are not yet fully diagnosed.
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1 1
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From Problem-Finding to Pioblem-Solving I
l Senior management regards Management -l l o Philosophy, SkiHs, and Practices as an integrated group that they must spearhead. l o People Performing the Work and Problem \
- 4 So/ving and follow-Up are important. R/C " !
managers and senior individuals have been named to determine the appropriate actions
! for these. l l
f '
o They have met with team members to absorb 1
and understand assessment data.
o Action plans have been developed, reviewed l
by senior management, and are being incorporated into the Nuclear Department Tactical Plan f1 ;
o Action plans have been reviewed by CPAT o These plans take into account prior initiatives, current actions, and schedules
}
I l- :
1 +
- ~ w ., . .
l Nuclear Dep. ment Tactic. E i Kev Success Factor: Assist Employees Achieve Their Full Potential Pronram or Action:
Reinforce Management Expectations /Accountabilities Primary Sponsor: Vice President- Nuclear Operations Key Focus items Supported: Management Actions and Establishment of Accountability (M3) !
Supervisory Practices that Support Professionals Who Make Decisions and Perform Work (M1) !
Sponsor Suppait Start Stop ;
Activity GM-SO Sta. Mgrs 1/93 12/95 Implement Salem Personnel Performance improvement Plan i GM-NHR&AS
. Develop and implement a supervisory monitoring program Mgr-Nuc Sicnificantly improve two-way communications j
. Comm.
l l
. Provide 360 degree feedback to Salem supervision i
. Resolve long-standing equipment deficiencies and reduce number of !
significant events, to eliminate chronic drain on resources and morale.
Expected results are a reduction in the number of events and the elimination of significant events l
. Establish effective vehicles for responding to station workers' issues, concems I
and productivity recommendations. f
. Improve personnel accountability and ownership relative to: )
6'
. procedure compliance
. compliance to work standards '
. self verification '
e schedule adherence pr ,
- ~ ~ ' ~ ' ~
t
9 i Deps ent Tactical PI- - E2 (cont'd)
Se-x-c-rt Start I Stop Sponsor Activity VP-NO GM-HCO Develop and Implement Strateav for Empowerina the IBEW Workforce GM-SO '
GM-NS&S Mgr-NP&MM i GM-HCO 1/94 6/94 VP-NO Work w/IBEW and management employees to develop tactical plan GM-SO GM-NS&S L
Work Standards Monitorina 12/95 Sta. Mgrs. 1/94 GM-SO
. Standardize approach (Nuclear Services, Salem and Hope Creek) GM-HCO ,
. Assess Indian Point 2 work standards program GM-NS&S
. Re-evaluate our program Mgt-NP&MM e involve IBEWleadership in program
. Monitor SOER 92-1 actions .
VP-NO GM-NS&S Deveh c Descriptive Supervisor Behavior Model (CPAT M11 2/94 3/94 I
Describe / reinforce model at spring supervisors dialogue. 9/94 9/94 Follow-up at fall supervisors dialogue All Mgrs/Supvr 1/94 12/95
. All managers / supervisors to spend at least 40% of their time in the field.
All Mgrs 1/94 12/94 VP-NO Improve the Performance n eeraisal Process (CPAT M31 L
All Mgrs 1/94 4/94
. Managers to review existing performance appraisals for all employees three ;i levels down in their organizations to insure the appraisals accurately reflect individual performance All Mgrs 1/94 4/94 ,
. Managers prepare and deliver new performance appraisals to employees, as required, to ensure a current performance appraisal (within 12 months) exists for all employees that meets standards (accurate reflection of individual 1/94 12/94 performance). -
. Continue to reinforce performance appraisal expectations at manager dialogues Compensation 1/94 4/94
. Review / revise guidance, policies, and rating definitions for performance appraisals s
we t.
W' M we ._
- 5 .
)
! i
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Nuclear Department Dynamics of Leadership I tliit .il Iligh ; g,,,n q 4 ii ,, ,..
l'r e Is ir in. int r 4 ,,ni nin it it .it iiisi
%t.itul.t f als -
I'I ' " \I' " ' " ^
sa ilit i,t liil,i r t A Oki. inn (.ihlt
%ti j)l)t 11-t l )t t t % f t til%
1 to -
< li.i ner x l'O f li st in.t int o N
( )])l)t it itiviit s 15 h.n ior for<,niuIh _
i To meet tomorrow's i i
business challenges J
( .
1 . . - -
, i I
r O PSIEG Nuclear Department Dynamics of Leadership ,
o Own the identification and e Explain decisions so people will solution of problems support them ,
o Stay involved - provide timely, e Set performance standards accurate and honest feedback e Know when to let your people decide e Good or bad, write it down so you can give valid feedback e Be a team player- give and get help e Remove barriers that e Support decisions
. impede performance e Ifit doesn't look, sound or feel e Expect and give respect right - take action because it i probably isn't right e LISTEN to your people
~
Consistently amo the best...Worki 40s to produce i competitive elec energy throu nucicar exectience l
- J t
. - . - - - - ~. . - . . . .. --~ -. .. . - - - _ - - - _ ..
- w ...
l I
E ment Tactic-E Key Success Factor: Assist Employees Achieve Their Full Potential Continue Management / Employee Development Training Prooram or Action _:
General Manager - Nuclear Human Resources & Administrative Services Primary Sponsor:
Content and Delivery of Management Training to Effectively Support Individuals and Groups (M4)
Kev Focus item Supported: Sponsor Support Start Stop Activity Mgrs. 1/94 ongoing GM-NHR&AS Deliver Core Manaaement and EmiAc;;; Develos,Kant Curriculum: # of courses Course Title offered in 1994 3 j
. Reaching Our Vision 2 l
. Orientation for Supervisors and Managers 2 l
. Industrial Relations 3
. Performance Planning and Appraisa! 3
. Failure Analysis 4 l
. Leadership training 12
. TQM " Making the Difference
- 2
. Technical Associate Development 1 l
. Administrative Associate Workshop 2 L
. Investigative Interviewing 2
. Root Cause Analysis 2 ,
. Positive Discipline 2 l
. Targeted Selection 1
. Management Oversight & Risk Tree Analysis !
f f
- ?
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N tm. - 4 i
i Department Tactical Plan - E7 (cont'd) l Suppset Start Stop Sponsor Activity Mgrs 1/94 ongoing GM-NHR&AS Deliver Continuina & Electivs Trainino: ^
- of courses Course Title offered in 1994 o !
. Getting Good Information From Others 3
. Effective Writing 2
. InnovationLeadingto Action 3
. Fair Employment Practices 3-TechnicalWriting l
. 3 l
. Systematic Analysis of Ideas 3 l
. Franklin Planner 12 j
. Stress Management Workshop 3
. Managing Towards Career Excellence o l
= Presentation Skills 6 l
. GettingYourIdees Across 2 I
. Achieving Balance o l
. Confronting Difficult issues 1 Career Coaching Workshop for Managers l
. 2 !
. Accounting Functions & Responsibilities 2
. Compensation Workshop 1/94 12/94 GM-NHR&AS Mgrs Develop and Implement Four Business Leadershio Dedmnt Prcorams in '
1994 Consistino of; Week one - group process and team building !i Week two - leadership and personal impact f!
Week three --- the leader as diagnostician and change agent I Week four - the leadership dialogue and stakeholder analysis tl o
Week five - effective conflict management - the leader's greatest challenge - {
. Group #1 - 2/28-3/4,4/11-15,5/9-13,6/13-17,8/15-19
. Group #2 4/18-22,5/23-27,66/20-24,7/18-22,8/8-12
. Group #3 - 9/12-16,10/10-14,11/14-18,12/12-16,1/16-20/95 a
Group #4 - 9/19-23,10/17-21,11/28-12/2,1/30-2/3/95, 2/27-3/3/95
j i
BUSINESSLEADExSHIPDEVELOPMENT GROUP INDIVIDUAL
-How Groups Work
-Diagnosis -SelfUnderstanding
-Intervention -Impact ;
-Design -Visioning !
-Collaboration Session I -Problem Solving
-Design LEADERSHIP DIALOGUE
-1:1 Relation / Direct Reports '
-Accountability
-Personal Development STAKEHOLDER SYSTEM
-Appraisal -Gathering, Analyzing,
-Managing Conflict Presenting Data / Measuring Cooperation Session III
-Proactive Problem Solving
-Trouble Shooting !
INTERVENTION -Negotiating
-Strategies y-Managing Conflict !
-Lessons Learned g,,,fo, f y ;l
-Design !;
Session V ll
)i t
+
~ ~ ~ ~ ~ ~ ^ ^ -- - - - -_- - _ ____._______ _ _ _
a .,
i E
Nuclear Department Tactic.
Achieve Coiair,aed improvement in Overall Performance to Foster Regulaisif and Public
' Key Success Factor:
Confidence .
Access to Timely & Accurate Technical Information Prooram or Action:
Vice i? resident - Nuclear Engineering Primanr Sponsor:
Access to T;w.eJ, and Accurate Technicalinformation versus reliance on interpersonal Start Stop contacts (
Kev Focus item Supported; Sponsor Support Activity Vendorinformation Controi 4/92 ongoing NEStd Mgr CCG Supv.
. Re-enforce requirenants for control of vendor information received from NEStd Mgr CCG Supv. 1/94 2/94 sources other than the TDRs or EDCC.
. Confirm adequacy of procedural guidance for control of vendor information Mgr- NP&MM Mgt-QAE&P received from sources other than the TDRs or EDCC. CCG Supv. 2/94 2/94 NEStd Mgr
. Confirm Salem Revitalization Project is correctly processing vendor information Mgr - Sp Proj received with shipments. Mgr.NP&MM 2/94 2/94
. Retrain stock handlers to the procedural requirements for processing of vendor information received with shipments.
MMIS Maintenance 5/94 NEStd Mgr CCG Supv. 2/94
. Confirm that no gaps exist in the DCP process such that MMIS database impacts are not recognized or otherwise incorporated. NEStd Mgr CCG Supv. 1/94 12/94 l
. Complete BOM Validation Project (1994 Scope) i!
. Assess BOM Control Ij
. Assess BOM Validity
. FDR/FDDIimpactReview(HC) '
. Solenoid Valve Verification (Salem) .
e Recommend future needs "
I i
_m._ ____ . . . . _ - _ - _ _ _ _ _ _ _ _
l
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l 1
i Nuclear Departme ME 1 - R13 (cor M l
S,,c,si.or Support Start Stop r Acuvny NEStd Mgr CCG Supv 2/94 4/94
. Communicate MDF Resolution Status to Nuclear Department NEStd Mgr CCG Supy 2/94 4/94 l TBD
- . Communicate MMIS Control & "Get-Well" Proce.ss NEStd Mgr NME Mgr TBD j . Develop ASME parts / Component Specification Sheets
. Screen established, never populated I . May be able to drive completion from CJP process Mgr-NP&MM NEStd Mgr 1/93 12/94 l
. Establish standard construction materiallists and inventory levels NME Mgr NEE Mgr
. Part of NE TS development plan under development NESciMgr Computer Hardware and Software Control Mgr-M&S All ND Mgrs 2/94 ongoing
. Support NC.NA-AP.ZZ-0036(Q) policies regarding the procurement of computer hardware and software Mgr-M&S N/A 2/94 5/94
. Clarify NC.NA-AP.ZZ-0036(Q) requirements regarding the procurement and developtrient of customized computer software and hardware Enaineerina Docu.aat Control and Distribution Mgr - NED CCG Supv 1/93 TBD
. Provide " Working Copies" from EDCC (DCPIT Task #30) Mgt - M&S DMS Proj. Mgr 1/93 12/94
. Provide " Working Copies" from DMS (DMS Protect Scope) Disc Mgr - NED CCG Supv 1/93 TBD
. Bank Changes to Drawings other than OWDs (DCPIT Task #32) - DUTT activity Mgr- NED CCG Supv 1/93 TBD
. Post MCRs against DCP CDs and EADs (DCPIT Task #31) Mgr - M&S DMS Proj Mgr 2/93 12/94
. Access scanning MCRs into DMS Disc Mgr- NED CBD Proj Mgr 1/91 ongoing
. Communicate CBD Development Plan / Status for Salem - original plan S&A Supv Mgr - M&S DMS Proj Mgr 1/93 6/95 'l
. Communicate DMS Development Plan / Status - original plan Disc Mgr - NED CCG Supv 2/93 ~ TBD
. Communicate DCPIT Task #30,31,32 Iri+4 mentation Plans i
o
'a - 1 l
Nuclear Dep. . Tactici Plan - R13 (co Support Start Sto;s Sponsor Activity - 6/91 12/95 NEE Mgr Saiem I&C
. Complete Salem Setpoint Picject Supv DCG Supv 2/94 4/94 Mgr - M&S Communicate Current TDR/EDCC Services and responsibilities CCG Supy DMS Proj Mgr 1/94 12/94 Mgr- M&S
" Baseline Reference Documents" identified and input to DMS CCG Supv !
DCG Supy Spare Parts / Components and Construction Component Availability Mgr - P&MC 2/94 3/94 j Mgr- NP&MM '
Communicate the inventory " Write-Off" strategy to tne working levels of the Ping Mgr-impacted organizations Salem i Maint Mgr-Salem Mgr - NED ,
Salem Maintenance Procedures 1/94 TBD !
Tech Mgr Tech Staff Tech Mgr Tech Staff 1/94 TBD
. Improve tum-around time for procedure revisions i
. Eliminate procedure revision backlog Tech Mgr Tech Staff TBD TBD
. Develop "New/Old" procedure cross-reference for repetitive tasks ,
i e
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Departm'ent Tactical Pt. - -
Safety K_ ev Success Factor:
Proaram or Action:
Improve Contractor Performance Vice President - Nuclear Engineering Primary Sponsor:_ .
Kev Focus item Supported: Stand nrds and Methods of Contractor Performance (W6) .
Support Start Stop Activ'ty Sponsor Mgr-Site Pro. 1994 ongoing ;
GM-SO Improve contractor industrial s4.;v performance throuah: GM-HCO Nuc. Med Dir.
Mgr.NEP Contractor Mgmt.
. Monitoring previous safety compliance problem areas (safety team) t
. Conducting safety talks with all contractors prior to the start of outages, I
emphasizing safety priority and performance expectations
. Inciuding cont-actors in Safety Dept. " Safety / Professional Recognition Gift Program"
. Including contract personnel in the Station APC Safety incentive Program
. Conducting special training for all contractor management and supervisory personnel in the new " Confined Space Permit" program
. Implementing a contractor Supplemental Injury (Medical) report to track and trend potential high risk / exposure jobs ei I
9 g .
'- ~ ~ - _._.._ ..
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, i Department Tactic - E Start Stop Activity Sponsor Suf+ sit improve overall contractor performance .
Station 1/14/94 3/1/94 Mgr- NEPS
. Maintain adequate supervisory - to - craft ratio. Maintenance, Nudear Support &
Services 1/14/94 3/1/94 ;
Mgr- NEPS
. Increase supervisory field presence Station 1/14/94 3/1/94 Mgr- NEPS t
. Evaluate the need to manage and train contractors with single group Maintenance [
1/14/94 3/1/94 Mgr - NEPS !
. Complete job observation training for ITEs and PMs Mgr - NP 1/14/94 3/1/94 Mgr - FEPS
. Specify training manhours separately in proposals Mgr - NEPS 9/1/94 ongaine
. Bring foreman /non-manuals in earlier for DCP familiarization Ops Mgr- Mgr - NEPS 1/14/94 3/1/94 !
. Iniplement initiatives from Safety Tagging Review Team Report Salem Ops Mgr- HC i I
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l SUMMER 1994 e CONTROLS MAINTENANCE DEPARTMENT ORGANIZATION 4TH l
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- REINFORCE STANDARD OF QUAUTY AND BARRIER MODEL l - SALEM /HC STATUS AND PROGROSS TO DA o CPAT ROLLDOWN (COMPLETE 1/94)
! e SALEM EMPLOYEE MEETING WITH NEW VP/GM l i (COMPLETE 2/94) ;I
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- N'EW VISION ROLL DOWN (1/94-2/94) l e STATUS OF THE DEPARTMENT YEAR END MEETING (3/94) e S. MILTENBERGER MEETINGS WITH SALEM EMPLOYEES (4/94) .
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- COMPREHENSIVE REVIEW OF CONTROLS CORRECTIVE ,
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' e FOCUSED STAFFING INCREASES AT SALEM STATION
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- ROLE OF INDEPENDENT AND SELF ASSESSMENT
! - ROLLED DOWN THROUGH THE ORGANIZATION 4
. - FINDINGS AND CORRECTIVE ACTIONS INCLUDE BARRIER ASSESSMENT e QA AND SAFETY PHILOSOPHIES
" SAFETY 18 OUR FIRST PRIORITY"
- ROLES OF QA AND NUCLEAR SAFETY e REORGANIZATION OF NSR AND FORMATION OF A i NUCLEAR REVIEW BOARD (NRB)
- FOCUS TO MORE GLOBAL ASSESSMENT OF
- NUCLEAR SAFETY s
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- 50.59 SURVEILLANCES OF PLANT OPERATIONS ADVISESENIOR MANAGEMENT '
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- UPGRADING PERFORMANCE APPRAISAL CRITERIA e HOLDING PERSONNEL ACCOUNTABLE FOR PERFORMANCE VIA THE APPRAISAL 1
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e PREVENTIVE MAINTENANCE OVERDUE l
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! IMPROVEMENT HAS BEEN DEMONSTRATED BY A -
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!~ \SHWEDIHhiPNOYEMAD vRE4dRT/@ HEN btONf 4
November 21,1994 NOTE TO: T. Marna J. White D. Vito J. Liebenman, OE /d5 W. Kane E. Seit W. Ianning 8. Barber e D. Cooper J. Joustra ,g
.,p -
PROM:
D. Holody g
] SURIECT: Of REPORT NO. 193 021R (SAUIM) AUJiOED HARASSMENT, DfTIMIDA110N AND Y j
DISCRIMINA110N (HIAD) 1
$ Anschad is a copy of the subject 01 report, dated November 4,1994 (received last week), ocecerming whesber there was EUAD by then Salem management of two members on the omelee Safety Review Group (SRO), anmely, a Samaor
- testflingmaer, and a Safety Revww Engmeer. Bassi.an absir *
, OI found 9 '
j >
- 1. the engmeers were harassed /intiandseed by I
__ _ y Manager ,,,,,,-
j 9 - L =11y: "
1~
- a. on December 3,1992, when the two eagesers attempted to process a safety imme in an incident -
report, in accordamos with senhos procedures, involving the qualifiestion of commercial grade air l supply asspoint presemo segulesars which oneirol the servios weenr flow to abs aam====w inn i cooling amies (also noes that at the and of a meshag in the Oeseral Manager's offios, 6e OM told i the indmenals to get out of his offios and livestemed to have them removed fresa 6e site) ;
~
, b. and ==8 g==dly when attempts were made (incinhag via a iseest from the then General Manager, i
'l Salem to abs Osmeral Manager, QA and Nuclear Safsey Review) to have the segmeers sumoved 6 i frees any direct involvesset with the sies.
J ., U
- 2. the Senior Staff Engineer was harassed and istumidated by abs , QA and Nuclear _
u-~ =~i , who esempeed to reprumand the engmeer for the benemg of the esisty isme, while the isme of the segmeer's site access was still umresolved (also note that the Osmeral Manager, QA dreRed a j ,
louer to the individual ocataining lenguage of a reprummed mense, ahhough it was not sent). ,
i.
i I noes that the hosesse aa=w an internal invasagation of his masser, the soport of what was ismed on April
} 2,1993 which found, in part, abat certain nuclear managers sageged in ammons of hassesment and i=*i-M +% or i
failed to respond to such actions e5scarvely. Ths4tauport inecuess that desciphanry schoes were taken agamst l the :=T-Ela individuals. In adehoa, he the{qaderal Manager, was subseguset),y removed._from his, =
Eas!ses in.1.994 and. is now wgrkag al APSE &O fossil fuel fasibey- } {
Oserations Maneser ses amoved, _, j j toss his posihom in 1993 and is working as a PSE&O J igwassesserve on loan to West!iggboues; and GEtes g General,
. Manage _rJA..and Nuclear _ Sal.nly.JQ(was - ' ' frees he company is 1994. Page 9 of the Of suport7 8 ,
proiides an organiassion chart that esisted at es tisms of teos eveses.
4 j
- {.j = ;;
? I Sinos te areions of suport has been mistred to DOI. .";.f' these -
tree individuals onestieusse possetial delibernes viola
! I
"; est soferral, the sleff aseds to seest to essermies es mest cours a s ! !
etassion, incladag evoluenos of es Of nadegs, as well as approprises emioseemset options for toes Em&ags.5 44 Q
'this euninstics should includs whe6ar any h sosion is -dad wie suspent to the niosases or es tree S :S mayonsible imervidnis. Any seer non imasenes antica, isole&ag es need for snamosmut eonfammass, should E -5 Q N
j also be essided, but should not heimpisessend aimes to sees has been sofered to DOI. A es5ssielusesdag
! CE andthethe to estanmine Ragles other I proposal BQ emos has been scheddedhas beam for 19:00 mm thatmheddad same day. for h 12 at 2:00 h pm 1
l (e @S U . '
I have 6e exhibits of the OI suport if you wish to ses tom. Bahibit 2A is he licensee's inveshgeboa report.
3 i.
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. <6 $
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1 DO NOT DISCLOSE - CONTAtNS 01 INFORMATIONc l
- (_JWfRla THHf NOTEMD REPORMENbQW J44&t70393% \
j i
DO NOT DISCLOSE - CONTAINS OMNFORMAI ON 6/6 "EHRED'TPilS Q " NOTsh AND4tEkOffT WAEN150W fy
}e V n.r.=h.,1, 1994 L (ff ,'g'
- NOTE To
- T. Martin J. White D. Vito J. I'iebenman, OE j W. Kane K. Smith W. Imaning S. Barber
! D. Cooper J. Joustra j-i j FROM: D. Holody '
i-
SUBJECT:
O! REPORT NO. 193 0215 (SAIDS) ALLEGED HARASSMENT, DrITMID AND
{
DISCRIMINATION (HI&D)
On November 21,1994, I distributed OI Report 193 0213 which found HI&D in 1992 and 1993 by aben Salem mannsensat against two ansebers on the assite safety Renew Orcup (SRO), anmely, a Senior Staff Engineer j j
a safety Renew Engmeer. Specifically, the Olieveshastion report (which was soferred to DOJ), found that:
{ 1.
I the engmeers were harassed /antunidated by the eben Salem Opershoes Manager and General specifically:
! a.
on Dar==har 3,1992, when the two engineers attempted to prooses a safety issue in an incidset i report, in accordance with stahan g= ' -
j
, involving the qualification ofcommercaal grade air supply seapoint pressure regulators whidi control the service weser flow to the aa=*====*
j fan coohng units (also note that at the end of a meeting in the General Manager's offios, the GM told the indinduals to get out of his offios and threatened to have ehem seawved front the site) ;
b.
and subsequently when setempts were anade (including via a letter from the then General Massg Salem to the General Manager, QA and Nuclear Safety Renew) to have the engineers renewed from any direct involvement with the site.
2.
t the Senior Staff Engineer was harassed and i=*i=id=*=d by Ibe then General Manager, QA and Nuclear safety Review, who enempted to repnmand the engineer for the headbag of Ibe safety issue, while the issue of the engmeer's site access was still maresolved (also note Ibst the Osmeral Manager, QA draAnd a letter to the individual containing language of a reprimand nature, akbough it was not samt).
, 1y, OI pronded the attached n,' --
- report (1-93 0212), doesd November 22,1994, comoerming 4
whether an additional instance of HIAD occurred against the Senior Staff Engsseer. Specifically, abs Senior Staff
- "f , in a complemt to DOL, alleged that the company had denied him aa p====*ia= and promotion to the level j
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of others perfonsing the suae fusceica based on his prachos of speaknag up on aseteese judgedBi to adverse t
anclear safety and the seguiremsats. While Of moems abat it has closed this case sinos it has been3assigned ! a priority (aAer the OI prioritiastica meeting ca October 17,1994),I noes that the DOL District Duector (DD)j i
found in the individual's favor, acting that a postion diet the individual had be seseus on January 26,1993, aAer being denied ,_J
'y on two occasions. DOL also indicated abat because the j
Senior Staff lingmaser was the imammbent and a leading casdsdate for the.'posinon, a j
i immedase supervisor iak he was the leading caadednee to fill Ibo position, die company's failare to All es mest is consensed as a '
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i Premated to Grade 5, and be gives restitution of backpay and legal espasses. While the company i ap j findag to Secretary a DOL of IJhor AU, on June a estatement was -h==r===ely seached between es perhos and-!
8,1994. w i I c gg -
i Snee a eeBegial meeting is scheduled with OE and other BQ effless for e .8 E K! !
i 12 at 2:00 by E55 an internal al meeting at It), I recanumend that this DOL DD flading she i In addities to this supplemental OI report, Pee also attached (1) the DOL seasidered seesting. j y g h j i s Rapest = = -: "- !
(previously provided to the staff) which provides the basis for the DOL DD eendosion; and (2) the Eceasse's response to the chining effect letter la which the liesasse takes imme with the DOL DD ==4=da= {
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DO NOT DISCLOSE - CONTAINS 01 INFORMATION
- \SHRI@DilS - NOTE"AND REPCTRT WH8N DONE v -
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)I DOL Cc4npliance Officer (CO) Report in the Williams vs PSE&G DOL complaint. De DOL District Director found in the individual's favor, stating that discrimination was a factor in t
the actions that comprised the individual's complaint.
' Williams, a senior staff engineer in the Nuclear Safety Review organization, alleged that the company has denied him compensation and promotion to the level of others performing the same function based on his practice of speaking up on matters that are judged to adversely i affect nuclear safety and the requirements. The individual indicated that he has often been a whistleblower on matters affecting nuclear safety.
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j In this finding, DOL states that the individual filed a safety concern internally in December
! 1993, and the same day, the Salem General Manager issued a memorandum to William's !
! third tier supervisor requesting that Williams be removec' from any direct or indirect I
involvement with Salem. Also, DOL noted that a position that Williams had been filling was
! approved for permanent status on January 26,1993, after being denied previously on two l~
occasions. Because Williams was the incumbent and a leading candidate for the position, and because the individual's immediate supervisor felt he was the leading candidate to fill the
! position, the company's failure to fill that position must be construed as a discriminatory l action. The DOL recommended that the individual, a Grade 4, be promoted to Grade 5, be 3 given restitution of backpay and legal expenses, but denied Williams request that he had 4
entitlement to a Grade 6.
1 Since the DCL found, in part, in the individual's favor, the panel needs to review and
} evaluate this Compliance Officer's report and DRP needs to prepare and send the licensee a
! chilling effect letter.
1
- cc
- T. Martin i W. Kane
- D. Cooper i W. Ianning j E. Wenzinger j J. White
! B. Ietts
, D. Vito {
} J. Lieberman, OE !
DJH 11/13/93 l l
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i amTEM Bnamn hiei1NG 3/21/95 l 1
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- The Salem facility performance has been discussed during -l four SMMs, due to frequent, significant operational !
I
- transients, initiated or complicated by equipment failures, personnel errors, ineffective or untimely corrective '
. actions, and inadequate management oversight and
! involvement. ;
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- The NRC has performed four AIT inspections in as many years, j and has closely inspected numerous automatic trips or forced i shutdowns during the same period. j Events or weaknesses of the same or similar nature continue !
to occur without a discernable. reduction in frequency or l l significance.
(
e obviously, the events of greatest concern to the NR. over ;
the last 4 years, include: j i
i e 11/91 Catastrophic Failure of Turbine on Overspeed i i i e 12/92 Disabled Overhead Annunciators t 2
0 5/93 Repetitive Startups with a Malfunctioning l j CRD System e 4/94 Loss of Plant Control During Grass Intrusion t e 12/92HarassmentandIntimidationofNY F Representatives ' jd r
e Repetitive Contributing Causes Evidenced by these Events ej,yW' include:
e Inadequate Problem Identification and Analysis; eg. Failed Overspeed Protection 725/~
g- "-'functie-i=; CRP 9y-t:r e Inadequate Corrective Action for Earlier Problem; eg. Turbine Overspeed Solenoids U J -* U Z-Atmospheric Steam Dump u , # A,M c40 m o Inadequate Management Oversight and Vertical M, ra* 4.-
Communications; *'5*-/0 eg. Failed Turbine ST Information in this record was dEie'ed Failed O/H Annunciator System J
in accordance with tha Freedom of !nformation Act, exem tions._4Iz_ / I folk. .- A d 0- -
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- Inadequate Contractor oversight; eg. CRD System Refurbishment Fire Watch Rounds and Logs Fa.hibber) e Inadequate Staff Performance; Grass Intrusion C & C eg.[TurbineST i
Overhead Annunciator Lockup QCR0 Spt** He-1 h , phy e Failure to Follow Procedure; eg. Turbine ST e Inadequate Maintenance; eg. Turbine Solenoid and Press Relay PMs e Inadequate Design; og. Turbine Protection Testability O
vsaeIIy soPp/Hs,pna.ot Annunciator
, Tamper Resist o Every one of ose events involved one or more hardware deficiencies, Significant problems with design, pa**Js4 ass m ,
installation maintenance and testing of continue challengeplantoperationh.[pbut, equipmentnote Of particular have problems wit -
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- Electrical Distribution System Coordination,
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gv//* ,,,, R; diction "cnitori"O 9'yeam T . b - 1/ b h et
,,J S C;fcgaard; Esaipm:nt Cahincts a# I f> [,,. M# /M'^kl* A solid Stoim F ctcction cyct~n gI Ay l 93 Turbine Controls tav gf Jpo e Mesm Steam ,Feedwater Controls t#
- Crntrcl ".;d Orn ; CyoLum s./a/ N /%,,,,p .$~h ,4,
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rrimar3 cy;;c_ 20Rm ..; cmam sofcei:
I ; ' Ruoctor Trip Drcakmio-
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gi par *9r r-e Sign fivaul CiLLcr5-g l
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i e Personnel errors have also precipitated or negatively _
contributed to numerous events of lesser immediate ;
consequences and are usually manifested by:
Failing to refer to or follow procedures f Failing to question the appropriateness of a I l
l procedure step or the response of equipment to an i l action taken !
l ' E Acting before thinking
- Inadequate management planning, communication, j control and oversight of activities :
l - Lack of clear accountability and assumption of I I
responsibility I r
e Many probleme recur due to ineffective or untimely l corrective action processes j i
l Inadequate questioning attitude of anomalous l conditions ;
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- The staff has learned to cope with and work around j problems f"r;bl : IP thrc held t:: high)
L - The staff has a tendency to buy into easy answers that avoid taking problem ownership l
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- The threshold for conducting root cause analysis i of problems is frequently too high l
- Engineering support for resolution of problems is under-utilized l
- Vertical and horizontal communication of problems is limited
- The scope of corrective actions for identified problems is frequently narrowly focused
- The QA and NSRG organizations and functions are i not. perceived to add value and appear to lack line !
, organization respect i-4 I l
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e The work of contractors has frequently been at the root of problems experienced, due to inadequate management oversight ,
and inadequate staff cognizance of contractor work ;
! activities. Examples include:
- Security Staff Performance l
Fire Watch Falsification ;
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- Overhead Annunciator System Design CRD System Upgrades l
\ S Y
- Contractors ar$e_ -
p:::flncre perrenn:1 fai14eg.to adhere to lic:n ::' -equipment tag out prer:d,.a -
and work control procedures:3 l March 9, 1994-$50,000 CP issued for numerous violations involving (1) performance of maintenance, including electrical breakers, without a>propriate tagging of the equipment ;
r to assure safety; (2) improper removal of tags that should have been maintained; (3) failure to adhere to written work orders or instructions. Examples:
l 7 Wh A contractor cut into an energized 125 VDC control cable berture it /was not tagged out; tagged out valves were repositioned while maintenance was still in progress; work @
perf:r-. d on electrical equipment prior to ,
assuring proper tag out; work @erformed without written procedures or instructions; performance of work activities without appropriate work authorization.
October 1994-a contractor electrical inadvertently cut into the wrong 4160 volt cable, it was fortuitous that the cable was de-energized at the time, o PSE&G has expended significant effort and resources over the last four years to improve Salem's hardware, material condition, maintenance backlog, procedures, and personnel l performance. There have been some notable successes in l several of the targeted areas, but overall, the facility has l shown little improvement in its overall performance.
/3raeors su i sqar av
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- In response to NRC concerns, PSE&G committed in July 1993 to re-examine events of several previous years, from a broad perspective, and determine if additional corrective action 1 was warranted. The resulting Comprehensive Performance Assessment Team (CPAT) effort was completed in January 1994, and emphasized deficiencies in the management and leadership of the Salem organization, personnel performance, and corrective action processes.
- During 1993 and 1994, overall performance declined. The )
units were subject to eight forced outages and eight ;
automatic trips. A potentially fatal accident was !
fortuitously avoided last October, when an electricalf v*#I i contractor inadvertently cut into the wrong 4160 49dh cable, l which had been de-energized for unrelated work. Both units i have required frequent power reductions to perform repairs l or replace degraded equipment.
- In July, NRC's pilot Customized Inspection Planning Process team inspection confirmed weaknesses in corrective action '
effectiveness and root cause analysis. Significant problems were found relative to the establishment and implementation of maintenance programs and activities.
- The trends in Salem's SALP ratings speak for themselves.
Like golf, higher scores are worse Significant performance improvements were made in the function area of Radiation Protection
- Otherwise, overall performance remained about the same until 1993, after which we have noted a significant decline ja w ./
- The most recent SALP report, vering the 18 month period ending November 5, 1994, as gned category "3" ratings to the operations and mainten nce functional areas. These based on the accommodation of longstanding ratings wegr equipment en / system problems, lack of a questioning attitude, weak operability determinations, frequent problems with procedural adherence and quality, and weaknesses in work control, troubleshooting activities and management control and oversight of maintenance activities. The engineering functional area was rated category "2" due, in i
part, to quality design and modification activities, counter-balanced by inconsistent engineering support to resolve chronic plant system and equipment problems. The plant support functional area was rated category "1" to acknowledge the continued strong performance in this area.
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In arriving at this assessment, we also observed: 11) the-
-tendency of y ur cperaticn depacts:nt at:ff t: ::: pt ani ;
accc- edet -cyetem perfermenue wh=L --e uvi-in ac Ordance- !
rith dreign; [) the tendency of your organization to not l aggressively q(uestion the validity of assumed causes of ,
degraded conditions or unexpected system performance, and to !
dismiss without adequate technical basis or rationale other ;
possible contributors or factors; (gy the general reticence l of your maintenance and operations organizations to solicit j technical support from the engineering organization for the j resolution of plant system or equipment issues; and the ;
engineering organization's apparent reservation to engage in the diagnosis or resolution of plant technical problems, unless specifically requested; 05) the lack of value j attributed to, or expected from, nuclear safety review and quality assurance activities, and the consequent ineffectiveness of these functions; (14 insufficient critical self-assessment initiatives to evaluate the ,
adequacy and performance of personnel, procedures and hardware; and (jf) insufficient supervisory oversight and ,
poor communication of senior plant management's expectations relative to the performance of activities.
e We acknowledge the significant expenditure in resources and the changes in the management, staff organization, and material condition of the units that have been made.
Notwithstanding these efforts, frequent and lingering problems have continued with equipment reliability and human performance. As a result, we concluded it was necessary to understand the Board of Director's views on the need for further improvements in facility and human performance.
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7 e Obviously, the events of greatest concern to the NRC over the last 4 years, include:
e 11/91 Catastrophic Failure of Turbine on Overspeed ,
o Failure to Track and Implement Commitments In 1990, Unit-1 solenoids, 20-OPC and 20-ET, were found to be degraded and were consequently replaced; a subsequent LER (272/90-030-00) ,
T solenoids would be committed that the Unit Y~
TEplaceg at the next outage of sufficient ~
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duration; the next forced outage was May 11, 199gl,u0 (an 11 day outage), but due to a management oversight error, the solenoid replacement was not identified as "Must Do" since the components were believed operable based on startup testing from 2R5 and the commitment tracking system already indicated that the item was closed based on the intention to replace the soln.oide in outage 2R6; subsequently the work was deferred to outage 2R6, scheduled for January-February 1992.
e Inadequate Maintenance Since the solenoids were BOP equipment and the vendor did not indicate any recommended preventive maintenance activity, only corrective maintenance was accomplished when surveillance activities indicated degradation or failure; low maintenance priority was assigned. Licensee failed to ;
consider operating experience information (other l solenoid f ailures at Ginna and Crystal River) and their own experiences at Unit-1 in 1988 and 1990. 1 The NRC's GL 91-15 (Sep;cember 23, 1991), which l described several other solenoid failures, was !
not considered seriously since it did not require j
'a response.
e Inadequate Surveillance Test Procedure j The licensee's procedures for surveillance testing j of turbine overspeed protection systems were deficient for the following reasons:
- Testing of the mechanical turbine trip l function (Front Standard) isolates 17 possible trip inputs while the test is in progress;
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- Surveillance testing did not specifically verify the proper hydraulic operation of each turbine trip solenoid valve independently... success was based only on the result that the turbine would trip during the test; 1
- The licensee's procedures verified the operability of steam admission and control ,
valves but not the overspeed protection i system 1
- The licensee used a generic I&C channel calibration procedure (a Category II procedure which does not require any record keeping of test performance) instead of a ,
specifically designed procedure to meet the !
applicable TS requirements. Consequently, there is uncertainty relative to previous conformance with the TS requirement.
e Inadequate Root Cause Analysis On October 20, 1991, during a Unit 2 restart, five licensed personnel were aware that the overspeed j protection test was unsuccessful, yet no action ;
was taken to understand the nature and cause of 1 the problem. The test result was essentially )
ignored and the startup step bypassed as startup l was continued without any resolution to the test discrepancy.
e Failure to Follow Procedure As described above, operating personnel failed to adhere to the requirements of the Integrated Operating Procedure by continuing startup without resolving the OPC test discrepancy. >
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e Inadequate Management oversight and Vertical Communications While various licensed individuals had differing levels of knowledge concerning the OPC test failures, communication errors among the individuals (two Ros, an operating engineer, the senior nuclear shift supervisor, and the unit nuclear shif t supervisor) resulted in failing to understand the implications of the test failure, and effect resolution of the procedural adherence and equipment problems. None of the supervisory personnel exercised sufficient initiative or questioning attitude to cause attention to be directed to the matter. No log entry was made relative to the test fail'ure or subsequent cecision to continue startup witnout_ resolution._
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g e Inadecuate Corrective Action for Earlier Problem Though the licensee had experienced similar problems with the turbine trip solenoid valves on Unit 1 in 1988 and 1990, corrective action initiatives failed to recognize the implications i of the matter, were untimely, and did not require any increased attention, maintenance, or surveillance. The licensee's actions were i
directed to fix what is known to be broxen, l resCoTe
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Ehe~ system, and7olit~IITUe on. No serious I eTTort was expended to unBerstand the nature of the problem or consider generic implications. ;
e Other contributing causes [M /Nc- r e> kWc-c.o;-
- Due to l_ack of PM requirements, the 63-3 AST pressure switch setpoint was at 39 psig, 10 to 15 psig less than the AST pressure switches that affect RPS logic.
Consequently, the governor valve was not re-referenced to a no-load condition and
~ reopened when the EHC system was repressurized.
- Due to lack of PM requirements, a local tachometer at the Front Standard, which could have provided early warning of turbine overspeed, was inoperable.
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e 12/92 Overhead Annunciators Disabled e Failure to Follow Procedure ,
1 A RO failed to follow procedures for operation of l the Remote Control Work Station (RCW) when !
attempting to troubleshoot the OHA system. By not referring to the procedures for the system, a control switch was mispositioned and the wrong keystrokes were entered on the computer which Etfectively " locked-up" the system and prevented any input from being processed and displayed on i the ORA.
e Inadequate Management Oversight and Vertical Communications The plant staff delayed notifying management of I the event. -
l Ineffective communication between and among operations and system engineering in that system i design and operating characteristics were never i effectively conveyed to the operators. Both organizations had limited knowledge of the system's operation and functioning.
A timely report was not made to the NRC relative to the ORA system failure.
- Inadequate contractor oversight The licensee did not require any training services from the vendor (BETA) relative to the system, consequently a third party was used to provide training in the hardware, but software was not s/
included or discussed. The software was 4 essentially a " black bnv"_ rn the licannae. System engineering training was limited, operator training was almost non-existent.
The DCP that installed the system was accomplished by contractors and consultants with little oversight by the licensee (only one project manager was assigned), No licensee expertise was available to assess and understand the associated software. Most utility effort was s_ pent on hardware, n5he on software. startup and~ resting of'The system wa57eHormEd by contractors without sufficient licensee oversight and understanding of performance characteristics.
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8 Tendency to Avoid Accountability ],
After investigation (NRC and LicenJee) revealed that the RCW had been manipulated contrary to the procedures, no individuals volunteered information or acc ted re nsibilit for the act.'
e Excessive Threshold for Root Cause Analysis Only after NRC attention was directed to this matter (AIT initiation) was there any effort to systematically perform comprehensive root cause analysis. Until that time, the licensee's efforts were directed to determining the most reasonable proximate cause, restoring the system, and continuing with normal operations. ,
e System Design Contributors to the Problem LTA human factor engineering-no warning to operators of system status or non-functioning condition; LTA design specification- alarm display was not designated as the priority task; and no trouble or warning indicators of system malfunctioning were required.
8 Other Contributing causes LTA software review by licensee.
No loss of annunciator procedure existed.
No simulator training on loss of annunciators existed. 1 LTA documentation by the vendor. System- j descriptions were high-level and not easily i
j understandable, j
System features were not readily or easily l testable. l Licensee's failure analysis of OHA did not consider software failure.
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e 5/93 Repetitive Startups with a Malfunctioning CRD System o Inadequate Root Cause Analysis No clear station policy or procedures relative to applying root cause assessment activities. ,
l Postulated causes were not tested to ensure soun_d engineerina bases for the determination, rather_
i the effort was to replace suspected components in l
hope that the prnblem would be resolved.
No policy existed to delineate what types of problems warrant detailed root cause investigation. ;
No relationship between root cause and system operability determination, i.e., the licensee ;
I attitude was clearly to get the system fixed and restored to support startup, with root cause 7 assessment to follow, if priorities permitted. !
- Inadequate Management oversight / Contractor (
Oversight Initial troubleshooting efforts and cause !
assessment were essentially turned over to i Westinghouse without adequate licensee oversight :
and control; Westinghouse's role was not defined ~
by procedure or contract and they participated as_
p_eers with PSE&G technicians but were relied upon_
for,exper,tise.in system. performance and, design.
In several instances,..they performed activities withod~t thd licensee's oversight. There was no'
'systematicIroot cause approach used by either the licensee or Westinghouse.
No clear leadership or delegation of responsibilities was established by licensee.
Licensee attention was always focused on efforts to resolve the most recent failure without any ,
consideration of the implications of the !
repetitive nature of the failures and need to i
l determine root cause.
l e Excessive Threshold for Root Cause Analysis j l
Only after NRC attention was directed to this matter (AIT initiation) was there any effort to
! systematically perform comprehensive root cause analysis. Until that time, the licensee's efforts were directed to determining ~thb inost reasonaW ~ d
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p]'dixIin&TE U3 hue','TeBroTIrif tee ~Fy~ stem, and-conETrrQing widi ffoMEl- 5pe'rTtiloHs'~~~~
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4 13 W e other Contributing Causes (Electronic)
Multiple transistor and IC failures Regulation Circuit Board Shorts I/O amplifier, I/O receiver, resistor, ar 3 Slave Cycler Logic Card Failures Some of these failures were attributed to insufficient controls for component handling and j inadequate precautions for avoiding damage to j circuit cards. ,/
e 4/94 Loss of Plant Control During Grass Intrusion /-
e Inadequate Corrective Actions Management and the operations department tolerated and willingly accommodated equipment problems.
Automatic rod cont ,1 system was not maintained in-ser tce which required manual control of reactor power; High steam flow signals (which in this case contributed to the initial automatic safety injection actuation) had been identified from several previous post trip reviews as early as 1989. Inadequate root cause attributed the phenomena to steam flow anomalies that might follow reactor / turbine trip events. In I actuality, the cause was a pressure wave initiated by stop valve closure; i Automatic control for SG atmosphere relief valves (MS-10s) were not maintained and consequently contributed to code safety ,
l actuation and subsequent second automatic safety injection. This condition likely I existed since 1977. Consequently, automatic function of the MS-10 required operator intervention to assure proper functioning.
An operator's failure to intervene in a timely manner contributed to the reactor l
system complications experienced during this l event. Compounding this finding was the fact
! that the system was not maintained as ,
described in the FSAR and no safety evaluation was performed that justified the l change from the design.
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- The licensee had sufficient operating experience to realize that the circulating water system was vulnerable to grass intrusion events. Several previous situations required operators to reduce power to accommodate loss of one or more circulators. Modifications to the circulating water system were planned but on an extended schedule. The licensee relied upon operator intervention to accommodate repetitive grass problems as they occurred.
o Inadequate Staff Performance Management provided inadequate direction to operators which contributed to operator errors, non-conservative decision-making by line managers, and deficiencies in command and control.
Management's expectations were clearly not communicated to the staff since they were intent to prevent plant trip by engaging in extraordinary efforts to maintain the reactor at power instead of taking a conservative action to effect a controlled shutdown. !
o Inadequate Management Control and Oversight i During the trip event, the SNSS temporarily lost command and control by leaving the control room to attempt to circumvent bypasses affecting the operation of a circulation water pump. In addition to abandoning his primary responsibility in a serious transient condition, the individual willfully engaged in violating procedures by attempting to bypass CW pump interlocks. l While the SNSS was disposed, the NSS designated as responsible for control room command function, elected to operate control rods, and abandoned his oversight responsibility for a short period.
Though Westinghouse had previously communicated the potential that inadvertent SI actuation could result in solidifying the pressurizer, management had not reacted to the information with any procedure or compensatory action. When the inadvertent SI occurred and filled the pressurizer, operators had to react without the benefit of procedures or training 7. elative to stabilizing the plant and restoring a bubble in the pressurizer.
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f J1 15 Other Contributing causes
! The primary NCO knew that Tave was below minimum temperature for criticality but failed to
- communicate the information to the NSS.
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The crew control of did not associate reactor power. the Low Tave alarm with The NCO erred by trying i to control reactor power at 7% while responding to j the Tave condition. He pulled rod to gain i temperature and no one was monitoring reactor power as it increased to 25%.
The STA and NSS failed to monitor plant heatup as part of the critical safety function status tree.
The STA was engaged in various restoration activities.
- (December 3, Representatives1992) Harassment and Intimidation of NSRG (<
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- j SALEM BOARD MEETING 3/21/95 i
e The Salem facility performance has been discussed during four SMMs, due to frequent, significant ope (ational transients, initiated or complicated by equipment fmilures, personnel errors, ineffective or untimely corrective actions, and inadequate management oversight and .
involvement. The NRC has performed four AIT inspections in j as many years, and has closely inspected numerous automatic trips or forced shutdowns during the same period. Events or weaknesses of the same or similar nature continue to occur ,
without a discernable reduction in frequency or significance.
- Obviously, the events of greatest concern to the NRC ;
over the last 4 years, include:
e 11/91 Catastrophic Failure of Turbine on Overspeed
- e Failure to Track and Implement Commitments ,
In 1990, Unit-1 solenoids, 20-OPC and 20-ET, were found to be degraded and were ;
consequently replaced; a subsequent LER (272/90-030-00) committed that the Unit-2 solenoids would be replaced at the next outage of sufficient duration; the next forced outage was May 11, 1995 (an 11 day outage), but due to a management oversight error, the solenoid replacement was not identified as "Must Do" since the components were blieved operable based on startup testing from 2R5 and the commitment tracking '
system already indicated that the item was closed based on the intention to replace the solenoids in outage 2R6; subsequently the work was deferred to outage 2R6, scheduled for January-February 1992.
. Inform 2tbn in this recc7d y;2 gc,ggg inat:Ordancev!i n cy,emgg - ,
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i i 2 j I e Inadequate Maintenance j 4
Since the solenoids were BOP equipment and the vendor did not indicate any recommended I
}
preventive maintenance activity, only corrective maintenance was accomplished when i surveillance activities indicated degradation 1 or failure; low maintenance priority was :
assigned. Licensee failed to consider j j operating experience information (other j i
solenoid failures at Ginna and Crystal River) and their own experiences at Unit-1 in 1988 l and 1990. The NRC's GL 91-15 (September 23, !
1991), which described several other solenoid
!, failures, was not considered seriously since j
it did not require a-response.
i j e Inadequate Surveillance Test. Procedure The licensee's procedures for surveillance i
i testing of turbine overspeed protection 4
systems were deficient for the following-i reasons:
i
)
- Testing of the mechanical turbine trip j function (Front Standard) isolates 17 d possible trip inputs while the test is l in progress; 7
- Surveillance testing did not j
specifically verify the proper hydraulic
- operation of each turbine trip solenoid valve independently... success was based only on the result that the turbine would trip during the test; J
- The licensee's procedures verified the j
- operability of steam admission and control valves but not the overspeed
- protection system;
- The licensee used a generic IEC channel calibration procedure (a Category II procedure which does not require any record keeping of test performance)
' instead of a specifically designed ,
procedure to meet the applicable TS !
requirements. Consequently, there is uncertainty relative to previous 4
- conformance with the TS requirement.
1
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. 3 5
i e Inadequate Root Cause Analysis On October 20, 1991, during a Unit 2 restbrt, j
five licensed personnel were aware that the overspeed protection test was unsuccessful,
/ yet no action was taken to understand the Thr, test nature and cause of the problem.
i result was essentially ignored and the i
j startup step bypessed as startup was
- continued without any resolution to the test j discrepancy.
!
- Failure to Follow Procedure As described above, operating personnel i
failed to adhere to the requirements of the i
! Integrated Operating Procedure by continuing startup without resolving the OPC test discrepancy.
Inadequate Management Oversight and Vertical j *-
communications While various licensed individuals had i
differing levels of knowledge concerning the OPC test failuren, communication errors among l the individuals (two Ros, an operating i engineer, the senior nuclear shift.
l supervisor, and the unit nuclear shift j supervisor) resulted in failing to understand j
the implications of the test failure, and effect resolution of the procedural adherence ;
]
and equipment problems. None of the l j
supervisory personnel exercised sufficient j
initiative or questioning attitude to cause j attention to be directed to the matter. No l
log entry was made relative to the test failure or subsequent decision to continue
' startup without resolution.
'
- Inadequate Corrective Action for Earlier l 1 Problem I
) Though the licensee had experienced similar problems with the turbine trip solenoid l
j valves on Unit 1 in 1988 and 1990, corrective action initiatives failed to recognize the implications of the matter, were untimely, l
and did not require any increased attention, i
maintenance, or surveillance. The licensee's j actions were directed to fix what is known to j be broken, restore the system, and continue j on. No serious effort was expanded to understand the nature of the problem or i
' consider generic implications.
4 i
4
- Other. contributing Causes
- Due to lack of PM requirements, the 62-3 AST pressure switch setpoint was at 39 psig,.10 to 15 psig less than the AST pressure switches that affect RPS logic.
Consequently, the governor valve was not (
re-referenced to a no-load condition and reopened when the EHC system was s/
repressurized.
- Due to lack of PM requirements, a local tachometer at the Front Standard, which could have provided early warning of turbine overspeed, was inoperable.
- 12/92 Overhead Annunciators Disabled e Failure to Follow Procedure A RO failed to follow procedures for operation of the Remote Control Work Station (RCW) when attempting to troubleshoot the OHA system. By not referring to the procedures for the system, a control switch was mispositioned and the wrong keystrokes were entered on the computer which effectively
" locked-up" the system and prevented any input from being processed and displayed on the OHA.
e Inadequate Management oversight and Vertical Communications The plant staff delayed notifying management of the event.
Ineffective communication.between and among operations and system engineering in that system design and operating characteristics were never effectively conveyed to the operators. Both organizations had limited knowledge of the system's operation and functioning.
A timely report was not made to the NRC relative to the OHA system failure.
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l
- Inadequate Contractor Oversight * ,
The licensee did not require any training (
services from the vendor (BETA) relative ,to
} the system, consequently a third party was l f
used to provide training in the hardware, but I t
software was not included or discussed. The j
software was essentially a " black box" to the !
l licensee. System engineering. training was l limited, operator training was almost non-I existent.
l The DCP that installed the system was accomplished by contractors and consultants
- with little oversight by the licensee (only i one project manager was assigned). No licensee expertise was available to assess and understand the associated software. Most l
j utility effort was spent on hardware, none on software. Startup and testing of the system i
j was performed by contractors without -
sufficient licensee oversight and l
understanding of performance characteristics.
- Tendency to Avoid Accountability ]k)
-b After investigation (NRC and Licensee) revealed that the RCW had been manipulated
- contrary to the procedures, no individuals i
volunteerad information or acce d r s for the act.
l 1 l i
!
- Excessive Threshold for Root Cause Analysis'
! Only after NRC attention was directed to this matter (AIT initiation) was there any effort j
to systematically perform comprehensive root cause analysis. Until that time, the f
licensee's efforts were directed to l
j determining the most reasonable proximate cause, restoring the system, and continuing i
with normal operations.
I t
f
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6 e System Design Contributors to the Problem, LTA human factor engineering-no warning to operators of system status or non-functioning condition; LTA design specification- alara display was not designated as the priority task; and no trouble or warning indicators of system malfunctioning were required.
e Other Contributing Causes I
LTA software review by licensee.
No loss of annunciator procedure existed.
No simulator training hlossofannunciators existed.
j LTA documentation by the vendor. N i
gysten-descriptions were high-level and not Basily understandable.
l System features were not readily or easily testable.
Licensee's failure analysis of OHA did not l
consider software failure.
e 5/93 Repetitive Startups with Malfunctions CRD System o Inadequate Root Cause Analysis No clear station policy or procedures relative to applying root cause assessment I
activities. I Postulated causes were not tested to ensure !
sound engineering bases for the determination, rather the effort was to replace suspected components in hope that the problem would be resolved.
No policy existed to delineate what types of f problems warrant detailed root cause j investigation.
I No relationship between root cause and system !
l operability determination, i.e., the licensee j
attitude was clearly to get the system fixed 4 and restored to support startup, with root cause assessment to follow, if priorities permitted.
d 7
l e Inadequate Management Oversight / Contractor .
l Oversight
' Initial troubleshooting efforts and cause ;
assessment were essentially turned over to Westinghouse without adequate licensee oversight and control; Westinghouse's role was not defined by procedure..or contract and they participated as peers with PSE&G ;
technicians but were relied upon for :'
l expertise in system performance and design.
' In several instances, they performed activities without the licensee's oversight.
There was no systematic root cause approach used by either the licensee or Westinghouse. '
i
- No clear leadership or delegation of
! responsibilities was established by licensee.
! Licensee attention was always focused on l efforts to resolve the most recent failure without any consideration of the implications of the repetitive nature of the failures and need to determine root cause.
- Excessive Threshold for Root cause Analysis Only after NRC attention was directed to this matter (AIT initiation) was there any effort to systematically perform comprehensive root cause analysis. Until that time, the licensee's efforts were directed to determining the most reasonable proximate cause, restoring the system, and continuing
! with normal operations.
e other contributing causes (Electronic)
- Multiple transistor and IC failures !
- Regulation Circuit Board Shorts
- I/O amplifier, I/O receiver, resistor, and Slave Cycler Logic Card Failures l Some of these failures were attributed to insufficient controls for component handling and inadequate precautions for avoiding i
damage to circuit cards.
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8 e 4/94 Loss of Plant Control During Grass Intrusion 4
- Inadequate Corrective Actions Management and the operations department tolerated and willingly accommodated equipment problems.
- Automatic rod control system was not maintained in-service which required manual control of reactor power;
- High steam flow signals (which in this case contributed to the initial automatic safety injection actuation)
} had been identified from several i previous post trip reviews as early as 1989. Inadequate root cause attributed
- the phenomena to steam flow anomalies
? that might follow reactor / turbine trip i events. In actuality, the cause was a
! pressure wave initiated by stop valve 2 closure;
- Automatic control for SG atmosphere
- relief valves (MS-10s) were not maintained and consequently contributed j
l to code safety actuation and subsequent second automatic safety injection. This condition likely existed since 1977.
4 consequently, automatic function of the MS-10 required operator intervention to assure proper functioning. An operator's failure to intervene in a timely manner contributed to the reactor system complications experienced during this event. Compounding this finding was the fact that the system was not i maintained as described in the FSAR and no safety evaluation was performed that justified the change from the design.
- The licensee had sufficient operating experience to realize that the i
circulating water cystem was vulnerable 4
to grass intrusion events. Several previous' situations required operators to reduce power to accommodate loss of one or more circulators. Modifications to the circulating water system were i planned but on an extended schedule.
The licensee relied upon operator l
' intervention to accommodate repetitive grass problems as they occurred.
4 4
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9 l I
- Inadequate Staff Performance Management provided inadequate direction ho operators which contributed to operator ,
errors, non-conservative decision-making by line managers, and deficiencies in command .
l and control.
l Management's expectations were clearly not communicated to the staff since they were l intent to prevent plant trip by engaging in '
1 i
extraordinary efforts to maintain the reactor at powar instead of taking a conservative l action to effect a controlled shutdown.
- Inadequate Management control and Oversight During the trip event, the SNSS temporarily lost command and control by leaving the control room to attempt to circumvent bypasses affecting the operation of a circulation water pump. In addition to l
abandoning his primary responsibility in a
' serious transient condition, the individual willfully engaged in violating procedures by attempting to bypass CW pump interlocks.
While the SNSS was disposed, the NSS designated as responsible for control room command function, elected to operate control rods, and abandoned his oversight responsibility for a short period.
Though Westinghouse had previously communicated the potential that inadvertent SI actuation could result in solidifying the-pressurizer, management had not reacted to the information with any procedure or l
l compensatory action. When the inadvertent SI l
occurred and filled the pressurizar, operators had to react without the benefit of l
procedures or training relative to I
stabilizing the plant and restoring a bubble in the pressurizar.
1
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1 .
e 8
l 10
- Other Contributing Causes .
i The primary NCO knew that Tave was below minimum temperature for criticality but
- failed to communicate the information to the NSS.
The crew did not associate th,e Low Tave alarm
'. with control of reactor power. The NCO arred by trying to control reactor power at 7%
while responding to the Tave condition. He pulled rod to gain temperature and no one was monitoring reactor power as it increased to 25%.
The STA and NSS failed to monitor plant heatup as part of the critical safety function status tree. The STA was engaged in various restoration activities. k L h I
l E.
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o Everyone of those events involved one or more hardware deficiencies. Significant problems with design, installation, maintenance and testing of plant equipment continue to challenge plant operations. Of particular note have been problems
! with:
- CW Intake g
- SW Piping i
e Electrical Distribution System Coordination, Capacity and Reliability l
- Radiation Monitoring System
- Safeguards Equipment Cabinets 1
- Solid State Protection System i
e Turbine <2c.P rols
- Feedwater Controls e Control Rod Drive System
- Primary System Code Safeties e Reactor Trip Breakers 1
L__:______________________ - - . _ _ _ _ _ _ ._
_ . _ __ _ - _._ _ _ . . _ _ . _ _ . . _ _ . . . _ _ . _ . _ . _ . _ . ~ _ . _ _ _ . _ _ _ . - - . _ .
w /
i 12 .
! i e Significant others o j,
/ _
! Attachment i "Salen Equipment Deficiency !
List" pertains. ;
- Personnel errors have also precipitated or negatively )
! contributed to numerous events of lesser immediate ;
consequences and are usually manifested by:
. )
l
- Failing to refer to or follow procedures ;
I
- Failing to question the appropriateness of a j l
procedure step or the response of equipment to an '
l action taken
- Acting before thinking
- Inadequate management planning, communication, control and oversight of activities l
- Lack of clear accountability and assumption of responsibility
- Many problems recur due to ineffective or untimely l corrective action processes -
- Inadequate questioning attitude of anomalous conditions
- The staff has learned to cope with and work around problems (Problem ID threshold too high)
- The staff has a tendency to buy into easy answers i that avoid taking problem ownership
}
- The threshold for conducting root cause analysis of problems is frequently too high
- Engineering support for resolution of problems is ;
?
under-utilized
- Vertical and horizontal communication of problems is limited
- The sco,pe of corrective' actions for identified J l
problems is frequently narrowly focused !
1
- The QA/NSRG/STA organizations and functions are I not perceived to add value and appear to lack line !
organization respect i
-c I
13 e The work of contractors has frequently been at the root of problems experienced due to inadequate management oversight and staff cognizance of their work activities. Examples include:
- Security Staff Performance
- Fire Watch Falsification .,
I
- Overhead Annunciator System Design
- CRD System Upgrades 1
- others contractors and licensee personnel failing to ,
adhere to licensee's equipment tag out procedures f and work control procedures:
March 9, 1994-$50,00 CP issued for numerous violations involving (1) performance of maintenance, including electrical breakers, without appropriate tagging of the equipment to assure safety; (2) improper removal of tags that should have been maintained; (3) failure to adhere to written work orders or instructions. Examples:
A contractor cut into an energized 125 VDC l control cable because it was not tagged out;-
tagged out valves were repositioned while maintenance was still in progress; work performed on electrical equipment prior to assuring proper tag out; work performed without written procedures or instructions; performance of work activities without appropriate work authorization.
October 1994-a contractor ' electrical inadvertently cut into the wrong 4160 volt cable, it was fortuitous that the cable was de-energized at the time.
e PSEEG has expanded significant effort and resources over the last four years to improve salem's hardware, material '
condition, maintenance backlog, procedures, and personnel performance. There have been some notable successes in ,
several of the targeted areas, but overall, the facility has j shown little improvement in its overall performance.
- _ . = - _ _ - - - . - - -- . . . - -.
A 14 i
e In response to NRC concerns, PSE&G committed in July 1993 to reexamine events of several previous years from a broad l perspective and determine if additional corrective action was warranted. The resulting comprehensive Performance Assessment Team (CPAT) effort was completed in January 1994, and emphasized deficiencies in the management and leadership 1 of the Ealem organization, personnel performance, and corrective action processes. ..
]'
e During 1993 and 1994, overall performance declined. The
. units were subject to eight forced outages and eight
- automatic trips. A potentially fatal accident was i fortuitously avoided last October, when an electrical contractor inadvertently cut into the wrong 4160 VAC cable, j which had been de-energized for unrelated work. Both units have required frequent power reductions to perform repairs
- or replace degraded equipment.
- In July, NRC's pilot Customized Inspection Planning Process team inspection confirmed weaknesses in corrective action effectiveness and root cause analysis. Significant problems
- were found relative to the establishment and implementation i of maintenance programs and activities.
k The most recent SALP report, covering the 18 month period
( ending November 5, 1994, assigned ratings of "3" to the operations and maintenance functional areas. These ratings, a j
i were based on the accommodation of long-standing equipment or system problems, weaknesses in work control and M
A ,
g troubleshooting activities. The engineering functional area $
, i was rated "2" due,.in part, to inconsistent engineering
' support to resolve chronic plant system and equipment (
problems. The plant support functional area was rated "1".
An Operational Safety Team Inspection is planned for April-
) May 1995, with the intent of assessing the effectiveness of the licensee's improvement efforts.
i e We acknowledge the significant expenditure in resources and changes in the management, staff organization, and material condition'of the units that have been made. Notwithstanding these efforts, frequent and lingering problems have .
continued with equipment reliability and human performance.
As a result, we cc,ncluded it was necessary the Board of Director's views on the need for further improvements in facility and human performance.
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