ML20134P371
| ML20134P371 | |
| Person / Time | |
|---|---|
| Site: | Zion File:ZionSolutions icon.png |
| Issue date: | 02/18/1997 |
| From: | COMMONWEALTH EDISON CO. |
| To: | |
| Shared Package | |
| ML20134P334 | List: |
| References | |
| NUDOCS 9702250392 | |
| Download: ML20134P371 (20) | |
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- Independent SelfAssessment Team i
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An Assessment of Zion Nuclear Power Station 4
An Independent Self Assessment l
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Febro.ary 18,1997 5
9702250392 970219 ADOCK 0500 PDR p
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0-Mr. liarold W. Keiser Vice President, Chief Nuclear Operating Officer i
1400 Opus One, Suite 900 Comed Company Downers Grove, Illinois 60515
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Dear liarry,
t We are pleased to have completed your request for an indepen&nt assessment of the perfonnance at Zion Station. The results of our assessment are summarized in the enclosed report, and respond j
to your request that we identify the fundamental causes or " whys" that drove declining perfonnance.
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We appreciate the spirit of openness, cooperation and interest shown by Comed personnel with j
whom we interacted during the course of the assessment. We acknowledge Comed management for steadfastly maintaining our independence and their commitment to critical self assessment.
j Vie decision to subject Zion Station and the Nuclear Operations Division to an independent self
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assessment is an aggressive and credible step toward your goal of sustaining superior performance.
We believe that the aggressive actiom you have begun will address the fundamental causes that our assessment identified. We wish you the utmost success in those efforts.
Sincerely, Die Independent Self Assessment Team
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Warren FujiniIito/ eader
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9 1.0 INTHODUCTION 1.1 Obiective ofIndependent Self Assessment he Independent Self Assessment Team (ISAT) was assembled at the request of the Chief Nuclear Officer of the Comed Nuclear Operations Division (NOD). The Independent Self Assessment (IS A) was led by a core group of seven senior nuclear consultants extemal to the Comed organization, who were requested to conduct an independent assessment of performance at Zion Station (Zion). The assessment was intended to provide Comed management with an
. independent persp ctive on major perfonnance weaknesses, with particular emphasis on the fundamental causes of those weaknesses. De ISAT was also invited to provide insights conceming the effectiveness of ongoing and planned Comed initiatives to improve identified perfonnance issues and to recommend post-assessment steps.
1.2 Methodolony and Standards for Assessment m
He ISAT assessed performance at Zion over the past two years in live functional areas:
Operations and Training, Maintenance, Engineering and Technical Support, Plant Support, and Management and Organization. The ISAT's assessment process consisted of three phases, in Phase 1, over a three week period, the core team perfonned a detailed review of existing i
perfonnance monitoring and assessment documentation. Rese documents included, but were not limited to, NRC inspections, evaluations, and Comed assessments, corrective action documents and perfonnance improvement plans. Essentially all of the weaknesses described in this IS A report were identified in these documents.
In Phase 2.
r a two week perial, the ISAT verified the Phase 1-identified weaknesses based upon Zion..arvations. Interviews and funher document reviews. The core team mernbers were augmented by INPO and industry peers in connection with the Phase 2 work.
In Phase 3, over a two week period, utilizing the results of Phases I and 2, associated causal factors for Zion weaknesses in four functional areas (operation, maintenance, engineering and plant support) were documented by the core team (Attachment A). A set of fundamental causes were then devek> ped for the assessment of management and organization.
As the assessment proceeded, the ISAT determined that it would deliver maximum value by concentrating on the perfonnance weakneues and the underlying causes. The ISAT's emphasis was placed on problem definition and idcntification of fundamental causes, rather than corrective actions. Consequently, the ISAT did not nrus upon the effectiveness of ongoing and plarmed improvement initiatives. The ISAT acknowledges that many corrective actions were in the process of being developed, and some were already implemented, to address Zion weaknesses.
De ISAT did not conduct detailed assessments of the perfonnance of the oversight and assessment functions within the Comed nuclear organization, nor did it assess the perfonnance of the regulatory assurance functions at Zion. In the context ofits integra ed review of Management and Organization, the ISAT examined the end results and effects of the Comed oversight and assessment functions. Those end results and effects are dest ribed in the Fundamental Cause Assessment in Section 3 of this report.
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j Die IS AT's standard for assessment of perfonnance reflected its collective experience and was intended to represent the performance of a best-perfonning plant. Unless otherwise specifically stated, this standard applied to all phases of the ISAT assessment. Die ISAT focused on the end results of NOD decisions. The ISAT did not attempt to define the specific actions that Comed management should take to assure safety, regulatory compliance or best-performance.
i Die ISAT did not reevaluate Comed's historical decision making processes or the conditions under which decisions were made. Vic ISAT placed emphasis on communication of observations and causal factors to assist Comed b understanding and accelerating its efforts to resolve the issues which are critical to achievemerit of sustained excellent perfonnance at Zion.
1.3 Assessment Team Membership and Composition t
'Ihe core members of the ISAT and their respective assessment responsibilities and backgrounds are; MemtKI Assessment RcSnonsibility
Background
Warren Fujimoto Team Leader and Management Fonner Vice President and Organization Pacific Gas & Electric Co.
Diablo Canyon 28 years nuclear power experience liarry Kister Management and Organization Fonner USNRC, Region I,111 and lleadquarters I&E 36 years nuclear power experience John Durham, P.E.
Engineering and Technical Fonner Engineering Manager Support impell Corp.; Carolina Power &
Light 23 years nuclear power experience Dr Benjamin Dow Engineering and Technical Former Manager Nuclear Services, Support Arkansas Power & Light 23 years nuclear power experience C.W. llendrix, Jr.
Maintenance Duke Engineering Services, Manager of Maintenance Engineering Services 25 years nuclear power experience Fred Dacimo Operations Former Operations Vice President, Northeast Utilities 20 years nuclear power experience John Sieber Plant Support Former Senior Vice President and Chief Nuclear Officer, Duquesne Light Company 36 years nuclear power experience 6
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fr The core IS AT members were augmented by INPO evaluators arv.1 industry peers, as follows:
AlcmentedIcam Personnel Assessn1cnt Resrxmsibility Oruanizational Affiliation L. Thibault Management & Organization INPO Vince Roppel Maintenance INPO Mike Ballard Engineering INPO George Northcutt Operations INPO Jose Ritter Management & Organization INPO Jim Varxlergrift Maintenance Entergy - ANO Bob Azzarello Engineering Entergy - Waterford John liesser Engineering APS - Palo Verde Joe Waid Operations Entergy - ANO Bob Gillespie Operations D.C. Cook The ISAT received support from Jim Abel, JoEllen Bums and Bill Fitzpatrick of Comed, who setved as liaisons to the line organization arx! were instrumental in gaining pnnnpt access to infomiation, documents arxi individuals.
2.0 FUNCTIONAL AREA CAUSAL FACTORS The ISAT's supporting observations and causal factors for operations, maintenance, engineering and plant support are summarized below.
2,1 Operations and Trainine The IS AT fourxl that models for arx! definitions of conservative operations decision making were not in place ark! nonconservative decisions were observed. Management accepted low standards, manifested in tolerance of deficient conditions and a lack of operational excellence toward improving performance. Training was not used to deliver and reinforce expectations, communicate standards of perfonnance, or prepare operators for organizational change.
Operations management has not maintained an active ownership of training. Operations did not have an understatuling of and a commitment to the principle that strong economic perfonnance must be driven by operational excellence. The ISAT observed a lack of bargaining unit buy in to management expectations and operational excellence, inhibiting improved performance.
2.2 Maintenance Weaknesses within the maintenance organization can be attributed to issues related to the work control process, preventive maintenance program, maintenance department management, and change management. The work control process has been hampered by an ineffective scheduling process ni an inability to manage emergent work, which are attributable to implementation of changes to the work control systems without a fully integrated change plan. Preventive i
maintenance (PM) effectiveness has been limited because management has not viewed the PM l
program as the key factor in maintaining plant system and equipment availability and reliability.
l Maintenance management has neither clearly and consistently communicated expectations and starxiants, nor implemented effective performance measures. Personal accountability for j
problem identification and resolution has not been emphasized. Maintenance and bargaining i
unit leadership have not recognized that in order to achieve excellent performance they must work as a team to acktress long-starnling issues. Changes to processes, procedures and practices have not been supported by effective action plans, standards of performance, bargaining unit buy in, accountability and first line supervisors functioning as change agents.
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.i or 2.3 Ennineering and Technical Suonort Engineering has not effectively addressed long-standing issues in the areas of work management, system engineering, work quality, equipment performance, materiel corxtition and configuration management. Effective work management has been limited by work backlogs, ineffective screening and prioritization, and resource constraints. System engineering has lacked the resourtes, experienced personnel and training to effectively implement the system engineering function. Past engineering arxl safety evaluations have often been noted as inadequate. Long-standing materiel condition and equipment problems have resulted from resource limitations and untimely corrective action. Design and licensing basis documentation has not been completely defined, updated, and consistently maintained. Zion engineering has not always functioned effectively as the design authority and technical conscience of the station.
2.4 Plant Support ne plant support orgardzations, which consist of radiation protection, chemistry, fire protection, security arxl emergency planning, have generally perfonned their assigned responsibilities adequately. Weaknesses were noted in the areas of collective worker radiation exposure, contaminated plant areas, radiation protection perfonnance monitoring and fim protection materiel condition.
3.0 FUNDANIENTAL CAUSE ASSESSNfENT-N1ANAGENTENT AND ORGANIZATION Upon completion of the Phase I and 2 reviews, the ISAT team conducted a review of the causal factors for operations, maintenance, engineering and plant support, and conducted a fundamental cause assessment for the management and organization functional area. Four fundamental causes were evident from the analysis of the causal factors: commitment to excellence, leadership, standards ant!
management skills. Under each of the fundamental causes, the core team identified a set of contributing causes. He fundamental and contributing causes are stated below.
3.1 Commitment to Excellence Comed has not consistently maintained focus on the vision of world class perfomiance and a commitment to the principle that stmng economic performance must be driven by excellence in nuclear operations and uncompromising safety. He following factors contributed to this fundamental cause:
Dere has not been sufficient and consistent appreciation of the resources needed to achieve arnt sustain long-term best-plant performance. An overemphasis on budget control has resulted in decisions that have hindered or eliminated important improvement projects.
The organization has not continually pursued a safety culture ahead of production and budgets. Pnx!uction and budget incentives appear to drive the organization.
3.2 Leadership i
Senior management has not consistently provided the leadership to achieve excellence in nuclear operations and safety. The following factors contributed to this fundamental cause:
Leadership has not always fostered an environment that promoted high standards, shared values, personnel accountability and conservative decision making.
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Improvement initiatives have not resulted in sustained performance improvements and
- management has not been held accountable for results.
- Accountability has not been consistently understood, practiced or enforced. Accountability often appears to mean discipline to the organization. To many employees, accountability is perceived as punishment rather than coaching and communicating high stmxlants and i
expectations.
Training programs have not routinely been viewed as a means to effect change and obtain results. There has been eiack of appreciation for the benefits that training provides.
Training has not been continuously evaluated and updated.
leadership has not always been able to gain bargaining unit ownership and commitment to
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nuclear operations excellence.
3.3 Standards Senior NOD and Zion management have not established consistently high standards of perfonnance. Standards have been accepted by management that result in a tolerance of deficient conditions and nonconservative decisions. De following factors contributed to this fundamental cause:
Corrective actions at times have been slow, narrowly focused, deferred or incorrectly prioritized to resolve important process, materiel cornlition and configuration management issues.
Engineering has not routinely been camsidered as an essential function for the safe and reliable operation of the station and, themfore, resources have not been provided to correct long-standing issues.
The operations department has not fully assumed primary leadership in assuring the safe operation of Zion.
3.4 Mananement Skills Re nuclear organization did not have the required management skills to impmvc substandant performance, to monitor and continue improvement efforts and to implement sound oversight programs. Senior management did not have a good understanding of the significance and depth of issues at Zion. The following contributed to this fundamental cause:
l Nuclear oversight organizations have not effectively evaluated the available infonnation on plant performance and have not been forceful in irlfluencing constnictive management actions forimproved perfonnance.
The budgeting prioritization process has not supported activites for improving station perfonnance. Zion was given an annual budget amount to plan work for the year, rather than planning the work for the year and then acquiring the necessary funds.
Lessons leamed were frequently not communicated, implemented and monitomd within the nuclear organization.
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Numerous personnel changes have contributed to instability and distrust, which has hindered I-upward communication and delayed resolution of important issues. As a result, personnel n
i changes have often not resulted in performance improvement, Management personnel selection did not always match a candidate's skills and experience 4
l with existing station performance issues.
Change management has been more like a trial and error process rather than a process which is planned, implemented, evaluted and adjusted,~as necessary. There has been a lack of
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understarnling of what it takes to effect change, including the buy in of personnel.
4.0 CONCI,USION This report provides a brief summary of the ISATs firulings. The IS AT's intent is to provide sufficient detail in its description of the fundamental cause assesseent arxl the functional area causal factors j
(Attachment A) so that Comed management can formulate reponsive and effective remedial actions.
The ISAT acknowledges the excellent cooperation it received fr im all elements of the Comed organization. In acklition, the ISAT recognizes Comed management for understanding the need for an indeperklent self-assessrnent,inaintaining die independence of the hxtependent Self Assessment (ISA) and j
sustaining their commitment to the pursuit of vigorous self-criticism.
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ATTACHMENT A ZION INDEPENDENT SEI.F ASSESSMENT CAUSAI, FACTOR
SUMMARY
2.0 FUNCTIONAL AREA CAUSAL, FACTORS The following discussion summarizes the causal factors derived by the ISAT for each of the functional areas of operations, maintenance, engineering, and plant support. As indicated in Section 1.2 of the ISA report, the ISAT's standard for assessment of perfonnance reflected its collective experience and was intended to represent the perfonnance of a best-perfonning plant. The ISAT's documentation review was generally focused upon the past two years and its obscwations were of current perfonnance. The IS AT did not reevaluate Comed's historical decision making process or the conditions under which decisions were made. In addition, the ISAT was directed by Comed management to identify issues and make critical observations using a low evidentiary threshold. In other words, Comed management did not expect the ISAT to definitively demonstrate the existence, frequency or breaddl of a particular problem.
Instead, when the ISAT's obsenation and experience indicated the likely existence of a particular problem, it was expected to identify that problem so diat Comed management could take appropriate actiort 2.1 Ooerations and Trainine i
Re ISAT review of Zion operations uncovered seven major areas of concem. The findings describe in broad terms "what is missing" or "what prevents" Zion from becoming a best-perfonning plant. Causal factors for each of the seven areas are provided below.
2.1.1 Conservative Operatinn Philosophy Within Ole operations organization there is a lack of appreciation for conservative decision j
making and the role it has in the defense-in-depth concept. Operations does not act as a i
standards bearer or as the gatekeeper for safety, 2.1.1.1 Causal Factors No clear definition has existed for conservative decision making and no role model of a conservative decision maker existed.
- Conservative decisions are seldom reinforced or celebrated to demonstrate desired behavior.
1 Ihluction and schedule have been the overriding considerations in making hour-tu.
hout decisions. Current senior management philosophy on conservative operations is in its early stages of implementation.
j Simulator training is not used as a tool to reinforce expectations for conservative decision making.
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2.1.2 Tolerance of Deficient Conditions Management and operators have accepted deficient conditions. Acceptance of these deficient conditions is not in keeping with industry standards. Further, these deficient conditions have affected plant performance. At Zion. little ownership of performance improvement existed.
Specifically, operators have not taken a lead role in improving performance.
2.1.2.1 Causal Factors Corrective actions are administrative in nature and (k) not appear to prevent e
recurrence.
Problem identification fonns (PIFs) are viewed as speeding tickets and do not substantively a<kiress issues.
Action Requests ( ARs) are not written to identify all issues because operators believe less important issues will not be corrected.
Tie standards of the organization are too low and are not consistent with an excellence in operath)ns philosophy 2.1.3 Line Management Ownership of Traininn Training was not utilized to deliver and reinforce expectations, communicate standants of perfonnance, or prepare operators for organizational change. Training was not utilized as a tool to drive change to improve operations perfonnance. Training is viewed as a license requirement with minimal impact on human perfonnance. It is used only to " brush up" on technical skills.
Operations management has not maintained an active ownership of training.
2.1.3.1 Causal Factors 1
Because training is not recognized as a vehicle to make change, management has not i
taken a personal and aggressive interest in training. A lack of ownership of training is clearly evident.
Poor enforcement of standards exists including inadequate critiques and a tolerance oflate arrival to class.
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An uncooperative atmosphere exists between instructors arul shift personnel. The e
majority of feedback to the ISAT on training was negative.
2.1.4 Operations iluman Performance Plarl The operations perfonnance plan does not address the centerpiece of operational excellence which is human performance. There have been numerous occasions where human perfonnance has been deficient. Operator human perfonnance is a significant issue at Zion.
2.1.4.1 Causal Factors Operations department : xpectations are not clear and lead to confusing standards on human perfonnance.
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co There has been a long-standing reluctance to confront substandard human perfonnance. Previous management has indirectly promoted a culture of inaction on j
human performance issues.
' Ihere has been a lack of feedback and coaching by supervision on hmnan F
perfonnance issues. 'Ihis is a result oflack of supervisory skills, lack of 1
management support for tough decisions that address human perfomiance anxi a low understanding of the impact of positive feedback on human performance.
2.1.5 Onerational Excellence j
'Ihe attributes utilized for assessment of operational excellence are the following:
Good procedure quality Strong procedural adherence Sou'xl communication techniques S'> lid self-checking programs l
Pesitive operator bearing with a questioning attitude l
Conservative decision making l
Good use and acceptance of supervisory oversight Technical competence and attention to detail i
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j During the ISAT visit to Zion, numerous signs and posters were observed which a(kiressed heing " committed to world class performance" of which operational excellence is an integral j
pan. This was considered a visible sign of management's commitment to excellence and a continual reminderto employees of management's philosophy.
When individuals in operations were observed it became apparent that few irxlividuals did a reasonable job of demonstrating any of the aforementioned eight attributes of operational
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excellence. From conversations with operators it was apparent that there was little recognition j
as to how an individual could contribute to improving perfonnance of Zion operations.
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2.1.5.1 Causal Factors 1
Irxlividuals did not recognize that a fundamental commitment to operational excellence and nuclear safety results in long-term economic performance. These individuals did not understand that the best-performing plants were invariably the most cost competitive. Little recognition existed of the INPO study regarding this subject.
Operations manageroent does not communicate consistent expectations as to what cortstitutes excellence.
- Zion has had an insulated culture. Individuals do not realize that the nuclear industry has significantly changed. More importantly, in certain instances they do not realize how much they must change just to catch-up with acceptable itxtustry practices. Mediocrity appears to have been acceptable at Zion, indicating a lack of understanding of operational excellence.
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2.1.6 Gao Between Mananement and the Barnaininn Unit As previously identified, the ISAT also detennined that bargaining unit and management relatkn.s require additional attention. It appears to the ISAT that management and bargair.ing unit persamel do not understand that the success of Zion requires interdependence of action, on:
group cannot succeed without the other. A phik> sophy of"we are all in this together" does nc,t exist.
The gap between management and the bargaining unit is a significant issue confronting Zion.
The ISAT is not aware of a nuclear station that has achieved high Icvels of perfonnance without a fully engaged wekforce. At Zion. management has pointed to the bargaining unit as the wee of declining perio.7 nance while the bargaining unit has pointed to management. Both sides have not taken responsibility to resolve their differences.
2.1.6.1 Causal Factors There is a perception of a hidden agenda on the part of management and on the part of the bargaining unit. Full disclosure of the " whys" of actions taken by both management and the bargaining unit (kjes not always appear to exist.
A class system is perceived. All decisions appear to the workers as being made on the " sixth floor" by senior management.
A high degree of mistrust exists. The barg.oning unit does not trust or believe
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management, and management does not trust the motives of the bargaining unit.
Poor communications exist. Issues are not completely shared. cxpectations are not continuously reinforced and dialogue is not fostered.
2.1.7 Harnaininn Unit Pathway to Mananement A number of Nuclea-b trion Operators (NSOs) are at the upper limit of their bargaining unit career path. Most licensed shift supervisors (LSS) are instant senior reactor operators (SRO) while many of the NSOs have had many years of experience in Zion operations. This difference in experience has created an "us versus them" situation and also amplifies the difference between a supervisory position and an operator position.
2.1.7.1 Causal Factors The bargaining unit views the union as a protective umbrella; a promotion is viewed as a loss of this protection.
Inconsistent standards result in confrontations between the NSOs and Control Room Supervisors (CRSs). This widens the gap between the bargaining unit and management which in tum reduces the interest and motivation in being promoted to management.
f The bargaining unit perceives the existing operations standards as unclear in certain areas and unnecessary in others. If promoted into management, they would be responsible for enforcing standants that have been poorly received.
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y-The adversarial relationship betwe-en the bargaining unit and management contributes to the reluctance to pursue advancement.
j 2.2 MAINTENANCE During the assessment of the maintenance function, four issues were raised which impact Zion's ability to identify, prioritize, plan, schedule and execute work. These issues have resulted in j
large work backlogs, poor materiel condithm, and low system and equipment availability and reliability. These issues involve substandard performance in the following areas:
Work control process j
1-Preventive maintenance prograrn j
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Maintenance department management i
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Viese major issues, along with significant subtier issues, are discussed in detail below, r
l' 2.2.1
.Wurk Control Procesj I
The work control process at Zion has not supported identilleation, prioritization, planning and j'
execution of work. This resulted in significant work backlogs and hindered station responses to i
issues important to safety and production. There is a work request backlog of more than 22(X) items arxl as much as fifty percent of the work on the schedule is emergent work which has not been effectively planned. The problems in the work control area may be masking other concems j
such as worker skill and pnxluctivity.
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2.2.1.1 Causal Factors 1
The primary cause for work control system deficiency issues is a lack of an effective change management metikxiology for implementation of significant changes in Zion processes and procedures. Changes to the work management system and the creation of the Fit It Now (FIN) team were implemented without a fully integrated change plan. The impact on implementing organizations (maintenance, operations atal scheduling) and their roles in the change process were not completely considered.
Management suppoit during implementation was weak. The mission for the FIN team was not clearly defined arni communicated. The process owner, who initiated the change for the wo?.ontrol system, was moved two months after implementation began. A new process owner was not assigned until five months later. Viis change management approach has resulted in a lack of ownership of the work control system by Zion grsonnel and misdirection of the FIN team. Persor.nel have no faith in these processes and consequently do not support those activities that would make them function properly.
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v 2.2.2 Jfinentive Maintenance (PM) Pronram The PM program is not being properly implemented. There are numerous PM tasks past their due date. In addition, there are over 100 PMs past their critical date. This has been a long-standing problem and has been previously identified. A NOD program to standardize and streamline the PM programs at all Comed stations is being implemented at Zion. At present, problems with work planning, scheduling and execution are nullifying the impact of these impmvement efforts.
2.2.2.1 Causal Factors Management has not provided the laatership and clear communication of expectations required to ensure that an effective PM program has been developed and implemented.
The PM program is given a lower priority than issues related to production. PM tasks have been routinely delayed due to resource unavailability or grid conditions.
Management has not viewed the PM program as a key factor in maintaining Zion reliability and availability.
2.2.3 Maintenance Department Manacement The overall management of the maintenance department has not met high standards in a number of areas. Maintenance management has not clearly and consistently communicated expectations and standards.
llolding first line supervisors and workers accountable for meeting challenging standards has not been a part of Zion's culture. Supervisors are not in the field to the extent required to ensure that maintenance work meets accepted standards. The training program for supervisors aryl workers is weak.
This has resulted in maintenance department performance that is below industry standards.
Significant work backlogs exist. Rework, when measured, has been significant. The PM program is not beiny Nplemented, equipment reliability is low and plant materiel condition is poor. Overall, woric.nkills appear to be weak.
2.2.3.1 Causal Factors There has not been a maintenance department practice of holding workers personally accountable for identification and resolution of problems.
Maintenance management has tolerated low standards. As a result, those activities which establish performance at or above industry standants and long-temt improvement are not supported. These include: developing and implementing challenging expectations; tracking expectation implementation with the appropriate perfomiance indicators; holding supervisors and workers accountable; developing and implementing effective training programs; and challenging those corporate, station and department policies that hinder achieving top performance in maintenance.
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- .c 4-i Maintenance management and bargaining unit leadership have not recognized that in order to succeed they must work as a team to address long-starxling issues.
1 2.2.4 Channe Management 1
l Re inability to create and implement effective change management plans has impacted 1
l maintenance depanment perfonnance. He implementation of the Electronic Work Contml j
System (EWCS) and twelve week schedule offer clear examples. There are numerous examples of process, procedure and metiniology changes undenaken without considering the impact on I
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other departments and processes. Action plans are not always documented and,if they are, implementation is typically not tracked. First line supervisors and workers are not engaged in or t
held accountable for making the changes required to acideve top perfonnance.
I 2.2.4.1 Causal Factors I
f Re changes required to improve maintenance department perf(mnance at Zion involve problems with long-standing, fundamental policies, processes and procedures. Rey involve adiressing bargaining unit and managemgit relations. A key element that has been missing in previous change plans is the selection, training,
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empowennent and suppon of first line supervisors as the principal implementors of required changes. This has been a significant barrier to implementing change.
I Maintenance management has set standants of performance that are below those j
l-typically set by industry. Here has been no accountability for changing these standants. As a result, there is no driving force for resolving the difficult challenges associated with implementing the changes needed to achieve best-performance in the maintenance depanment.
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2.3 ENGINEERING AND TECHNICAL SUPPORT Re engineering organization was assessed to determine its perfonnance as the design authority and technical conscience of Zion. De ability of the engineering organization to provide high i
quahty and responsive engineering and technical support to other station organizations was also assessed.
i he ISAT detennined that the perfonnance of Zion's engineering is significantly below that of best-perfonning plants. Engineering has prim 2rily focused on resolving short-tenn emerging issues. Engineering has not effectively addressed long-standi'ig equipment issues, necessary j
programs and resource issues needed to establish and sustain good perfonnance. This has been F
demonstrated by repeated equipment failures inadequate design and licensing basis 1
documentation, increasing backlogs and inadequate safety evaluations. The following areas were j
found to be in need ofimprovement:
i Wort management Engineering work quality System engineering function Long standing equipment arxl materiel condition Design basis and configuration management' ~
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e Deficiencies in these areas have been identified in the past, were confinned in this assessment and have existed for several years. The reasons for these deficiencies are discussed below.
Past leadership of the engineering organization has not been effective in establishing, communicating, and enforcing high standards of pedonnance. Low standants of performance have been tolerated, and less than adequate work products have been accepted. Corporate and Zion engineering management have not provided the direction, focus and coaching needed for die staff to be successful. Contributing to this has been the large tunxr.er of supervisors and group leads within the engineering organization.
1 Zion engineering is a reasonably young organization. Prior to 1993, the majority of design engineering was perfonned by architect engineers. The Zion engineering organization was developed without a well-defined implementation plan.
Engineering has generally supported day-to-day operations but has failed to plan for and manage its long-term responsibilities. Resource constraints in engineering were not effectively conununicated to other station groups and support of other departments for work prioritization was not obtained. A lack of engineering teamwork was noted during the evaluation. Engineering teamwork with the station for work prioritization was lacking. Strong teamwork was not exhibited during engineering meetings or in meetings with other station departments.
Perfonnance goals and measurement irxlicators have not been established and consistently implemented to improve engineering performance. Corporate and Zion management have not committed the appmpriate resources to achieve engineering excellence. Engineering has not been a self-critical teaming organization. It has not implemented corrective actions known to be important. An environment exists where individuals do not bring errors or problems forwant for the purpose of improving perfonnance. Finally, Zion engineering has not postured itself to be the technical conscience of the station which is needed to achieve and sustain excellence in operations.
The perfonnance of engineering in each area noted above is discussed below:
2.3.1 Work Mananement There has been inadequate identification arxl control of engineering work activities. There has also been ineffective screening and prioritization of requested engineering work by operations, maintenance and engineering. Priorities frequently change and engineering is not always working high priority items with the proper individuals to support Zion's needs. The lack of effective work management inhibits engineering fmm being proactive arxl having the ability to self-identify and correct problems in a timely fashion.
2.3.1.1 Causal Factors Engineering lacks an effective work control system to manage its workload.
There is clearly too much work to do with the resources available. Resource constraints in engineering have not been effectively communicated to other site groups.
Engineering management has not been an effective champion forengineering issues and " driven home" the need to address important engineering work in a timely and complete fashion.
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I 2.3.2 Ennineering Work Ouality Past engineering evaluations arxl safety evaluations have often been inadequate. In some instances the design basis was not well understood.
4 2.3.2.1 Causal Factors The importance and significance of safety evaluatiorts and assessments have not been fully appreciated by the engineering staff.
The safety culture within engineering is weak. The engineering staff has not recognized the need to make changes to improve the safety culture.
Design and licensing basis infonnation has not always been maintained up-to-date.
In some cases, the technical knowledge of the engineering staff is deficient. Past training has not been sufficient to improve perfonnance.
2.3.3 System Ennineerine A proactive system engineering function is not being implemented. System engineers are mainly reacting to daily requests for support and are frustrated by constantly changing priorities.
2.3.3.1 Causal Facturji System engineers have not been able to fullill their roles and responsibilities.
e System engineers are often engaged in nonsystem engineering activities such as project management, work package preparation and routine post maintenance testing. There is a lack of task prioritization and system engineers are mainly l
reacting to shott-tenn crises.
Training has not been effectively used to improve system engineering perfonnance.
1 System engineers have not been required to detennine system design. operational and testing requirements and assure these requirements are met.
2.3.4 Lonn-Standinn Eauioment and Materiel Conditions
'Ihe identification and resolution oflong-standing equip nent problems have not always been i
rigorously pursued by engineering. A number of long-starkling and recurring equipment problems have not been resolved.
2.3.4.1 Causal Factors Management has not provided sufficient resources or reinforced the timely resolution of many equipment problems. The cause of equipment pmblems is not always detennined unless there is an immediate impact on Zion opemtion.
Proper root cause analysis has not always been utilized.
Corrective action programs to address equipmen: problems have been developed arxlplanned but not implemented.
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'2.3.5 Desian Basis and Confinuration Mananement Lack of design basis infonnation and configuration management control have been identified on a number of occasions. Discrepancies between the Uplated Final Safety Analysis Review (UFS AR), Technical Specifications, plant drawings, arxl as built corxlitions have been identified.
2J.5.1 Causal Factors Zion design and licensing bases docwnentation has not been completely defined, e
has not been teglated and is not easily accessible. Existing Design Basis Documents (DDDs) do not contain sufficient infonnation arxl are not maintained current.
Budget constraints have affected the completeness of design information e
documents.
Zion engineering has not postured itself to be the design authority and technical e
conscience of the station. Engineering management has not effectively championed configuration management issues and " driven home" the need to a(kiress these issues in a timely and complete fashion.
2.4 PLANT SUPPORT Plant suppon consists of radiation protection, chemistry, fire protection, security and emergency planning. At Zion, plant materiel condition and housekeeping present challenges to the quality of the radiation protection program and the fire protection program. The radiation protection program is also impacted by the practices of plant workers doing work within the radiologically posted area (RPA). All plant support functions are adversely impacted by the failure of L
management to prioritize and allocate the resources necessary to maintain high perfonnance in the plant suppon areas. Notwithstandmg these adverse factors, the plant supp>rt functions have been implemented adequately.
2.4.1 Radiation Protection j
2.4.1.1 Worker Radiation Exposure l
2.4.1.1.1 Causal Factors The radiation source tenn in the plant is higher than the industry median. Over j
e sixty-five " hot spots" exist in the plant. Additional effort is needed to reduce or eliminate these hot spots. A prime example of major hot spots in containment is the resistance temperature detector (RTD) manifolds in each reactor coolant k)op.
Most utilities removed the RTD manifolds some years ago.
The cobalt reduction program, while initially making progress, has slowed recently I
to the point that little progress is being made, i
Early boration, commonly used during major shutdowns at pressurized water 3
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reactors that have been effective in reducing the source term, have only recently
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been adopted at Zion.
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Radiation worker practices contribute to higher radiation worker dose.
Observations and reconis of worker practices include: workers awaiting work lingering in areas other dian the low dose area, a worker not following the radiation work permit (RWP) and work instructions, resulting in a significant uptake of airbome radioactivity; and numerous examples of poor housekeeping practices. On the positive side, a training program called " enhanced N-GET* was developed which has been successful in significantly reducing personal contamination events (PCE). liowever, current plans are to discontinue the program.
Conduct of maintenance contributes to the higher worker exposure at Zion.
Analysis of ALARA exposure records irklicates that emergent work is a major contributor to the failure to achieve ALARA goals. While it is expected that unplanned emergent work will a&l dose to total worker exposure, the degree of emergent work undemiines the dose goal setting process, thus reducing the effectiveness of the ALARA process. In addition, diis places added bunlen on the radiation protection department to hurriedly prepare an ALARA analysis that might not be as effective as an analysis that was prepared in ample time before the actual perfonnance of the job. Further, repeat work and rework unnecessarily add to worker exposure.
Full management support for the ALARA Program has not existed and ownership of dose by departments and sections is not consistent. For example, the chaimian aIKI several key members of the ALARA review committee failed to show up for a j
scheduled committee meeting. In response, the new site vice president appointed himself the new chairman. lie rescheduled the meeting for later in the day and required the attendance of senior Zion management.
1 2.4.1.2 Contaminated Plant Area 2.4.1.2.1 Causal Factors i
The apparent cause of the large number of contaminated areas is the materiel e
condition of plant equipment. Leaks and drips from piping and components cause widespread contamination. Accumulation of leakage products and chemical deposits have caused the contamination levels of these areas to become higher.
Continued neglect of the buildup of contamination in the RPA will continue to cause inefficient operation and maintenance of Zion.
Poor housekeeping in some areas (i. c., anti-C clothing, mop heads, ladders, loose plastic, a detached catch basin, loose buckets,55 gallon drums and caustic were scattered on the floor) exacerbates the contamination issue.
2.4.1.3 Radiation Worker Practices 2.4.1.3.1 Causal Factors Poor radiation worker practices are due in part to a low level of mentoring and coaching by supervision of their workers in the field. Many workers report that their supervision is seldom seen at the job site.
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Workers seldom write PIFs on the activities of other workers. so the opportunities to learn the extent of radiation worker problems and to develop specine remedies to correct those problems are missing.
2.4.1.4 Performance Indicators and Benchmarkinn 2.4.1.4.1 Causal Factors A lack of meaningful management perfonnance indicators and benclunarking at Zion contributes to management's inability to fully appreciate the extent to which corrective actions must be applied to become a best-perfonning plant. Therefore.
development of extensive perfonnance indicators to help to manage these areas was not considered important.
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2.4.2 Chemistry The analytical equipment, techniques, quality control and expenise to perfonn accurate and consistent analysis has been demonstrated by the chemistry staff. The bases for chemical treatment programs at Zion have been consistent with industry practice.
2.4.3 Emernency Plannine 1
Except as noted below, the perfonnance of emergency planning at the station is satisfactory.
2.4.3.1 Operations Suonort Center 2.4.3.1.1 Causal Factors The location of the OSC is not shicided nor does it have a filtered breathing air I
supply and would therefore not be habitable during a significant release from the plant. It would be a best practice to change the k) cation of the OSC to a shielded, filtered h) cation.
2.4.4 Fire Protection 2.4.4.1 Material Condition of Fire Protection Eauioment.
2.4.4.1.1 Causal Factors Cognizant personnel indicate that the reason for the large number of outstanding work orders is the low priority given to maintenance of fire protection equipment.
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2.4.4.2 Fire Protection Euuinment 2.4.4.2.1 Causal Factors l
The root causes of the high rate of emergency lighting failures was determined to be:
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A failure to recognize that the failure rate was excessive.
No root cause analysis was performed.
Inadequate surveillance procedure.
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Fai!ure to follow procedure.
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- Failure to take corrective action.
r In addition,6 volt battery voltage readings were recorded for some 12 volt batteries.
l The issues surrounding the emergency battery issues indicate a breakdown of management control over the testing and maintenance of this important fire protection j
system.
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2.4.5 Securitv l
4 2.4.5.1 Security Performance l
2.4.5.1.1 Causal Factors 4
The cause of.a mcxlerate decline in security perfonusnce was detennined to be low i
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morale caused by excessive overtime resulting fratri staffing shortfalls. The j
conective actions of the security department were examined and detennined to b.c adequate flowever, the overall effectiveness of those plans should be reevaluated
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periodically until perfonnance regains its proper level.
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