ML20134K962
| ML20134K962 | |
| Person / Time | |
|---|---|
| Site: | Crystal River  |
| Issue date: | 10/31/1996 |
| From: | FLORIDA POWER CORP. |
| To: | |
| Shared Package | |
| ML20134K953 | List: |
| References | |
| PROC-961031, NUDOCS 9611200103 | |
| Download: ML20134K962 (45) | |
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CRYSTAL RIVER UNIT 3 MANAGEMENT CORRECTIVE i
i ACTION PLAN l
PHASE II (MCAP II)
Rev 0 Oct. 31,,36 9611200103 961112 PDR ADOCK 05000302 P
. 8 MANAGEMENT CORRECTIVE ACTION PLAN PHASE II Statement from P. M. Beard, Jr.
5 to Nuclear Operations Personnel This is the Crystal River Unit 3 (CR-3) Management Corrective Action Plan, Phase II (MCAP II).
It charts the course for bringing our plant to the standards the owners, regulators, and public expect and deserve. MCAP II will not be an easy l
task to accomplish. We have learned to live with and accept certain conditions and ways of doing business. Changing these ways, changing these conditions, and changing what we expect of ourselves and others, is what this document is all l
about.
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Safe plant operation is our first and foremost obligation.
The plant and its j
equipment must be operated in a manner that minimizes the potential for adverse safety consequences.
A cornerstone of safe operation involves conservative decision-making, practiced in all aspects of plant operation and management. Any potential problem related to safety must be promptly identified, evaluated, communicated, and resolved. Some recent issues have necessitated an examination of how well we are meeting this obligation.
As you are aware, several assessments have been conducted over the last few months.
These assessments were conducted by our staff, the Nuclear Pa;ulatory Commission, as well as teams of highly-qualified, experienced, nuclear industry professionals.
I have used these assessments to help me determine what needed to be fixed and, more importantly, whether the plant should be operated while we make the fixes.
I have evaluated these assessments and concluded that certain design and configuration issues must be resolved during our current forced outage in order-to assure that the plant will be operated with appropriate design margins while we make further improveinents.
How we got where we are today is useful only in pointing out what we need to do to improve and assure ourselves we won't repeat those mistakes tomorrow.
In my assessment of CR-3's past performance, I conclude that management was the key ingredient to the shortc aings. As you read this MCAP II document, it should be no surprise that many o' the corrective measures relate to enhancing management effectiveness.
I and my management team are committed to providing the leadership and management necessary to take CR-3 to the top.
There is one area that I particularly want to stress because it is so critical to the successful operation of a nuclear power plant.
I am referring to oversight.
At CR-3, as is the case at all nuclear plants, there are multiple groups that serve the purpose of monitoring all phases of the plant's performance. There is external oversight such as the NRC and INPO, and there is internal oversight such as QA, NGRC, PRC, and NSAT. While those responsible for CR-3's internal oversight activities cannot be blamed for the plant's shortfalls in performance, they can be criticized for failure to recognize and help assure 1
s they were corrected.
However, oversight organizations can not be effective if line management fails to respond appropriately to critical appraisals. There is some indication that this has occurred at CR-3.
Accordingly, I emphatically affirm that it is my policy to support the proper functioning and effectiveness of all internal oversight activities.
All levels of management will look upon oversight as a positive and benef'cial attribute and will respond accordingly.
For a number of reasons, some design argins of the plant are at a level where there is little or no flexibility to resolve emergent issues. We intend to aggressively address this problem.
As we restore the design margins of the plant, we will be putting in place an effective program which will ensure the margins and configuration are maintained.
There is no reason CR-3 cannot become the best plant in the United States.
Although it may take time, I am convinced we can rise to the occasion.
I encourage each and every one of you to work together.
If you think of ways to improve areas that are not being addressed, tell your supervisor.
If you don't think you are getting through, come and talk to me.
We need everyone to be a part of this program.
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. M. B ard, Jr.
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I.
Introduction and Overview:
This document is the Florida Power Nuclear Operations Phase II Management Corrective Action Plan (MCAP II).
It is the follow on plan to the Management Corrective Action Plan (MCAP) initiated in the Spring of 1995 to address specific performance issues arising from events that had occurred in late 1994.
l The Management Corrective Action Plan Phase II redirects improvement efforts to incorporate the results from numerous internal and external assessment and evaluation activities during 1996. The MCAP II identifies the root and contributing causes (barriers) to achievement of excellence, assigns responsibility to an appropriate management or supervisory level individual, and establishes completion dates for specific corrective actions to address the identified root and contributing causes. The original MCAP has been completed.
Several individual issues have been transferred to MCAP II for completion.
Further, where analysis of completed MCAP issues has indicated that previous corrective actions did not achieve the desired results, additional actions have been incorporated in MCAP II.
These are shown in Appendix A.
The MCAP II communicates management expectations and provides direction to the entire Florida Power Corporation Nuclear Operations Organization. It supports the fundamental " Performance Triad" of Safety, Production, and Cost. The MCAP II is predominantly directed at the safety aspects of the triad.
It is principally focused upon improvement of the safety culture of Crystal River Unit 3 using the broadest definition of safety culture.
Nuclear Operations line management has developed the MCAP II with two fundamental principles in mind:
(1) to identify the major issues and deficiencies in Crystal River 3's performance and to (2) direct action to resolve those deficiencies. The MCAP II consists of five major areas, all bearing directly on the safety culture, that were identified during the evaluation process:
Leadership Oversight and Involvement Configuration Management / Design Basis Regulatory Compliance Engineering Performance Operations Performance Specific root and contributing causes are identified within each area as are comprehensive action plans to correct the root and contributing causes.
Specific Managers and Supervisors have been assigned completion date and content accountability.
Measures of monitoring progress and effectiveness have been established.
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2.
Expected Results This plan begins the process of bringing Crystal River 3 into the community of top performing nuclear power organizations. It is a road map designed to provide the basic performance competencies which will permit rapid progress along that road.
It will provide the fundamental foundation to enable subsequent plans to complete the journey to excellence in all areas of the " Performance Triad."
3.
Planning Assumptions Several key assumptions guide plan development, including:
The overall objective is to reach (and maintain) top performance.
The planning horizon extends through the end of FY 97 (December 31, 1997).
The plan needs not only to address issues identified in assessments, it must also include strategic initiatives necessary to achieve the overall objective.
The plan assumes that necessary resources (people and money) will be avail able.
It includes resources required over present level of effort to accomplish goals.
Meaningful measures of effectiveness are required to monitor and communicate progress both internally and externally (e.g., NRC).
Continuous improvement on the part of industry is assumed in developing where CR 3 needs to be at the end of FY 97.
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a:\\ intro
l SECTION A 1.
Area of Concern and Management Sponsor:
Leadership Oversight and Involvement z
Sponsor:
P. M. Beard, Jr.
II.
Problem
Description:
Leadership oversight and involvement in plant issues has been inadequate in emphasizing its safety culture role.
This has occurred in areas.
ranging from communication and reinforcement of core values and expectations to site processes and priorities. Further, where assessments have been conducted, they have neither focused on elements from the safety culture perspective, nor have they been sufficiently self-critical to enable assessment of root or apparent causes.
III.
Present condition:
In response to plant events over the past two years, several initiatives have been implemented, including:
a.
Establishment of a formalized self-assessment and performance monitoring program.
b.
Restructuring the NGRC, including an annual review of the self-assessment program by the NGRC.
c.
Establishment of a Nuclear Safety Assessment Team (NSAT).
d.
Creation of a Management Review Panel (MRP) to review the effectiveness of a corrective action taken in response to more i
significant events (those involving
- NOVs, LERs, and other significant management concerns).
e.
Increasing the emphasis of on-shift oversight, including redefining the role of the Shift Manager and adding a position (Operations Manager) directly over the Shift Supervisor.
Despite these efforts, a difference in performance standards exists between CR-3 and INP01/SALP 1 plants in areas such as safety culture, procedural adherence, event investigation, root cause determination, sensitivity to operability issues, adherence to design bsses, QA organizational effectiveness, and implementation of the corrective action process for emergent issues.
These differences should have been determined through leadership oversight and involvement, but were not.
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i IV.
Corrective Actions to Address the Root Causes of the Problem:
The following are the root causes of the problem and the corrective-actions that.have been/will be taken to achieve top performance in leadership oversight and involvement.
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' Site leadership has not been effective in carrying out its safety culture role because it has not:
- 1. Clearly and consistently communicated and reinforced core values and expectations with emphas
- 2. Implemented site processes with appropriate emphasis on safety culture.
- 3. Established site wide priorities with proper emphasis on safety culture.
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- 4. Implemented balanced accountability with respect to safety.
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- 6. Established constructive self criticism and selfimprovement as an integral wyof doing business.
Corrective Actions:
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1 Action Target Responsible Completion Date A-RC1 1.
Conduct a Safety culture Index J. S. Baumstark 11/15/96 A RC-2.
Plan a Supervisor's workshop which J. S. Baumstark/
2/21/97 emphasizes:
R. C. Vridell a) Lessons learned from the Safety Culture Inder b) Manager / supervisor role in implementing a safety culture c) The relationship between accountability, authority, and responsibility
. d) Behavioral expectations related to a safety culture
. Explains the seriousness of the problem
. Explains the benents of self criticism -
. Provides positive reinforcement for self.
Identified criticism A.RC1-3. Conduct the Supervisor's workshop discussed in Mgmt. Team 3/28/97 2 above.
A RCl-4. Evaluate and revise mission statement, core J. S. Baumstark 12/6/96 values, and expectations with emphasis on safety culture; the evaluation will include a review by a cross functional / level team.
A.RCl 5. Establish site wide priorities which emphasize a Mgmt. Team 11/15/96 safety culture.
A-RC16. Independently assess the senior site management P. M. Beard 11/29/96 team and determine "best At* roles for carrymg out transition to the new safety culture.
A.RC17. Establish a self-critical view frota the top down P. M. Beard /
Continuing that accepts identification of problems and takes Mgmt. Team action to address them rather than rationalizing it away.
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Target Action Responsible Completion j
Date A RCl 8.
Communicate, advertise, coach, and constantly Mgmt. Team Continuing
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reinforce our Mission Statement, Core Values and i
Expectations down throughout the. organization.
- a. Advertise
- b. Establish performance standards in writing for each department Stand down to launch the program c.
- d. Directors and Managers recruit each individual l
(Core Values to a personal level and expectations to a job specine level) e.
Measure results f.
Conduct periodic reinforcement sessions with employees l
g.
Hold management sessions to discuss progress and problems i
A-RCI 9 Conduct human error reduction training R. C. Widell 12/31/96 for selected site supervisors (90).
A-RC1-10.
Conduct human error recognition and R. C. Widell 4/25/97 reduction techniques training for selected site workers (120).
A RC111. Ensure appropriate management level attendance Mgmt. Team continuing at NRC entrances and exits.
A-RC1 12.
Formally enhance the Operating Experience J. S. Baumstark 12/5/96 Review Program which identines emerging j
industry issues (both equipment and organizational & programmatic).
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Root Cause 2:
1 Excessive and ineffective organizational and programmatic changes have increased human error rates.
j Corrective Actions:
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ACTION RESPONSIBLE TARGET 0
COMPLETION DATE A-RC2-1 Develop a change management J. S. Baumstark 1/3/97 process for significant organizational and programmatic changes to include:
Communications plan including new standards expected.
Evaluation of personal / personnel impacts.
Workload assessment prior to and after the change.
Monitoring the effectiveness of the change.
Required training or re-training.
A-RC2-2 Monitor and control the number Mgmt. Team 1/3/97
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of significant organizational and Business programmatic changes being Plan implemented simultaneously.
Establish a policy to limit such changes to no more than 2-3 having significant impact on a single work group.
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l Root Cause 3:
An inadequate root and e.ommon cause analysis process inhibits management from addressing the right issues in the right priority.
Corrective Actions:
i ACTION RESPONSIBLE TARGET COMPLETION DATE A RC3-1 Redefine the corrective action J. S. Baumstark Nov.18,19%
process to include a single graded approach for development of root and apparent causes as well as corrective action plans.
I A RC3 2 Establish a core group ofin-depth J. S. Baumstark Nov.18,1996 root cause analysis experts.
A-RC3-3 Establish apparent cause J. S. Baumstark Nov.18,1996 reviewers in each line department.
A-RC3-4 Develop training package ori R. C. Widell Nov. 8,1996
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corrective action program changes for delivery by site supervisors.
i A-RC3-5 Conduct training for site Site Supe; visors /
Nov.15,1996 personnel on changes to Mgmt. Team corrective action program.
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Contributine Cause 1:
Inadequate performance monitoring and trending which inhibits proactive identification of emerging issues and results in an excessive number of investigations with little value added.
Corrective Action:
ACTION RESPONSIBLE TARCET COMPLETION DATE A-CC1-1 Establish centra!ized monitoring D. Wilder Feb. 28,1997 and trending of "real time" process performance indicators and repeat events / failures.
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.Contributine Cause 2:
Inadequate analysis of performance monitors has resulted in ineffective detection of adverse trends related to site programs, processes, and procedures.
Corrective Action:
ACTION RESPONSIBLE TARGET COMPLETION DATE A-CC21.
Establish a method for identifying D. Wilder Feb.28,1997 trends needing further analysis with respect to root cause.
Contributine Cause 3:
An inadequate feedback process has resulted in self-assessments not being controlled by the corrective action process and consequently, missed opportunities to improve.
1 Corrective Actions:
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ACTION RESPONSIBLE TARGET COMPLETION e
DATE A-CC3-1.
Establish standards for self-R. Yost Nov.18,1996 assessment performance.
A-CC3 2.
Formally incorporate results R. Yost (NOD-45)
Nov.18,1996 obtained thru self-assessments D. Wilder (CP-111) into the corrective action process for follow-up, tracking, and trending.
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Contributine Cause 4:
Inadequate adjustments (corrective actions) have resulted in frequent ineffective changes that may cause additional problems.
Corrective Actions:
ACTION RESPONSIBLE TARGET COMPLETION DATE A-CC4-1.
Establish standards for corrective D. Wilder (CP 111)
Nov.18,1996 actions which:
Ensure changes are a.
supported bj and directly relate to root cause analysis.
- b. Will reduce recurrence rate significantly and in a timely manner without creating another undesirable condition.
c.
Can be implemented within a management control.
- d. Are consistent with industry standards.
e.
Can be implemented cost-effectively.
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Contributine Cause 5:
1 The Quality Assurance process has not effectively communicated or followed up on issues.
q-Corrective Actions:
1-1 ACTION RESPONSIBLE TARGET 4
COMPLETION
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DATE i
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A-CC5-1.
Establish new management in J. S. Baumstark Completed QA.
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A-CC5-2.
Provide new guidance for the R. E. Yost Nov.1,1996 l
I conduct of audits.
l A-CC5 3.
Establish 18 to 24 month J. 5. Baumstark/
Dec.13,1996 rotational assignments in QA for R. E. Yost approximatley 30% of assigned positions.
A-CC5-4.
Recruit new talent for QA from J. S. Baumstark/
Jan.10,1997 both on-site and off-site assets.
R. E. Yost V. Measures of Effectiveness The following measures will be used to monitor progress and gauge the effectiveness of corrective actions in addressing the problem:
1.
Number of LERs attributable to human performance errors.
2.
Number of NOVs attributable to human performance errors.
3.
Self-identified issues on NRC plant issues matrix.
4.
Percent of violations that are not cited.
5.
Percent of problem reports that reflect a recurring problem.
6.
Number of CR-3 NOVs compared to regional / national NOVs (per unit).
7.
Number of CR-3 LERs compared to regional / national LERs (per unit).
au cito-si-96 9
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Appendix A Action Items Carried Over from Previous MCAP Submittals and Meetings i
l Section A:
Leadership Oversight and Involvement-1 Action Responsible Target Completion Date l
A-FU-1:
Management Continuing i
i Ensure applicable elements at the Team Event Free Operation Program continue to be a focus of the i
day-to-day way we do businers j
with emphasis on:
Direct observation of work in t
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progress Audits and surveillance i
Independent review group oversight (NGRC and PRC) i-A-FU-2:
J. S. Baumstark Sept. 26, 1997 Establish a single user-friendly action tracking system.
A-FU-3:
Management Jan. 31, 1997 Determine the most effective role Team for Issue Managers.
Coordinate this effort with establishment of responsibility for managing site Top 10 Priority elements.
D. Wilder May 1, 1997 A-FU-4:
Probabilistic Safety Analysis I
(PSA) - identify enhanced 4
applications.
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a.
I SECTION B ENGINEERING PERFORMANCE i
I.
Area of Concern and Management Sponsor:
The engineering department has not supported plant operations well, particularly in maintenance and application of the plant design basis.
Sponsor:
G.L. Boldt I
II.
Problem
Description:
The focus of the concern in engineering is primarily. on design and analytical work, configuration management, and teamwork with other departments.
The systems _ engineering area is generally perceived to be satisfactory, although some performance problems have been noted here too.
Overall, the engineering department has had an inconsistent record -of performance. Over the last several SALP periods it was rated SALP 3, SALP 2, SALP 2 (and IMPROVING), and SALP 1 only to decline back ~to SALP 2 in 1995.
Although inspection reports identify some engineering strengths, they are overshadowed by weaknesses in the following areas:
timeliness and accuracy of design and analytical support for plant operation, adequacy of regulatory correspondence, quality of 10CFR50.59 evaluations, planning and prioritization of work load, and maintenance / communication of the plant design basis.
III.
Present Condition:
The engineers were challenged to self-identify the key -factors contributing to the problems described above.
Their input is summarized below:
1.
For the first eighteen years of plant operation there was a heavy reliance upon A/E, contractor, and NSSS resources for performance of design activities.
Corporate engineering personnel served as project managers over these resources and were not intimately involved with the details.
As a result, there was ineffective technology transfer from the external resources to CR3 engineers.
2.
Ineffective management'of change within the engineering organization had a negative affect on its performance.
The combined effect of downsizing, relocation of corporate personnel to the Crystal River plant site, implementation of the business process improvement (BPI)
' recommendations to the design processes, and the reduction in reliance upon external engineering resources, negatively influenced 1
Otevision 0,10/31/96)
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i productivity and product
- quality, frustrated personnel, and increased engineering work backlogs.
The reduction in reliance in external resources, although recognized by all as a potentially positive move, was performed in a more aggressively than the FPC team was prepared to accommodate given the i
existing level of engineering knowledge and skills.
In response, several initiatives have been implemented over the last two years, including:
a.
Recombined systems engineering with design engineering, configuration management, procurement engineering, and engineering projects under a single engineering director.
b.
Increased management oversight within engineering by creating a new
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manager position and group to control engineering programs
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[ inservice inspection; new/ finite term programs (e.g. GL 96-01, j
setpoint verification, tank calculations); and continuing life-of-the-plant programs (e.g.
boron corrosion, erosion corrosion, maintenance rule, charcoal testing, and tendon inspections)].
c.
Increased teamwork among departments by:
Teaming operations and engineering personnel in calculation development, design inputs, and assessments of impact on documents and procedures, Teaming licensing, operations, and engineering personnel in system and equipment operability assessments, and 1
Implementing the use of Project Teams for conceptual design (alternatives), final design, construction, and startup of significant plant changes.
Despite these actions, developed as an integral part of the nuclear operation's Management Corrective Action Plan (MCAP) beginning in March of 1995, performance differences remain between CR-3 and SALP 1 plants.
The actions described above, dealt with symptoms in many cases rather than rootcause(s). To correct this condition, FPC teams working together with Failure Prevention Incorporated (FPI) conducted a structured root cause l
determination of the ' engineering performance problem.
IV.
Corrective Actions to Address the Root Causes of the Problem:
The following are the root and contributing causes determined by the FPC/FPI team along with the respective corrective actions to achieve top performance in engineering effectiveness.
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Root Cause 1
-An appropriate safety culture was not effectively emphasized.
As a result, activities were not given a level of safety attention commensurate with that given to-production or cost priorities.
This led to design basis concerns being primarily resolved through analytical means in lieu of physical means (such as plant modifications and equipment testing) directed at maintaining or improving design margins.
Corrective Action:
Responsible Target Action Manager Completion Date B-RCl
-1 Implement a " stand down" in Nuclear F. Sullivan Complete Operations Engineering to emphasize the importance of improving safety culture.
Stress the need to enhance safety sensitivity, i
quality, and attention to detail in the performance of 10CFR50.59 safety evaluations and the lessons learned from the recent USQ experience.
2 Institute an interim change to F. Sullivan Complete require 50.59 evaluations be performed for engineering activities in lieu of a screening evaluation.
This action is to remain in place until formal training and establishment of qualified reviewers for 50.59's are completed.
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i Corrective Action (cont'd)
Responsible Target Action Manager Completion Date 1
B-RCl j
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-3 Incorporate improved safety R. Widell Complete sensitivity into 50.59 evaluation training in the Technical Staff and Management continuing training curriculum.
-4 Hold a special meeting with N0E F. Sullivan Complete (design) personnel to further increase safety sensitivity to 50.59 reviews.
Use industry experience (FP&L, Cooper, and FPC) to reinforce the points made.
-5 Extend the current outage to FPC Management Complete achieve immediate, near term Team improvements in plant safety / design margins.
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-6 Evaluate personnel in managerial G. Boldt Interim and supervisory roles.
Engineering Actions Managers Complete
-7 Increase authorized engineering G. Boldt Interim staffing level.
Seek engineering Engineoring Actions talent from outside FPC that can Managers
- Complete, bring in fresh ideas, practices and Continuing i
increased design competency, to Hire
-8 Issue a directive to restore system G. Boldt Complete design margins primarily through physical means (modification or testing) as opposed to analytical means.
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(Revision 0,10/31/96)
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Root Cause 2 Insufficient. communication of management expectations - particularly with respect. to safety culture.
Corrective Actions:
I Responsible Target i
Action Manager Completion Date B-RC2
-1 Establish a clear departmental G. Boldt 12/31/96 mission statement with emphasis on plant safety, and a concise set of i
expectations for' engineering managers.
-2 Develop a department wide G. Boldt, 3/1/97 Administrative Instruction " Conduct Engineering of Nuclear Engineering and
- Managers, 1
Projects" and supporting Supervisors, instructions in each departmental and Work Group i
group to promulgate management Employee Teams expectations to each engineering employee.
-3 Communicate, coach, and continually G. Boldt, Interim-reinforce adherence to mission and Engineering Actions expectations through frequent Managers and Complete department wide meetings, balanced Supervisors accountability, and site wide teamwork.
-4 Establish and promulgate the top FPC Management Complete ten plant priorities for Nuclear Team Engineering and Projects.
-5 Ensure resources are provided to FPC Management Interim achieve quality engineering support Team Actions in for plant operations commensurate Progress with established priorities, goals, and expectations.
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(n vision o, 10/31/96)
Contributina Cause 1 i
Inadequate performance monitoring, trending, and self-assessment within engineering which precludes:
Early identification of equipment reliability problems.
Highlighting repeat failures.
Identification of organizational and programmatic issues.
j a
Corrective Actions:
Responsible Target Action Manager Completion Date B-CCl
-1 Establish an engineering tracking K. Baker 1/1/97 and trending program that includes:
Heasures of the resources needed versus workload (including that necessary to address
-MAR /REA/ precursor backlog).
i Organizational and Programmatic (0&P) indicators.
Equipment reliability, end-of-life, and repeat failure
-indicators (for human events and systems / components).
-2 Implement a program of engineering G. Boldt 1/1/97 i
self-assessments that detects and All corrects problems before the NRC, Engineering INP0, and other external agencies Managers do.
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Contributina Cause 2
)
Inadequate deviation analysis of performance indicators which results in ineffective detection of adverse trends related to O&P issues.
Corrective Action:
Responsible Target Action Manager Completion Date B-CC2
-1 Assure the tracking and trending of G. Boldt 1/1/97 measures and indicators established as All 1
corrective action for Contributing Engineering Cause 1 (above) are assessed by Managers engineering managers to uncover:
Adverse trends requiring increased management attention.
Potential common causes of both equipment and human performance issues.
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Contributina Cause 3 Inadequate root and common cause analysis process precludes engineering
-from addressing the right issues in the correct priority.
'I Corrective Action:
i NOTE:
Corrective action for this item is addressed under Root Cause 3 in Section A, Leadership Oversight and Involvement, of this plan.
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(Revision o, 10/31/96)
Contributina Cause 4 Inadequate communication among managers, supervisors, and engineering personnel which leads to:
Lack of common awareness of problem extent, Expended effort to resolve problems at too low a level in the organization, Focus on inappropriate priorities, Denial, or rationalization, of problem existance.
Corrective Actions:
Action Responsible Target-Manager Completion Date B-CC4
-1 Conduct a series of small group G. Boldt Complete meetings between the engineering director and.the engineering 3
personnel (no managers or-supervisors present) to discuss problems and ' concerns. Conduct a small group meeting G. Boldt Complete between the engineering director with engineering supervisors (no
)
managers or non-supervisors present to discuss problems and concerns).
-3 Increase the frequency of G. Boldt Complete engineering staff (manager level) meetings.
-4 Increase the use of engineering G. Boldt Interim stand downs and other all-hands Engineering Actions communication and training forums Managers Complete to communicate expectations and lessons learned from events.
-5 Increase formal and informal Engineering 4/1/97 opportunities for improving Managers horizontal communications at each level.
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V.
Measures of Effectiveness:
The following measures will be used to monitor progress and gauge the effectiveness of corrective actions in addressing engineering performance:
REA, MAR, and precursor backlogs Engineering resource needs versus workload Number of FCN's per MAR Number of engineering personnel changes (absolute and as a percent of total staff)
Number of significant, active 0&P changes with impact on engineering The number of precursors and problem reports that identify engineering problems as a percent of the total number of precursors and problem reports.
Repeat failures (human events and system / component failures) l l
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(Revision 0,10/31/96) l
Appendix A Action Items Carried Over From Previous MCAP Submittals and Meetings Section 8:
Engineering Performance Responsible Target Action Manager Completion Date B-FU
-1 Complete a manager level review and F. Sullivan 4/1/97 l
prioritization of all backlogged J. Terry REA's.
(other engineering managers as necessary)
-2 Revise Administrative Instructions K. Baker 4/1/97 and/or NEP's to capture the need to review design basis calculations and procedures when either document is changed.
-3 Complete the action plan for S. Powell Tied to CCHE resolution of Control Complex corrective Habitability Envelope issues.
action plan
-4 Complete corrective actions resulting K. Baker 5/1/97 from the self-assessment performed on Engineering interdisciplinary interaction in Managers engineering.
-5 Enhance.the use of lessons learned to K. Baker 4/1/97 improve performance in engineering.
Engineering Managers 1
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SECTION C CONFIGURATION MANAGEMENT AND DESIGN BASIS I.
Area of Concern and Management Sponsor:
Weaknesses have existed in implementing programs for maintaining plant configuration consistent with design basis.
Sponsor: Gary L. Boldt II.
Problem
Description:
The NRC's expectation, as contained in the commission's policy statement dated August 10, 1992, is
...the licensee will have current design documents and adequate technical bases to demonstrate that the plant physical and functional characteristics are consistent with the design basis, the
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systems, structures and components can perform their intended' functions, and the plant is being operated in a manner consistent with the design basis."
i FPC has not fully met this expectation. Weaknesses that have been identified include:
Discrepancies between the physical plant and design documentation.
Inaccuracies ih the technical content of design documents including incorrect assumptions and calculational errors.
Discrepancies between operational configuration (procedures) and the supporting design documentation.
Inconsistencies among design documents and between the design basis and licensing basis.
Examples of deficiencies in these areas have been documented by FPC and the NRC.
Some of these deficiencies date back to the original design of the plant.
We are concerned with the number and cumulative potential effect of these issues on continued safe plant operation.
The identification and resolution of these issues has impacted the workload and priorities of the entire nuclear operations organization, and in particular on engineering, operations and licensing.
FPC has had to operate in a reactionary mode to address these issues as they arose.
FPC's 10CFR50.59 process is also viewed as inconsistent and' examples of weak 50.59 reviews have been cited in NRC inspection reports and PRC reviews. A quality 10CFR50.59 process is reliant on readily available, consistent and accurate design information.
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-III.
Present Condition:
A number of actions have been taken. to. date which are focused on assuring future engineering design work is properly performed and all
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changes affecting plant design are appropriately documented.
These actions are as follows:
a.
Process changes have been implemented to correct weaknesses and eliminate problems from future work.
Positive controls have been added to assure modifications are not turned over to operations unless appropriate j.
procedures have been revised.
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A requirement to obtain an operations signoff on inputs and assumptions to calculations has been implemented.
A requirement for engineering u review and sign off changes f
to the Emergency Operating Procedures has been implemented, b.
A review of the potential cumulative effect of design basis issues i
on plant safety has been completed.
c.
A ' review of the plant Emergency Operating Procedures has been F
completed to assurefthe accident mitigation strategies utilized i
have a complete and accurate technical basis.
o d.
The modification process has been revised to incorporate Project Teams to assure all groups within nuclear operations have input to the project design and can more readily assess impact of the project.on their area.
e.
Utilization of the precursor card process has been increased for documenting and resolving configuration and design issues.
f.
Design Review Panels are formed to review large modifications and provide a critical, questioning assessment of the design to assure all design requirements have been addressed and the design impacts are reasonable.
The above efforts are primarily forward looking, ~and FPC remains challenged to complete focussed reviews of past design efforts (including the original plant design / basis).
Some problems were also identified by the NRC IPAP. team with more recent engineering work. This has indicated that FPC may have taken actions based on treating symptoms rather than the root.cause(s) of the problems.
For this reason, FPC i
formed a team to apply the methodolgy of Failure Prevention Incorporated l
(FPI) to determination of the root and contributing causes of the configuration maragement-design basis concern.
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IV.
Corrective Action to Address the Root Causes of the Problem:
The following paragraphs describe the root causes, contributing causes, and corrective actions to address them to achieve top performance in 4
management of plant configuration and design basis 1
documentation / understanding.
Root Cause 1 Limited emphasis on nuclear safety culture in relation to more traditional production priorities, such as capacity and cost, resulting in:
Inadequate design margins that have not been addressed.
Limited definition, documentation, and on-site understanding of the plant design basis.
Lack of comphrehensive plant configuration controls.
Lack of networking with other B&W plants to maintain consistent designs / design margins.
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1 Corrective Actions:
Responsible Target Action Manager
_ Completion Date C-RCl
-1 Esu blish an Independent Design P.M. Beard Complete Review Panel (IDRP) to review the cause and extent of CR3's design basis problem.
-2 Complete review, approval, and FPC Management 12/31/P7 disposition of the IDRP final Team report recommendations (to be included as Appendix B).
4
-3 Improve nuclear safety culture.
FPC Management See 1
' NOTE: This issue is being addressed Team Sections A i
as an integral part of Leadership and B of Oversight and Engineering This Plan Performance in Sections A and B of this plan.
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-4 Extend the current forced outage to G. Boldt
' Completion i
improve selected system design tied to end j
margins by physical plant of the modification or equipment testing.
forced l-outage
-5 Develop and implement longer lead G. Boldt Completion time plans to further improve plant tied to end design margins and restore of Refuel consistency with " typical" B W 11 j
plant configurations in Refuel 11.
-6 Establish a clear understanding of K. Baker 4/1/97 i
- what constitutes the plant " design F. Sullivan basis" which is consistent with industry standards and regulatory expectations.
Then promulgate
~through plant procedures and training.
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CorrectiveActions(cont'd):
Responsible Target Action Manager Completion Date fr..B.C.1
-7 Establish a comprehensive K. Baker 6/30/97 management control process for F. Sullivan the design basis'which includes requirements for:
Implementation (how to)
Maintenance Training and qualifications Reportability/ operability Prioritization/ timely action
-8 Coordinate future design basis P. M. Beard Continuing issues through the B&W Owners R. Widell Group.
Contributino Cause 1 Inadequate self assessment which precludes comprehensive, proactive identification and resolution of design basis issues.
Corrective Actions:
Responsible Targat i
Action Manager Completion Date C-CC1
-1 Conduct a comprehensive failure J. Maseda Prior to modes and effects analysis (FMEA) restart of LOCA, LOOP, and loss of DC Power from the scenario (s).
current forced outage
-2 Include SSFI style self-assessments G. Boldt Each year of safety significant systems in through the next five CR3 annual plans.
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i V.
Measures of Effectiveness:
The following measures will be used to monitor progress and gauge the effectiveness of corrective actions in addressing the configuration management-design basis concern:
The number of precursors and problem reports that identify discrepancies in the design basis as a percentage of all precursors and problem reports.
The number of design basis LER's compared to industry benchmarks and the trend in this measure.
Age of design basis calculation reviews.
Number of operator work-arounds created by design basis issues.
Feedback from operability /reportability review teams.
The number of completed and open IDRP recommendations.
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SECTION D REGULATORY CONPLIANCE I.
Area of Concern and Management Sponsor:
Regulatory Compliance Sponsor:
Larry Kelley II.
Problem
Description:
Crystal River Unit 3 (CR-3) does not have a sufficient understanding of NRC regulations and does not assign full compliance with the intent of NRC regulations a sufficiently high priority.. Also, there appears to be a perception that conservative decision making regarding regulatory issues is seen as secondary to plant availability.
This is supported by the following specific concerns:
A. Examples of failure to report or untimely reporting of events or conditions.
B. Examples of questionable interpretations of the regulations by both licensing and.non-licensing personnel.
C. Examples of not meeting commitments made in licensing correspondence.
D. Examples of questionable or incorrect technical information provided in NRC submittals.
III.
Present Condition The licensing organization has been modified to infuse knowledge and skills from other areas of Nuclear Operations into the department.
The Assistant Director, Site Support position was created and filled by the former operations manager. This new position is dedicated to interfacing with the resident inspectors, facilitating NRC inspections, and developing licensee event reportsmand. violation responses. This dedicated resource has improved the ability to identify and respond to regulatory issues in a more. timely manner.
Nevertheless, the regulatory interface in some areas of the organization is still inconsistent and more reactive than proactive.
The Manager, Nuclear Licensing was previously a supervisor in the ' design engineering organization. This experience has improved the capability of the licensing department to review the.. technical information in NRC submittals and more fully -participate in design basis issues and q
operability evaluations. The focus of this position is on managing the NRR interface, preparing all licensing submittals (except those noted above) and. supporting teamwork 'throughout Nuclear Operations.
- However, additional improvement is necessary in at least two aspects of licensing submittals:
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- 1. Technical quality of submittals, which will require 15.a organizations to take more of a front-end ownership role in submittals for which they provide the technical input.
- 2. More timely and accurate root cause analyses to support LER development.
It is also apparent that the knowledge of regulations and of the general regulatory process is not to the necessary level in the other departments.'
To facilitate spreading this knowledge to the other organizations, the previous Licensing Manager was transferred to Operations Support to provide the benefit of his experience to the procedure writers group and Operatio,ns Manager.
Additionally, a three-day training course on the regulatory process is being offered to all managers and supervisors in Nuclear Operations. The training course provides the information needed for non-licensing management to understand the foundation for the regulatory process. We expect a better understanding of the regulations i
and associated requirements governing nuclear power plant operation. This will result in improved compliance and reinforce the expectation that compliance is a fundamental aspect of nuclear safety, j
Additional emphasis needs to be given to internal prmesses that assure regulatory compliance.
For example, the safety evaluation process must include regulatory compliance as a necessary condition for acceptance of an alternative.
The processes that maintain the current licensing basis must have the proper checks and balances to ensure changes are consistent with the regulations.
Also, processes that do not directly change the i
current licensing basis, but deal with the decisions and implementing documents used in the plant, must likewise have the checks and balances to ensure activities are performed within the proper authorization of the licensee.
IV.
Root Causes, Contributing Factors and Corrective Actions The following are the root and contributing causes determined -by the FPC/FPI team along with the respective corrective actions to improve regulatory compliance throughout the CR-3 organization.
Root Cause 1 Inadequate communication of management expectations and priorities with respect to safety culture and regulatory compliance resulting in:
FPC positions on some regulatory issues not meeting the safety intent of regulations.
Regulatory compliance not being considered pro-actively and with high priority when dealing with site activities.
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- A perception by personnel that regulatory requirements should be addressed only from a perspective of minimum cost.
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Inadequate and inconsistent explanations of technical issues to the i
NRC.
Imprecise or unclear commitments to the NRC.
Corrective' Action Root Cause 1:
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Action r.esponsible Target
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Manager
. Completion Date 1
D-RCI-1.
Establish a safety culture from the top P. M. Beard Dngoing down that clearly understands and values the relationship between safe plant operations and regulatory compliance, j.
D-RCl-2.
Train managers and supervisors on the
- 8. Gutherman 12/31/96 elements of achieving and maintaining regulatory compliance and its priority in plant activities.
l D-RC1-3.
Establish a method which will identify
- 8. Gutherman 12/31/96 early on issues with regulatory impact and ensure these issues are appropriately integrated into site priorities for resolution.
D-RC1-4.
Develop a site issue integration matrix G. Halnen 12/31/96 that parallels the NRC Resident's matrix. Make comparisons to ensure i
accuracy.
4 D-RC1-5.
Conduct a third party facilitated self-
- 8. Gutherman 12/31/96 assessment of Licensing, d
0-RCl-6.
Benchmark key regulatory processes against SALP 1 plants and revise processes as necessary:
- Safety Evaluation Process (Al-400C, G. Boldt/G.
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NEP-210)
Halnon
- Maintaining of Current Licensing
.L. Kelley 2/28/97 Basis Process (N00-11, 52) e Conduct of the On-Site Safety Review G. Halnon 12/31/96 Canalttee (Al-300) e FSAR Update Prncess (NL-7)
- 8. Gutherman 12/31/96
- Operability Process (CP-150)
R. Davis 2/28/97 4
- Reportability Process (CP-111
- 8. Gutherman 12/31/96 presently) i s
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Root Cause 2 Inadequate performance monitoring and trending from a regulatory compliance perspective which preclude:
Focussing on the right issues in the right priority.
Obtaining first-hand information on issue content and sensitivity.
Obtaining real-time information on emerging issues Effective implementation of the safety evaluation process.
Corrective Action:
Action Responsible Target Completion Manager Date D-RC2-1. Ensure a Licensing B. Gutherman Completed representative is part of the graded precursor screening team to provide regulatory perspective to the corrective action program.
D-RC2-2. Assure appropriate G. Boldt 11/1/96 levels of management L. Kelley meet with the SRI on a B. Hickle weekly basis at his convenience for open, candid communication.
D-RC3-3. Identify and monitor L. Kelley/
2/28/97 emerging industry J. Baumstark issues in the regulatory area using the CR-3 monitoring / trending program.
D-RC4-4. Provide periodic case B. Gutherman On-going on a studies of regulatory periodic basis issues and events, both internal and external, to help provide parallels to CR-3 experiences.
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Contributina Cause 1:
Inadequate root cause/ common cause analysis process which precludes resolution of long term, high visibility regulatory issues.
Corrective Actions:
See corrective actions for Root Cause 3 of Leadership Oversight and Involvement section.
l V. Measures of Effectiveness:
The following measures will be used to monitor' progress and gauge the effectiveness of corrective actions in addressing the problem:
Safety Performance Index CR-3 Violations vs. Region II Average Ratio of Non-Cited / Total Violations Ratio of Strengths to Strengths + Weaknesses
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i Appendix A Action Items Carried Over from Previous MCAP i
Submittals and Meetings l
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i Section D:
Regulatory Compliance i
Action Responsible Target Completion Date D FU 1 Review the CR 3 50.59 Program and associated B. Gutherman 2/28/97 processes to ensure it is consistent with the 50.59 rule, industry guidance, and j
j current regulatory feedback.
1 D FU-2
. Review the FSAR system chapters and compare G. Halnon 3/1/97 the description information to the foplamenting plant documents to ensure they 4
are consirtent.
D FU 3 Provide training to managers and supervisors B. Gutherman 12/31/96 on the overall regulatory process.
Customize course for 3 days of training by outside professionals with regulatory 1
expertise, facilitated by in-house Licensing personnet to answer plant specific j
questions.
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l SECTION E OPERATIONS PERFORMANCE I.
Area of Concern and Management Sponsor:
Operations Performance /B. J. Hickle II.
Problem
Description:
The Operations Department has not attained a level of performance equivalent to those measured as excellent by INP0 and the NRC.
Recent outside and internal audits have detailed several areas in need of improvement in order to attain operational excellence, i
III.
Present Condition:
Although Operations has some noted strengths such as the conduct of shift turnovers, the use of STAR by control board operators and the use of alarm i
response procedures, additional effort is needed to address areas needing improvement.
A number of initiatives have been undertaken since March 1995, as part of MCAP I and in response to the MUT event to address these 4
areas.
These have included:
Implementation of the Event Free Operations Program.
Establishment of a mentoring program for NSS's and individuals selec+,ed for the SRO upgrade program.
Creation and staffing of a work controls position for day shift.
Creation of an additional level of management to improve management oversight of day to day operations; especially in the control room.
Additional staffing with seven engineers including outside hires to infuse new talent into the Operations Department.
Performance of an outside team self-assessment to enhance operators questioning attitude and self-critique behaviors.
Notwithstanding these efforts, some problem areas have not been fully corrected as evidenced by:
Component mispositioning events.
Failure to follow procedure events.
Inconsistent log keeping practices.
Failure to properly self-identi fy mistakes with the problem reporting process.
Consequently, MCAP II actions to address root and contributing causes of Operations problems have been developed as described in the following.
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IV.
Corrective Actions to Address the Root Causes of the Problem:
The following are the root and contributing causes with the corrective actions to upgrade Operations performance.
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Root Cause 1 Inadequate implementation of established standards.
Supervision has not consistently reinforced operating standards and this has resulted in:
- 1. Challenges to plant safety.
- 2. Inadequate work practices.
- 3. Failure to follow operational and administrative procedures.
i Corrective Actions:
Action Responsible Target Completion Date E RC1 1 Present a two hour class in Event Free R. W. Davis 10/31/96 operations which focuses on safety culture to all shifts, specific items to be covered included: self disclosure of problems, the need for self-assessments, conservative decision making, importance of increasing margin of safety and the fuel handlfr3 event from 10R.
E RC12 Develop and implement a recurring training J. Lind 6/30/97 class on Event Free operations with a major focus on safety culture and self assessment to be given annually to NLO's, RO's, SRO's and Operations management. Special attention will be t'ven to the need to be self-critical, self disclosing, and to do self assessments.
E RC13 Develop and implement a scheduling / tracking R. W. Davis.
11/30/96 program that will ensure increased management observation of daily shift activities.
E RC14 Develop structured program for benchmarking R. W. Davis 12/31/96 by Operations personnel to ensure awareness of current industry best practices.
E RC15 Develop structured and recurrent program for D. Kurtz 12/30/96 self assessment.
E RC16 Ensure administrative procedures are included J. Lind 12/31/96 in required reading program and in the licensed operator requalification program.
E RC17 Fine tune performance indicators which will R. W. Davis 12/31/96 monitor shift to shift performance consistency.
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Contributina Cause 1:
Inadequate resotu es within Operations.
CorreQXxAcLM my is + a
- Action Responsible Target 1
Completion Date E CC1 1 Recruf t six deereed SRO's for the purpose of R. W. Davis 11/30/97 (or providing an STA/SRO Work Control Supervisor completes STA to each operating shift. This will allow the training)
NSM to asstne Emergency coordinator responsibilities full time and allow the Shift Supervisor to focus solely on connand and control of operating crew.
E CC12 Reduce the operating procedure backlog to less R. W. Davis 12/31/97 than 25 outstanding consents through the use of contract prc:edure writers.
E CC13 Improve operations ability to stoport R. W. Davis 3/31/97 Engineering by adding additional resources to Operations Engineer section.
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E CC1-4 Reduce the abnormal procedure backlog to less R. W. Davis 12/31/97 than 10 outstanding connents through the use of contract procedure writers.
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.i E CC15 An Instant SRO class is in progress with seven R. W. Davis 6/30/98
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(7) candidates.
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4 Contributina Cause 2:
Vague and unclear operating expectations or standards have resulted in operating short falls.
Corrective Actions:
Action Responsible Target Completion Date E CC21 genchmark through plant visits and INPO R. W. Davis 12/31/96 contacts, those plants noted for strengths in clear, concise expectations and standards.
E CC2 2 Review and revise operations adninistrative R. W. Davis 3/31/97 procedures to reflect the information gained through benchmarking.
E CC2 3 Ensure operations standards reflect the core R. W. Davis 12/31/96 values and principals for conducting business of Nuclear Operations.
Contributina Cause 3:
Inadequate root and common cause analysis resulting in management failure to address the right issues with proper priority.
Corrective Action:
E-CC3 See Management oversight and involvement.
Contributina Cause 4:
Inadequate performance monitoring and trending which precludes proactive identification of emerging issues.
Corrective Action:
E-CC4 See Management oversight and involvement.
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Measures of Effectiveness:
1 The following measures will be used to monitor progress and gauge the effectiveness of corrective actions in addressing the problem:
Procedure Compliance Indicator i
Precursor Cards by Shift Watch Station Appraisals / Shift j
Component Not in Expected Position-1 l
Number of Weaknesses, Violations, and LER's i
RAD Dose / Shift TPM Signoffs/ Shift
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d Appendix A Action Items Carried Over from Previous MCAP Submittals and Meetings Section E: Operations Performance f
Action Responsible Target completion Date A FU 1 Nuclear Shif t Supervisor (NSS), targeted NS$s, R. W. Davis Continuing and SR0 upgrade mentor program established.
A FU-2 -Implesanted NSS annual performance goals that D.deMontfort 12/31/96 address weaknesses identified by FPC/NRC/INPO.
A FU 3 Address att identified E0P weaknesses.
G. A. Becker 11/30/96 f
A FU 4 Operations weaknesses are evident in work R. W. Davis 12/31/97 practices outside the control room, self-critical attitude, and operating procedure backlogs. Operability assessments require increased sensitivity.
A FU-5 Mentor Program meetings are continuing, R. W. Davis continuing mentors receiving more frequent communications from operations personnet regarding on shift i
concerns.
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